Mortality risk prediction of high-sensitivity C-reactive protein in suspected acute coronary syndrome: A cohort study

Amit Kaura, Adam Hartley, Vasileios Panoulas, Ben Glampson, Anoop S V Shah, Jim Davies, Abdulrahim Mulla, Kerrie Woods, Joe Omigie, Anoop D Shah, Mark R Thursz, Paul Elliott, Harry Hemmingway, Bryan Williams, Folkert W Asselbergs, Michael O'Sullivan, Graham M Lord, Adam Trickey, Jonathan Ac Sterne, Dorian O HaskardNarbeh Melikian, Darrel P Francis, Wolfgang Koenig, Ajay M Shah, Rajesh Kharbanda, Divaka Perera, Riyaz S Patel, Keith M Channon, Jamil Mayet, Ramzi Khamis

Research output: Contribution to journalArticleAcademicpeer-review

Abstract

Background AU There: Pleaseconfirmthatallheadinglevelsarepresentedcorrectly is limited evidence on the use of high-sensitivity C-reactive : protein (hsCRP) as a biomarker for selecting patients for advanced cardiovascular (CV) therapies in the modern era. The prognostic value of mildly elevated hsCRP beyond troponin in a large real-world cohort of unselected patients presenting with suspected acute coronary syndrome (ACS) is unknown. We evaluated whether a mildly elevated hsCRP (up to 15 mg/L) was associated with mortality risk, beyond troponin level, in patients with suspected ACS. Methods and findings We conducted a retrospective cohort study based on the National Institute for Health Research Health Informatics Collaborative data of 257,948 patients with suspected ACS who had a troponin measured at 5 cardiac centres in the United Kingdom between 2010 and 2017. Patients were divided into 4 hsCRP groups (2, 2 to 4.9, 5 to 9.9, and 10 to 15 mg/L). The main outcome measure was mortality within 3 years of index presentation. The association between hsCRP levels and all-cause mortality was assessed using multivariable Cox regression analysis adjusted for age, sex, haemoglobin, white cell count (WCC), platelet count, creatinine, and troponin. Following the exclusion criteria, there were 102,337 patients included in the analysis (hsCRP 2 mg/L (n = 38,390), 2 to 4.9 mg/L (n = 27,397), 5 to 9.9 mg/L (n = 26,957), and 10 to 15 mg/L (n = 9,593)). On multivariable Cox regression analysis, there was a positive and graded relationship between hsCRP level and mortality at baseline, which remained at 3 years (hazard ratio (HR) (95% CI) of 1.32 (1.18 to 1.48) for those with hsCRP 2.0 to 4.9 mg/ L and 1.40 (1.26 to 1.57) and 2.00 (1.75 to 2.28) for those with hsCRP 5 to 9.9 mg/L and 10 to 15 mg/L, respectively. This relationship was independent of troponin in all suspected ACS patients and was further verified in those who were confirmed to have an ACS diagnosis by clinical coding. The main limitation of our study is that we did not have data on underlying cause of death; however, the exclusion of those with abnormal WCC or hsCRP levels >15 mg/L makes it unlikely that sepsis was a major contributor. Conclusions These multicentre, real-world data from a large cohort of patients with suspected ACS suggest that mildly elevated hsCRP (up to 15 mg/L) may be a clinically meaningful prognostic marker beyond troponin and point to its potential utility in selecting patients for novel treatments targeting inflammation.

Original languageEnglish
Article numbere1003911
Pages (from-to)e1003911
JournalPLoS medicine
Volume19
Issue number2
DOIs
Publication statusPublished - Feb 2022
Externally publishedYes

Keywords

  • Acute Coronary Syndrome/blood
  • Aged
  • Aged, 80 and over
  • Biomarkers/blood
  • C-Reactive Protein/metabolism
  • Cohort Studies
  • Female
  • Follow-Up Studies
  • Humans
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Mortality/trends
  • Predictive Value of Tests
  • Retrospective Studies
  • Risk Factors
  • United Kingdom/epidemiology

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