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This
is a contribution from a member of THINCS, Letter to Wall Street Journal sent by Paul Rosch commenting an article by Tara Parker-Pope. The letter was not published. Parker-Pope's article is included below. August 6, 2003
Letters To The Editor CRP, LDL And Association Never Proves Causation Re: "A Number That Can Change Your
Life" (August 5) it is important to reemphasize that an elevated CRP is
merely a marker for coronary heart disease, as are countless other things
like a deep earlobe crease, premature vertex baldness and elevated
cholesterol or LDL. Lowering
CRP per se will not reduce heart attacks any more than would cosmetic
earlobe surgery or a hair transplant. Association
never proves causation and the same applies to cholesterol and LDL.
As indicated, studies show that CRP is a more accurate predictor of
coronary events than LDL and there is abundant evidence that the
cardioprotective benefits of statins are related to their anti-inflammatory
activities rather than any lipid lowering effects.
Therefore, current guidelines for statin therapy
that mandate lowering LDL to an arbitrary level are inappropriate and
dangerous. Studies show
that this goal is difficult if not impossible for most high-risk patients to
attain, which will only lead to higher doses and more complications.
All statins have been shown to be carcinogenic in animals in doses
equivalent to those currently being prescribed. Although the lag time
between exposure to a carcinogen and clinical detection is often a decade or
more, a disturbing twelve-fold increase in breast cancer has already been
reported in one study and more skin malignancies were noted in another.
Like aspirin, the optimal dose of statins to reduce inflammation may
be much lower than for other indications and perhaps monitoring CRP would be
a more accurate and safer method of determining this. President Clinical Professor of Medicine and Psychiatry New York Medical College
A
Number That Can Change Your Life This Simple Heart Test Leads to Better Habits Good
health often gets down to numbers like your weight, your blood pressure and
your cholesterol. Now it's time to add a new number to the list -- your CRP.
It stands for C-reactive protein, and it's a blood test that detects
coronary-artery inflammation and could signal increased risk for heart
attack. Guidelines
issued in January by the American Heart Association say the test is
necessary only for patients who already show some heightened risk for heart
disease. But many patients -- and their doctors -- are asking for the test
anyway. There's
little incentive not to. The test is cheap and easy -- costing about $20.
The test results come back as a single number -- a score of three or higher
puts you at high risk, while a score below one is ideal. The sheer
simplicity of the score makes your CRP score far less confusing than the
myriad cholesterol numbers and ratios and blood-pressure fractions you're
usually subjected to. That's one reason CRP is proving to be such a powerful
tool in motivating patients to make dramatic and important lifestyle changes. Doctors
say patients who seemed unconcerned about their heart health are suddenly
motivated to exercise, diet and quit smoking when presented with their CRP
score. "Everyone
who practices preventive medicine has seen this," says Harvard
professor Paul Ridker, director of the Center for Cardiovascular Disease
Prevention at Brigham and Women's Hospital in Boston. "Physicians
respond to numbers, and patients respond to numbers." One
of those patients is Kurt Fretthold, a 51-year-old administrator for a
Cleveland-area university. Mr. Fretthold knew a family history of heart
problems put him at risk, and he took cholesterol-lowering drugs and
blood-pressure medicine. Though he was still overweight, he felt good that
his total cholesterol was 193. Then a visit with doctors at the Cleveland
Clinic prompted a look at his CRP. When it came back at 3.9, it was a
wake-up call. He
began limiting calories to 2,000 to 2,500 a day and taking regular walks on
the treadmill or outside, using fire hydrants and telephone poles to gauge
his progress. Since November, he has dropped 65 pounds, and his CRP has
dropped below one. "I
knew I wasn't feeling as comfortable as I should -- sometimes it just takes
something to trip it," Mr. Fretthold says. "I read something about
[CRP], and it scared me a little bit." Doctors
say they have been pleasantly surprised by the impact of the CRP score,
which measures a protein produced by the body when blood-vessel walls are
inflamed. Right now, the only proven way to lower your CRP is by diet and
exercise. "If
they are overweight and their diet is poor and exercise is suboptimal, there
is no better way to get them on track than using this test," says Eric
Topol, chairman of cardiovascular medicine at the Cleveland Clinic.
Cholesterol-drug therapy "fixes LDL [bad cholesterol] and you can cover
up the lifestyle issue," Dr. Topol says. "But CRP is like the
truth serum for that." The
medical community hasn't endorsed widespread use of the test in part because
it doesn't want it to replace more traditional measures like cholesterol and
blood pressure. The official guidelines say it should be used only on those
with some other risk factors for heart disease. But many doctors like
testing CRP anyway because it's cheap, and it's a way to better help people
who have normal cholesterol gauge their heart-attack risk. It's well known
that half the people who have heart attacks have normal cholesterol levels. Indeed,
a Harvard study that measured CRP levels in 28,000 healthy women found the
CRP may be a better way of gauging heart-attack risk than LDL -- the bad
cholesterol that for years has been the barometer for heart risk. In the
eight-year Harvard study, women with the highest CRP levels (of 4 mg/L) were
twice as likely as those with high LDL (154 mg/dL) to have had a heart
procedure, heart attack or stroke, or to have died from heart disease. Women
with a high CRP but a low bad cholesterol score were at higher risk than
those women with high cholesterol and a low CRP. What is so troubling is the
current methods most doctors use to assess heart risk would miss the women
in the study at highest risk. One
problem with CRP is there is still much that isn't known about it. It isn't
clear if lowering CRP makes a difference in heart-attack risk or if it's the
other changes -- lower cholesterol, weight loss, lower blood pressure and
exercise -- that make the difference. And
the Harvard Heart Letter notes that unlike high blood pressure, a high CRP
isn't a disease -- it is a symptom, like a fever, that simply signals
something is wrong. Harvard
is in the midst of another major study that will try to determine if
cholesterol-lowering drugs known as statins can have a meaningful impact on
CRP in patients who have normal cholesterol. But right now, having a high
CRP isn't reason enough to start drug therapy or even undergo significant
medical testing. The only real solution for a high CRP is to make lifestyle
changes. "Doctors
shouldn't order a stress test or an angiogram, but they should tell the
patient they've got to stop smoking, go to the gym, diet and exercise,
because their risk is higher," Dr. Ridker says. "If you know your
CRP, you've got very important additional information." E-mail
me at healthjournal@wsj.com.
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