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    The Top 5 Biomarkers in Cardiovascular Disease Prevention


    Hs-CRP (high-sensitivity C-reactive protein). Hs-CRP is a biomarker whose characteristics (ie, its constant half-life) make it ideal as an indicator of acute ongoing inflammation. A meta-analysis from the USPSTF demonstrated that hs-CRP >3 mg/dL was associated with 60% increased risk of cardiovascular disease.The biomarker became a prominent topic in CVD prevention in 2008 with results of the JUPITER trial.1 JUPITER was a large outcomes trial that randomized ~18,000 primary prevention patients with LDL-C <130 mg/dL and hs-CRP >2 mg/dL to statin therapy (with rosuvastatin) vs placebo. The trial had to be stopped early in light of a 44% lower hazard for the primary composite endpoint with statin use in the treatment group.

    The ACC/AHA have given hs-CRP screening in the decision to use a statin a Class IIa indication and a Class IIb recommendation for men >50 years and women >60 years.

    Lp(a) (lipoprotein-a). This is a marker for CVD I tend to use when: (1) cholesterol is well controlled but the patient has a significant family history of premature heart disease, or (2) there are other risk factors that are readily captured by the ACC’s ASCVD risk calculator (eg, a high-risk ethnic group such as South Asians that tends to have elevated Lp(a) levels)

    Lp(a) represents an LDL-like particle and an apolipoprotein (a) and is a genetically determined marker. Ideally, levels should be <14 mg/dL and very high risk (for atherosclerosis and vascular events) is >50 mg/dL. Recently, it has been found that PCSK9 inhibition reduced Lp(a) by ~30% (read about PCSK9 inhibition and test your knowledge here) by an uncertain mechanism.


    BNP (B-type natriuretic peptide). BNP belongs to a family of hormones that are upregulated in period of myocardial wall stress and the most common clinical use is in the setting of acute heart failure (usually for diagnosis) or chronic heart failure (usually for prognosis).  In primary prevention, there have been consistent associations with elevated BNP and cardiovascular risk and in multiple analyses, BNP (or its precursor NT-proBNP) has been shown to have independent prognostic value. I don’t check it often unless there is HFPEF or diastolic heart failure present; in these cases, it helps to establish a baseline in patients who are euvolemic.

    Payal Kohli, MD
    Payal Kohli, MD, is an attending cardiologist for Kaiser Permanente in Denver, Colorado.


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