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  • High sensitivity C-reactive protein

    Is anyone using this test? Good, bad, useless, who knows?

  • #2
    I use it, along with the Electron Beam CT, to decide what to do with the midrange elevated cholesterols in at-risk patients. Of course the literature is mixed, and most importantly United Health Care won't pay for it, so I am selective... I had one and it was low so I'm staying off HMG's for my LDL of 135.

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    • #3
      Great question. Seeing more of these people after they get a "consumer" EBCT. Cardiologists recommend stress test (stress thal/echo) if asymptomatic and elevated calcium score. How is that an advancement? I thought screening TMTs were of little value given that most MI's occur with 50-60% blockage, a level that would allow a normal stress test. Is there evidence to support the idea that treatment of high calcium scores in asymptomatic otherwise low risk patients results in better outcomes?

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      • #4
        Hirschr what risk model are you using? Framingham 10 year risk has no allowance for either EBCT or CRP or homocysteine. ATPIII I think asks for 10 year risk, then stratifies further.

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        • #5
          Kursk, at risk meaning three or more of the ATP risks.
          My strategy is positive calcium score 0-100= HMG and ASA; 100 and up= HMG, ASA and stress test with nuclear, over 1,000= cardiologist.

          The USPSTF just came out as "insufficient evidence in high risk individuals" US PSTF but that beats the D recommendation for screening all people.

          There is never a "right" answer, but the only answer that matters is the one that you give to the family when their loved one drops dead of an MI, with no past history but a high cholesterol, and they ask "why?"

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          • #6
            Do we get reimbursed for HS-CRP before I even look at the evidence?

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            • #7
              Dude, never like being in that situation, but on the other hand I do feel an obligation when recommending expensive therapies to young folks that may be on meds a long time. As my mentor was famous for saying "a test or procedure not indicated but ordered will always be abnormal. And you will have to explain it". With primary prevention NNT = 70 for 5 years to prevent one death. Personally, I 'd take a statin but worry about memory loss and muscle problems. And I'd learn which meds I could take with it.
              Last edited by Kursk; 04-11-2004, 07:32 PM.

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              • #8
                Calcium score > 300 in people with Framingham´s intermediate risk was associated with an increse in CHD risk (JAMA 2004; 291: 210-215). It has been stated that EBT can add incremental value in low and intermediate risk asymptomatic patients and can predict coronary events more accurately than traditional factors (ACC 2003 Scientific Sessions). I don't have much experience with calcium score, but one of the problems is what to do when you have a positive score in an intermediate risk asymptomatic patient. Would he/she go to the cath lab inmediately?; What would you do if non-singnificant coronary lessions are found?. This may prompt for another test, either stress echo (pharmacologic or non pharmagologic) or nuclear scan to look for ischemic changes. The choice will depend of your center expertise. Where I work, we would go for stress echo. Besides, there is an added cost for doing the extra tests.

                My personal view is that there is some researh ahead before the real value of calcium score can be taken for granted and in the meantime, I'd stick with cost benefit proven tactics.

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                • #9
                  Originally posted by Cardiodoc
                  This may prompt for another test, either stress echo (pharmacologic or non pharmagologic) or nuclear scan to look for ischemic changes. The choice will depend of your center expertise. Where I work, we would go for stress echo. Besides, there is an added cost for doing the extra tests.
                  Sooooo IF you are going to do a screening test then do stress echo as the first test instead of the second test! Has anyone sent folks directly from the EBCT to the cath lab?

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                  • #10
                    Nope, what we usually do in our hospital is to screen for risk factors (Framingham's) and order the appropiate risk modification strategies regardless of symptoms. If the patient was symptomatic, we would start with conventional stress test, not only to asses ischemic response, but to evalaute BP and excercise tolerance. If an ischemic response is elicited, either symptoms or EKG changes, the patient goes to stress echo and then to the cath lab. Why?. With echo guidence we try to entervene only on the coronary artery responsible for wall motion abnormalities during the test, so we can save one or two stents.

                    With asymptomatic high risk patients, we treat modifiable risk factors and perform a TT to meaure physical capacity and taylor an exercise program.

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                    • #11
                      Originally posted by Cardiodoc
                      Nope, what we usually do in our hospital is to screen for risk factors (Framingham's) and order the appropiate risk modification strategies regardless of symptoms. If the patient was symptomatic, we would start with conventional stress test, not only to asses ischemic response, but to evalaute BP and excercise tolerance. If an ischemic response is elicited, either symptoms or EKG changes, the patient goes to stress echo and then to the cath lab. Why?. With echo guidence we try to entervene only on the coronary artery responsible for wall motion abnormalities during the test, so we can save one or two stents.

                      With asymptomatic high risk patients, we treat modifiable risk factors and perform a TT to meaure physical capacity and taylor an exercise program.
                      Thanks CardioD, appreciate your take on this. I think we are pretty close to your approach in our clinic.

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                      • #12
                        Originally posted by brooks31
                        Is anyone using this test? Good, bad, useless, who knows?
                        I have not read the latest, but I am not sure it really did pan out, did it?
                        Mike

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                        • #13
                          PROVE-IT and REVERSAL highlight role of inflammation in atheroma

                          http://www.theheart.org/viewArticle....maryKey=378041

                          Lowering CRP had an independent association with lowered cardiac risk. Statin effect on lipids, LDL, + inflammation.

                          Ridker et al write: "Our data are consistent with laboratory work indicating the importance of inflammation as a determinant of plaque instability, as well as experimental data indicating that statins have lipid-lowering and anti-inflammatory effects. Our data also provide support for ongoing efforts to find agents capable of lowering CRP as a potential method of reducing vascular risk."

                          "Our study raises the provocative question of whether the effects of statins on CRP, as well as LDL cholesterol, should be considered in decisions regarding therapy."
                          Growing old is mandantory, Growing up is optional.

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                          • #14
                            Are there any pharmacologic treatments for elevated C Reactive Protein? It is being promoted as a very important risk factor, up there with HTN and cholesterol, and that clinically makes sense to me based on the pathophysiology of atherosclerosis, but can we treat it?
                            CUT2CURE. We heal with steel! It can't hurt you if it's in a bottle...and the Rule of the Artery is Supreme

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                            • #15
                              These studies suggest the antiinflammatory properties of statins may be as/more important than their lipid lowering effects. My take is that perhaps statins be considered with high CRP & other risk factors even if LDL etc OK. Interesting developments.
                              Growing old is mandantory, Growing up is optional.

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