In my practice, C-reactive protein (CRP) appears to be better than LDL at predicting such ischemic events as infarcts or strokes. Among my patients at high risk for ischemic events, those treated with rosuvastatin and simvastatin seem to do better than those taking other statins. (Those taking the ACE inhibitor ramipril also do well, but ramipril is known to produce significant reductions in mortality and ischemic events.) I think that the more prominent decreases in CRP seen with rosuvastatin and simvastatin play an important role. Some patients with LDL levels above goal but reduced CRP experience no recurrence of ischemic events, while other patients whose LDL is within set goals have recurrent stroke episodes. Has anyone else made similar observations?
—Alberto Abreu, MD, Utuado, P.R.
Dr. Abreu brings up two important points. The first—that CRP levels may be a better predictor of MI and strokes than LDL levels alone, especially when there is a lack of concurrence between the two (elevated LDL with normal CRP and vice versa)—is borne out by studies in the literature measuring CRP and LDL levels after statin therapy (N Engl J Med. 2005;352:20-28). The second point relates to comparative efficacy of statins. Rosuvastatin and simvastatin are excellent agents, but the data on atorvastatin are equally impressive and emphasize the importance of all the statins (and to some degree the ACE inhibitors) as anti-inflammatory agents—hence the reduction in CRP and benefits for prognosis (J Am Coll Cardiol. 2005;46:1425-1433).
—Peter F. Cohn, MD (122-11)