Clinical study| Volume 114, ISSUE 9, P715-722, June 15, 2003

Association between C-Reactive protein levels and subsequent cardiac events among patients with stable angina treated with coronary artery stenting



      To investigate the prognostic value of elevated C-reactive protein levels in patients with stable angina who underwent coronary stenting.


      We followed a consecutive series of 1152 patients with stable angina who had undergone coronary stenting. We measured baseline C-reactive protein levels before stenting with a high-sensitivity assay; 651 patients (57%) had elevated C-reactive protein levels (>5 mg/L). The primary endpoint was either death or myocardial infarction within 1 year after the procedure. Angiographic restenosis was defined as a ≥50% diameter stenosis at follow-up angiography.


      During the 1-year follow-up, 62 (9.5%) of the 651 patients with an elevated C-reactive protein level and 24 (4.8%) of the 501 patients with normal levels died or had a myocardial infarction (P = 0.002). In a multivariate analysis, elevated baseline C-reactive protein levels were associated with almost a twofold increase in the rate of death or myocardial infarction after coronary stenting (hazard ratio = 1.8; 95% confidence interval: 1.1 to 2.9). Most of the difference in the event rates developed within the first 30 days. Baseline C-reactive protein levels did not correlate with restenosis.


      Elevated preprocedural C-reactive protein levels are associated with a less favorable prognosis in patients with stable angina who undergo coronary stenting. The measurement of C-reactive protein levels in these patients may help to identify those who may benefit from a treatment strategy aimed at the attenuation of inflammation.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ridker P.M.
        • Cushman M.
        • Stampfer M.J.
        • et al.
        Inflammation, aspirin, and the risk of cardiovascular disease in apparently healthy men.
        N Engl J Med. 1997; 336: 973-979
        • Tracy R.P.
        • Lemaitre R.N.
        • Psaty B.M.
        • et al.
        Relationship of C-reactive protein to risk of cardiovascular disease in the elderly. Results from the Cardiovascular Health Study and the Rural Health Promotion Project.
        Arterioscler Thromb Vasc Biol. 1997; 17: 1121-1127
        • Morrow D.A.
        • Rifai N.
        • Antman E.M.
        • et al.
        C-reactive protein is a potent predictor of mortality independently of and in combination with troponin T in acute coronary syndromes.
        J Am Coll Cardiol. 1998; 31: 1460-1465
        • Lagrand W.K.
        • Visser C.A.
        • Hermens W.T.
        • et al.
        C-reactive protein as a cardiovascular risk factor.
        Circulation. 1999; 100: 96-102
        • Danesh J.
        • Pepys M.B.
        C-reactive protein in healthy and in sick populations.
        Eur Heart J. 2000; 21: 1564-1565
        • Liuzzo G.
        • Biasucci L.M.
        • Gallimore J.R.
        • et al.
        The prognostic value of C-reactive protein and serum amyloid A protein in severe unstable angina.
        N Engl J Med. 1994; 331: 417-424
        • Buffon A.
        • Liuzzo G.
        • Biasucci L.M.
        • et al.
        Preprocedural serum levels of C-reactive protein predict early complications and late restenosis after coronary angioplasty.
        J Am Coll Cardiol. 1999; 34: 1512-1521
        • Walter D.H.
        • Fichtlscherer S.
        • Sellwig M.
        • et al.
        Preprocedural C-reactive protein levels and cardiovascular events after coronary stent implantation.
        J Am Coll Cardiol. 2001; 37: 839-846
        • Chew D.P.
        • Bhatt D.L.
        • Robbins M.A.
        • et al.
        Incremental prognostic value of elevated baseline C-reactive protein among established markers of risk in percutaneous coronary intervention.
        Circulation. 2001; 104: 992-997
        • Mueller C.
        • Buettner H.J.
        • Hodgson J.M.
        • et al.
        Inflammation and long-term mortality after non-ST elevation acute coronary syndrome treated with a very early invasive strategy in 1042 consecutive patients.
        Circulation. 2002; 105: 1412-1415
        • de Winter R.J.
        • Heyde G.S.
        • Koch K.T.
        • et al.
        The prognostic value of pre-procedural plasma C-reactive protein in patients undergoing elective coronary angioplasty.
        Eur Heart J. 2002; 23: 960-966
        • Schömig A.
        • Neumann F.J.
        • Kastrati A.
        • et al.
        A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary artery stents.
        N Engl J Med. 1996; 334: 1084-1089
        • Ellis S.G.
        • Vandormael M.G.
        • Cowley M.J.
        • et al.
        Coronary morphologic and clinical determinants of procedural outcome with angioplasty for multivessel coronary disease.
        Circulation. 1990; 82: 1193-1202
        • Armstrong P.W.
        Stable ischemic syndromes.
        in: Topol E.J. Textbook of Cardiovascular Medicine. 3rd ed. Lippincott-Raven, Philadelphia, Pennsylvania1998: 333-364
        • Rutherford J.D.
        • Braunwald E.
        • Cohn P.F.
        Chronic ischemic heart disease.
        in: Braunwald E. Heart Disease A Textbook of Cardiovascular Medicine. 3rd ed. W. B. Saunders Company, Philadelphia, Pennsylvania1988: 1314-1378
        • The EPISTENT Investigators
        Randomized placebo-controlled and balloon-angioplasty-controlled trial to assess safety of coronary stenting with use of platelet glycoprotein-IIb/IIIa blockade.
        Lancet. 1998; 352: 87-92
        • Schühlen H.
        • Kastrati A.
        • Dirschinger J.
        • et al.
        Intracoronary stenting and risk for major adverse cardiac events during the first month.
        Circulation. 1998; 98: 104-111
        • Hutchinson W.L.
        • Koenig W.
        • Frohlich M.
        • et al.
        Immunoradiometric assay of circulating C-reactive protein.
        Clin Chem. 2000; 46: 934-938
        • Levinson S.S.
        • Elin R.J.
        What is C-reactive protein telling us about coronary artery disease?.
        Arch Intern Med. 2002; 162: 389-392
        • Walter D.H.
        • Fichtlscherer S.
        • Britten M.B.
        • et al.
        Statin therapy, inflammation and recurrent coronary events in patients following coronary stent implantation.
        J Am Coll Cardiol. 2001; 38: 2006-2012
        • Ridker P.M.
        High-sensitivity C-reactive protein.
        Circulation. 2001; 103: 1813-1818
        • Mortensen R.F.
        C-reactive protein, inflammation, and innate immunity.
        Immunol Res. 2001; 24: 163-176
        • Cermak J.
        • Key N.S.
        • Bach R.R.
        • et al.
        C-reactive protein induces human peripheral blood monocytes to synthesize tissue factor.
        Blood. 1993; 82: 513-520
        • Fichtlscherer S.
        • Rosenberger G.
        • Walter D.H.
        • et al.
        Elevated C-reactive protein levels and impaired endothelial vasoreactivity in patients with coronary artery disease.
        Circulation. 2000; 102: 1000-1006
        • Pasceri V.
        • Willerson J.T.
        • Yeh E.T.
        Direct proinflammatory effect of C-reactive protein on human endothelial cells.
        Circulation. 2000; 102: 2165-2168
        • Bhatt D.L.
        • Topol E.J.
        Need to test the arterial inflammation hypothesis.
        Circulation. 2002; 106: 136-140
        • Albert M.A.
        • Danielson E.
        • Rifai N.
        • Ridker P.M.
        Effect of statin therapy on C-reactive protein levels.
        JAMA. 2001; 286: 64-70
        • Chew D.P.
        • Bhatt D.L.
        • Robbins M.A.
        • et al.
        Effect of clopidogrel added to aspirin before percutaneous coronary intervention on the risk associated with C-reactive protein.
        Am J Cardiol. 2001; 88: 672-674
        • Doo Y.C.
        • Kim D.M.
        • Oh D.J.
        • et al.
        Effect of beta blockers on expression of interleukin-6 and C-reactive protein in patients with unstable angina pectoris.
        Am J Cardiol. 2001; 88: 422-424
        • Malik J.
        • Melenovsky V.
        • Wichterle D.
        • et al.
        Both fenofibrate and atorvastatin improve vascular reactivity in combined hyperlipidaemia (Fenofibrate versus Atorvastatin Trial—FAT).
        Cardiovasc Res. 2001; 52: 290-298
        • Wu L.
        • Iwai M.
        • Nakagami H.
        • et al.
        Roles of angiotensin II type 2 receptor stimulation associated with selective angiotensin II type 1 receptor blockade with valsartan in the improvement of inflammation-induced vascular injury.
        Circulation. 2001; 104: 2716-2721
        • Riesen W.F.
        • Engler H.
        • Risch M.
        • et al.
        Short-term effects of atorvastatin on C-reactive protein.
        Eur Heart J. 2002; 23: 794-799