Agency for Healthcare Research and Quality (AHRQ)

Disclosures

March 01, 2012

In This Article

Comparison of Recommendations: Inflammation Markers (CRP, Fibrinogen, White Blood Cell Count, Lp-PLA2)

ACCF/AHA (2010)

Recommendations for Measurement of CRP

Class II a

  1. In men 50 years of age or older or women 60 years of age or older with LDL-C less than 130 mg/dL; not on lipid-lowering, hormone replacement, or immunosuppressant therapy; without clinical CHD, diabetes, chronic kidney disease, severe inflammatory conditions, or contraindications to statins, measurement of CRP can be useful in the selection of patients for statin therapy (Ridker et al., "Rosuvastatin to prevent vascular events," 2008). (Level of Evidence: B)

Class II b

  1. In asymptomatic intermediate-risk men 50 years of age or younger or women 60 years of age or younger, measurement of CRP may be reasonable for cardiovascular risk assessment (Ridker et al., 2007; Ridker et al., "C-reactive protein and parental history," 2008). (Level of Evidence: B)

Class III: No Benefit

  1. In asymptomatic high-risk adults, measurement of CRP is not recommended for cardiovascular risk assessment (Baigent et al., 2005). (Level of Evidence: B)

  2. In low-risk men younger than 50 years of age or women 60 years of age or younger, measurement of CRP is not recommended for cardiovascular risk assessment (Ridker et al., 2007; Ridker et al., "C-reactive protein and parental history," 2008). (Level of Evidence: B)

Recommendation for LpPLA2

Class II b

  1. Lp-PLA2 might be reasonable for cardiovascular risk assessment in intermediate-risk asymptomatic adults (Lp-PLA2 Studies Collaboration et al., 2007; Daniels et al., 2008; Garza et al., 2007; Koenig et al., 2004). (Level of Evidence: B)

NACB (2009)

Inflammation Biomarkers and Cardiovascular Disease Risk

Clinical Science

1a. After standard global risk assessment, if the 10-year predicted risk is <5%, hsCRP should not be measured. (Classification of recommendation: I; Level of evidence: A)
1b. If the 10-year risk is 5% to <10%, it is expected that 10% might be reclassified to a higher risk group with the test. More information is needed on clinical application, particularly in relation to longer-term lifetime risk prediction and selection of an appropriate intervention (lifestyle/medical). (Classification recommendation: II; Level of evidence: B)
1c. If risk is intermediate (10% to 20%) and uncertainty remains as to the use of preventive therapies such as statins or aspirin, then hsCRP measurement might be useful for further stratification into a higher or lower risk category. (Classification of recommendation: I; Level of evidence: A)
2. Therapies prescribed based on hsCRP concentrations should be based on clinical judgment of the physician because benefits of such treatment are uncertain. (Classification of recommendation: IIb; Level of evidence: B)
3. There are insufficient data that therapeutic monitoring using hsCRP over time is useful to evaluate effects of treatments in primary prevention. (Classification of recommendation: III [against use]; Level of evidence: C)
4. The utility of hsCRP concentrations to motivate patients to improve lifestyle behaviors has not been demonstrated. (Classification of recommendation: IIb; Level of evidence: C)
5. Evidence is inadequate to support concurrent measurement of other inflammatory markers in addition to hsCRP for coronary risk assessment. (Classification of recommendation: IIb; Level of evidence: C)

Population Science

Clinical Science/Laboratory Testing

  1. Measurement of hsCRP should be done in the fasting or nonfasting state in metabolically stable patients free of infection or acute illness. If the hsCRP concentration is <3 mg/L, it does not need to be repeated. If the value is >3 mg/dL, repeat the measurement at least 2 weeks later in metabolically stable state, free of infection or acute illness. The lower of the two results should be considered the patient's value. If hsCRP is ≥10 mg/L this might relate to CV [cardiovascular] risk. Other conditions such as acute infection or inflammation or inflammatory disorders might be responsible. Extensive evaluations with imaging tests or other testing for these patients is not recommended unless pertinent history and physical examination findings are present, or if pursuing normal practice for age-appropriate population screening. (Classification of recommendation: IIa; Level of evidence: A)

Laboratory Testing

  1. Of the examined inflammatory markers for assessing CV risk, hsCRP has the analyte and assay characteristics most appropriate for use in clinical practice. (Classification of recommendation: I; Level of evidence: A)

  2. There are sufficient data that fibrinogen is an independent marker of CVD risk; however, because of analytical concerns, insufficient assay standardization, and uncertainty in identifying treatment strategies, measurement is not recommended for this application. (Classification of recommendation: III; Level of evidence: A)

  3. There are sufficient data that WBC is an independent marker of CVD risk; however, because utility in reclassifying risk level and identifying treatment strategies is not known, measurement is not recommended for this application. (Classification of recommendation: III; Level of evidence: C)

  4. hsCRP results regardless of the method used, should be expressed as mg/L. (Classification of recommendation: I; Level of evidence: C)

  5. hsCRP using standardized assays categorizes patients as follows:

    1. Low Risk <1.0 mg/L

    2. Average Risk 1.0 to 3.0 mg/L

    3. High Risk >3.0 mg/L

    4. Very High Risk ≥10.0 mg/L
      (Classification of recommendation: IIa; Level of evidence: A)

  6. Caution is recommended in application of the hsCRP categorization in recommendation 5 for risk prediction in certain populations such as nonwhites and the elderly, as the clinical utility is less established. (Classification of recommendation: IIa; Level of evidence: C)

USPSTF (2009)

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of using the nontraditional risk factors discussed in this statement* to screen asymptomatic men and women with no history of CHD to prevent CHD events. This is an I statement.

*hs-CRP, ABI, leukocyte count, fasting blood glucose level, periodontal disease, carotid IMT, CAC score on EBCT, homocysteine level, and lipoprotein(a) level.

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