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C-Reactive Protein and Other Markers of Inflammation in the Prediction of Cardiovascular Disease in Women
JUNE 2001, VOL 73,NO 6 R E V IEW
RESEARCH REVIEW C-REACTIVE PROTEIN AND OTHER MARK€RS OF INFLAMMATION IN TH€ PREDICTION OF CARDIOVASCULAR DISEASE IN WOMEN P M Ridker et a1 The New England Journal of Medicine Vol342 (March 2000) 836-843
A
therosclerosis is an inflammatory process believed to play a role in cardiovascular events. One-half of myocardial infarctions occur in people whose plasma lipid levels are normal. To better predict cardiovascular events, several risk markers of inflammation were studied to evaluate their role in predicting risk. Twelve risk markers were studied. Some include I high-sensitivity C-reactive protein (hs-CRP), I serum amyloid A, mi cytokines (eg, interleukind), and M adhesion molecules (ie, soluble intercellular adhesion molecule type 1 [SICAM-11). Data of this type have not been studied widely; in fact, data are limited almost exclusively to studies of hs-CRP in middle-aged men. Additionally, standardized, commercial assays for most markers of inflammation only now are being developed. Researchers have found higher levels of hs-CRP in healthy postmenopausal women participating in the Women’s Health Study who later had cardiovascular events. In this study, researchers sought to compare 12 measurements of risk markers to determine whether these lipid levels might be clinically useful in predicting the risk of cardiovascular events. Methodology. Women enrolled in the Women’s Health Study who
S
had no history of cardiovascular disease or cancer were studied using a prospective, nested casecontrol study. Blood samples from 28,263 postmenopausal women were collected and stored in liquid nitrogen until the time of analysis. Study participants were those women who had a cardiovascular event during a mean follow-up period of three years. For each woman who had a confirmed cardiovascular event, two control subjects of the same age and smoking status were selected. Using these criteria, 122 case subjects and 244 control subjects were selected. Baseline plasma samples from case and control subjects were thawed and assayed for lipid levels. Samples were handled in blinded fashion and random order to reduce bias and interassay variation. Results. Statistical analysis was performed using a variety of tests, including the Student t test, chi-square test, logistic regression, and analysis of trends. Women who had suffered cardiovascular events were more likely to have hypertension, diabetes, and parental history of premature myocardial infarction. These women also were heavier. Levels of several markers of inflammation were highly correlated. For example, the correlation coefficient for the relationship between hs-CRP and serum amyloid A was 0.81 (P< .001). To address the clinical observation that many people with safe lipid levels nonetheless have cardiovascular events, a subgroup analysis was performed of women whose levels of low-density lipoprotein cholesterol were less than 130 mg per dL, the level currently recommended for primary prevention of coronary heart disease by the National Cholesterol Education Program.
1176 AORN JOURNAL
Dlscussion. Four markers of inflammation were found to be significant predictors of the risk of future cardiovascular events in women, with hs-CRP being the most significant predictor of risk. These results have public health implications in terms of the use of inhibitors, such as 3-hydroxy-3methylglutaryl coenzyme A (HMG-CoA) reductase. In light of this data, one must question the possibility that the addition of hs-CRP to the standard lipid screening could identify women at high risk for future cardiovascular events and who might be candidates for primary prevention interventions, such as the use of HMG-CoA reductase inhibitors. MARY LYNNE WEEMERING RN, MSN, CNOR NUR~INQ RESEARCH COMMITTEE
ROOK REVIEW
ON€ LAST HUG BEFOR€ I GO By Carla Wills-Brandon 2000,292 p p $1 2.95 paperback
T
his book is written to provoke the reader into believing that deathbed visions experienced by the dying and their significant others are normal. The author states that the dying reach out to loved ones (alive or deceased) at the time of death and the reader should not fear sharing experiences of deathbed visions with others. Deathbed visions need to be understood so the public will overcome the belief that the person experiencing deathbed visions is mentally unstable. Overall, this is a good book to help educate nurses on what they may encounter when caring for dying patients. Perioperative nurses often have patients who die
RESEARCH REVIEW C-REACTIVE PROTEIN AND OTHER MARK€RS OF INFLAMMATION IN TH€ PREDICTION OF CARDIOVASCULAR DISEASE IN WOMEN P M Ridker et a1 The New England Journal of Medicine Vol342 (March 2000) 836-843
A
therosclerosis is an inflammatory process believed to play a role in cardiovascular events. One-half of myocardial infarctions occur in people whose plasma lipid levels are normal. To better predict cardiovascular events, several risk markers of inflammation were studied to evaluate their role in predicting risk. Twelve risk markers were studied. Some include I high-sensitivity C-reactive protein (hs-CRP), I serum amyloid A, mi cytokines (eg, interleukind), and M adhesion molecules (ie, soluble intercellular adhesion molecule type 1 [SICAM-11). Data of this type have not been studied widely; in fact, data are limited almost exclusively to studies of hs-CRP in middle-aged men. Additionally, standardized, commercial assays for most markers of inflammation only now are being developed. Researchers have found higher levels of hs-CRP in healthy postmenopausal women participating in the Women’s Health Study who later had cardiovascular events. In this study, researchers sought to compare 12 measurements of risk markers to determine whether these lipid levels might be clinically useful in predicting the risk of cardiovascular events. Methodology. Women enrolled in the Women’s Health Study who
S
had no history of cardiovascular disease or cancer were studied using a prospective, nested casecontrol study. Blood samples from 28,263 postmenopausal women were collected and stored in liquid nitrogen until the time of analysis. Study participants were those women who had a cardiovascular event during a mean follow-up period of three years. For each woman who had a confirmed cardiovascular event, two control subjects of the same age and smoking status were selected. Using these criteria, 122 case subjects and 244 control subjects were selected. Baseline plasma samples from case and control subjects were thawed and assayed for lipid levels. Samples were handled in blinded fashion and random order to reduce bias and interassay variation. Results. Statistical analysis was performed using a variety of tests, including the Student t test, chi-square test, logistic regression, and analysis of trends. Women who had suffered cardiovascular events were more likely to have hypertension, diabetes, and parental history of premature myocardial infarction. These women also were heavier. Levels of several markers of inflammation were highly correlated. For example, the correlation coefficient for the relationship between hs-CRP and serum amyloid A was 0.81 (P< .001). To address the clinical observation that many people with safe lipid levels nonetheless have cardiovascular events, a subgroup analysis was performed of women whose levels of low-density lipoprotein cholesterol were less than 130 mg per dL, the level currently recommended for primary prevention of coronary heart disease by the National Cholesterol Education Program.
1176 AORN JOURNAL
Dlscussion. Four markers of inflammation were found to be significant predictors of the risk of future cardiovascular events in women, with hs-CRP being the most significant predictor of risk. These results have public health implications in terms of the use of inhibitors, such as 3-hydroxy-3methylglutaryl coenzyme A (HMG-CoA) reductase. In light of this data, one must question the possibility that the addition of hs-CRP to the standard lipid screening could identify women at high risk for future cardiovascular events and who might be candidates for primary prevention interventions, such as the use of HMG-CoA reductase inhibitors. MARY LYNNE WEEMERING RN, MSN, CNOR NUR~INQ RESEARCH COMMITTEE
ROOK REVIEW
ON€ LAST HUG BEFOR€ I GO By Carla Wills-Brandon 2000,292 p p $1 2.95 paperback
T
his book is written to provoke the reader into believing that deathbed visions experienced by the dying and their significant others are normal. The author states that the dying reach out to loved ones (alive or deceased) at the time of death and the reader should not fear sharing experiences of deathbed visions with others. Deathbed visions need to be understood so the public will overcome the belief that the person experiencing deathbed visions is mentally unstable. Overall, this is a good book to help educate nurses on what they may encounter when caring for dying patients. Perioperative nurses often have patients who die