It’s an all-too familiar story: you learn that your patient was brought to the emergency department with symptoms of heart attack—the same patient who recently had normal cholesterol and triglyceride results at the time of their annual wellness visit. Could this heart attack have been prevented with additional testing?
Studies show that about half of heart attacks and strokes occur in patients with “normal” cholesterol levels.1,2 It is now well recognized that, in addition to plaque buildup along the vessel wall, inflammation plays a major role in cardiovascular disease (CVD)—from early risk to adverse cardiovascular events. This means that assessing lipids alone may not fully identify patients at increased risk for adverse events. Fortunately, there are inflammatory biomarkers that may be measured to help evaluate a patient’s risk for cardiovascular events.
How injury + response to injury spell trouble
Heart attack, stroke, and other events have been associated with inflammation3, specifically vulnerable plaque related to increased white blood cell activation. But inflammation gets to work well before vulnerable plaque formation. Briefly, here is the progression of disease from initiation to full-blown atherosclerosis:
- Risk factors such as smoking, hypertension, and diabetes can damage the vessel wall, making it more susceptible to penetration and accumulation of excess LDL-cholesterol particles.
- As cholesterol accumulates, LDL is oxidized and the inflammatory response is initiated.
- The process becomes dysregulated, leading to increased cholesterol deposits and vulnerable plaque formation. When the underlying risk factors including dyslipidemia aren’t addressed, the inflammatory process continues, placing a patient at risk of plaque rupture and subsequent heart attack or stroke.
Various inflammatory biomarkers are associated with all stages of disease, from early risk of disease to development of vulnerable plaque and increased risk of adverse events:
- F2-Isoprostanes (F2-IsoPs) and oxidized LDL (OxLDL), which may result from lifestyle factors (e.g., smoking, reduced physical activity), may signify risk of disease
- ADMA/SDMA, urinary microalbumin, and high-sensitivity C-reactive protein (hsCRP) may signify disease presence
- Myeloperoxidase (MPO) and Lp-PLA2 Activity may signify disease activity, indicating increased risk for an adverse event
These markers and their associations with atherosclerosis are shown below:
After testing, then what?
Uncovering a patient’s hidden risk for inflammation—and thus disease progression—can point to a range of treatments, depending on the inflammation panel results. A definitive test result for a patient with elevated levels of F2-IsoPs and OxLDL, for example, may better motivate him to change his lifestyle behaviors and make healthier choices to reduce his levels, while other inflammatory markers may indicate the need for prescription or nonprescription drugs, or supplements.
This enhanced knowledge can lead to improved patient engagement and more effective treatment—for better health outcomes. That all-too familiar story can be reversed, preventing adverse cardiovascular events for more patients.
Next: A closer look at individual inflammatory biomarkers. For this and other upcoming articles on what’s new in diagnostics, subscribe to Primary Insights.
1. Ridker PM, Danielson E, Fonseca FA, et al. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med. 2008; 359: 2195-2207.
2. Sachdeva A et al. Lipid levels in patients hospitalized with coronary artery disease: An analysis of 136,905 hospitalizations in Get With The Guidelines. Am Heart J. 2009; 157:111-117.
3. Ross R and Glomset JA. The pathogenesis of atherosclerosis (first of two parts). N Engl J Med. 1976; 295: 369-377.