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Screening for heart disease: C-reactive protein versus coronary artery calcium

The Framingham model has become the standard to assess future risk of coronary artery disease. Several nontraditional risk factors have been suggested to improve risk stratification to provide a new algorithm for predicting coronary heart disease (CHD). Two factors with the most available data include C-reactive protein (CRP) and coronary artery calcification (CAC). CRP, a well-established biomarker of inflammation, has shown very inconsistent data to predict CHD, and no study to date shows improvement in the C-statistic; in addition, reclassification is modest (<10% of patients are reclassified to higher or lower risk categories). CAC seems to hold a greater promise in the prediction of CHD and demonstrates a stronger relationship to future cardiac events, with all studies demonstrating improvement in the C-statistic when added to the Framingham risk score. Measurement of CAC consistently provides reclassification of patients more accurately to the Framingham risk model. Only four studies have evaluated both CAC and CRP in the same cohort for future cardiovascular events, but all of these showed significant prediction for coronary artery disease using CAC and no significant prediction ability for CRP. Current review of the literature available suggests CAC to be more relevant in evaluating CHD in a clinical setting. Given the higher cost of CAC scanning compared with CRP, cost–effectiveness studies are still needed.