According to reports, a C reactive protein (CRP) level >2 mg/L can raise the risk of MI even in patients on statins whose LDL is <70 mg/dL (N Engl J Med. 2005;352:20-28). What can be done to lower MI risk in these patients?
—Seema Maheshwari, MD, Eclectic, Ala.

CRP, an acute-phase reactant produced in the liver, is a nonspecific marker reflecting activation of the inflammatory system. Because current concepts of the pathogenesis of atherothrombosis include inflammation as a contributing factor, elevated CRP levels—especially those determined on the recently developed high-sensitivity assay—have been linked to a poor cardiovascular prognosis. Often the elevated CRP levels are associated with elevated LDL levels, and therapy with statins—because of both their antilipemic and anti-inflammatory properties—can lower both CRP and LDL. There are situations, however, in which the LDL is not elevated while the CRP is. This is an area in which a firm consensus is currently lacking, but based on studies, such as the previously noted study by Ridker et al, I agree with those who recommend aggressive statin therapy for CRP levels >2, regardless of the LDL level. In patients with known CAD, lowering both LDL and CRP reduces the risk of future CV events, as Ridker et al have demonstrated.
—Peter F. Cohn, MD (121-2)