Years of Follow

Fig. 3. Cardiovascular event-free survival according to baseline levels ofhsCRP and LDL-C. (Reproduced from ref. 12.)

terms of either population-based quintiles or simple cut points. The latter approach, in which hsCRP levels <1, 1-3, and >3 mg/L represent lower-, moderate-, and higher-risk groups, provides comparable predictive utility to that of the former approach and has greater clinical appeal.

The largest ofthe US studies is the Women's Health Study, an 8-yr follow-up of27,939 initially healthy middle-aged women who underwent hsCRP evaluation along with a full lipid panel and Framingham risk assessment. After adjustment for age, smoking, diabetes, blood pressure, and postmenopausal hormone therapy, the RR of a first cardiovascular event for women in the lowest to highest quintiles of hsCRP at baseline (<0.49, >0.49-1.08, >1.08-2.09, >2.09-4.19, >4.19 mg/L) were 1.0 (referent), 1.4 (95% CI: 0.92.2), 1.6 (95% CI: 1.1-2.4), 2.0 (95% CI: 1.3-3.0), and 2.3 (95% CI: 1.6-3.4). hsCRP levels were minimally correlated with LDL-C, and a combined approach using both variables yielded improved prediction of cardiovascular event-free survival. Figure 3 shows cardiovascular event-free survival data for participants with LDL-C above or below the study median of 124 mg/dL and hsCRP above or below the study median of 1.52 mg/L (12). As expected, event-free survival was poorest for persons with elevations in both LDL-C and hsCRP, whereas the best survival was observed for those with low values on both tests. Women with an elevated reading on only one test had an intermediate risk. However, contrary to many clinicians' expectations, event-free survival was significantly worse for those with high hsCRP and low LDL-C compared with those with high LDL-C and low hsCRP, suggesting that hsCRP may be a stronger predictor than LDL-C of incident CVD. More important, as shown in Fig. 4, hsCRP, categorized as <1, 1-3, and >3 mg/L, adds prognostic information not only at all levels of risk defined by the current LDL cut points

□ <1.0 □ 1.0-3.0 ■ >3.0 25-i C-Reactive Protein (mg/L)

□ <1.0 □ 1.0-3.0 ■ >3.0 3 -i C-Reactive Protein (mg/L)

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