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Relationship of C-Reactive Protein to Risk of Cardiovascular Disease in the Elderly

Arteriosclerosis, Thrombosis, and Vascular Biology. 1997;17:1121-1127

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(Arteriosclerosis, Thrombosis, and Vascular Biology. 1997;17:1121-1127.)
© 1997 American Heart Association, Inc.


Articles

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

Russell P. Tracy; Rozenn N. Lemaitre; Bruce M. Psaty; Diane G. Ives; Rhobert W. Evans; Mary Cushman; Elaine N. Meilahn; ; Lewis H. Kuller

From the University of Vermont (R.P.T., M.C.), Colchester; Cardiovascular Health Research Unit (R.N.L., B.M.P.), University of Washington, Seattle; and the University of Pittsburgh (Pa) (D.G.I., R.W.E., E.N.M., L.H.K.).

Correspondence to Dr Russell Tracy, University of Vermont, Aquatec Bldg, 55A S Park Dr, Colchester, VT 05446. E-mail rtracy@moose.uvm.edu


* Abstract
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*Abstract
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Abstract Markers of inflammation, such as C-reactive protein (CRP), are related to risk of cardiovascular disease (CVD) events in those with angina, but little is known about individuals without prevalent clinical CVD. We performed a prospective, nested case-control study in the Cardiovascular Health Study (CHS; 5201 healthy elderly men and women). Case subjects (n=146 men and women with incident CVD events including angina, myocardial infarction, and death) and control subjects (n=146) were matched on the basis of sex and the presence or absence of significant subclinical CVD at baseline (average follow-up, 2.4 years). In women but not men, the mean CRP level was higher for case subjects than for control subjects (P<=.05). In general, CRP was higher in those with subclinical disease. Most of the association of CRP with female case subjects versus control subjects was in the subgroup with subclinical disease: 3.33 versus 1.90 mg/L, P<.05, adjusted for age and time of follow-up. Case-control differences were greatest when the time between baseline and the CVD event was shortest. The strongest associations were with myocardial infarction, and there was an overall odds ratio for incident myocardial infarction for men and women with subclinical disease (upper quartile versus lower three quartiles) of 2.67 (confidence interval [CI]=1.04 to 6.81), with the relationship being stronger in women (4.50 [CI=0.97 to 20.8]) than in men (1.75 [CI=0.51 to 5.98]). We performed a similar study in the Rural Health Promotion Project, in which mean values of CRP were higher for female case subjects than for female control subjects, but no differences were apparent for men. Comparing the upper quintile with the lower four, the odds ratio for CVD case subjects was 2.7 (CI=1.10 to 6.60). In conclusion, CRP was associated with incident events in the elderly, especially in those with subclinical disease at baseline.


Key Words: clotting • inflammation • coronary heart disease • C-reactive protein


* Introduction
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*Introduction
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The C-reactive protein is an acute-phase protein originally named by Tillet and Francis in 1930.1 Elevated levels of CRP have been related to increased risk of CHD, MI, and CHD deaths among individuals with angina pectoris.2 3 The level of CRP also predicted subsequent risk of CHD death among MRFIT participants, men aged 35 to 57 years who smoked at baseline and were followed up for an average of 10 to 17 years.4 The levels of CRP can increase several hundredfold within 24 to 48 hours after an acute inflammatory stimulus; however, the regulation of CRP in chronic low-level disease is less well understood.1 5 Inflammation of arteries may be an important component of changes in plaque morphology, rupture, and thrombosis.6 7 In this setting, inflammation may or may not include immune activation but would certainly include the elaboration of proinflammatory cytokines. CRP taken up by monocytes may also increase production of tissue factor and the propensity for subsequent thrombosis.8

The correlates of CRP have not been studied extensively. It is known that levels of CRP are increased among cigarette smokers.9 In a cross-sectional CHS analysis, the levels of CRP were positively correlated with smoking, body mass index, and triglyceride levels and inversely correlated with HDL cholesterol.10

The present study is a prospective, nested case-control design using stored plasma collected at baseline from CHS participants. We also report confirming results from a similar analysis in the RHPP. The goal of this study was to determine the relationship of CRP to CHD, angina pectoris, and CHD deaths among men and women with and without subclinical CVD at baseline.11 12 Subjects with clinical CVD were excluded. The hypothesis was that among individuals with subclinical CVD by CHS criteria,11 12 elevated CRP levels would be associated with an increased incidence of clinical CVD, especially MI.


* Methods
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*Methods
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Populations
The CHS cohort was recruited from four communities in the United States from a defined sample of Medicare beneficiaries aged 65 years or older in 1989 to 1990 (mean age, 72 years).13 14 15 16 There were 5201 participants in the original sample, including 2955 women (153 black) and 2246 men (91 black). A baseline evaluation included a home interview and a physical examination in the clinic.13 Clinical and subclinical vascular disease definitions were based on the resting electrocardiogram, echocardiogram, carotid artery duplex scanning, ankle-brachial blood pressure, history of CVD, Rose questionnaire, cardiovascular surgery, and use of selected medications consistent with the diagnosis of angina or congestive heart failure.11 The definition of subclinical CVD in the present study is the same as previously described12 : ankle-arm index <0.9;> thickness >80th percentile; common carotid wall thickness >80th percentile; carotid stenosis >25%; major electrocardiogram abnormalities; abnormal ejection fraction on echocardiogram; abnormal wall motion on echocardiogram; Rose questionnaire claudication positive; or Rose questionnaire angina positive.

The CHS protocol involved intensive data collection for incident CVD events and all deaths.15 16 The potential incident cardiovascular events were initially identified from telephone calls at 6-month periods and annual clinic visits, with further verification from Medicare part A hospital discharge lists.15 For MI and angina, ICD codes 410 through 414, 427.4, 427.5, and 428 were reviewed in detail. The hospital records, outpatient records, and physician reports were obtained for the selected diagnostic codes and then reviewed by an events subcommittee of the CHS.16 At baseline, 31.6% of the participants had neither subclinical nor clinical CVD, 37.2% had subclinical CVD alone, and 31.2% had clinical CVD.11

The participants included in this analysis had no clinical CVD at baseline and had an average of 2.4 years (maximum of 3 years) of follow-up.12 The incidence of clinical CVD, including MI, angina pectoris, and CHD deaths, and the relation of events to both subclinical disease and cardiovascular risk factors have been published previously.12 There were 69 (8.2%) total CHD events (fatal and nonfatal) among men, 42 (3.8%) among women with subclinical disease at baseline, 23 (4.3%) for men, and 16 (1.5%) for women without subclinical disease. Plasma samples, stored at -70°C, were available for the present study for 89 of these 92 men and 57 of these 58 women. The control subjects were individually matched with the case subjects on the basis of sex, presence or absence of subclinical disease, and duration of follow-up, at a matching ratio of 1:1.

The RHPP was a Medicare-funded preventive healthcare demonstration project17 in five rural counties in northwestern Pennsylvania targeting Medicare beneficiaries aged 65 to 79 years who participated in both part A and part B of Medicare.18 Participants, identified through Medicare entitlement records,18 were community dwelling, ambulatory, and without life-threatening diagnosis of cancer within the 5 years preceding the study. They completed a 1.5-hour health-risk appraisal including information about demographics, medical care, health habits, self-reported history of disease, and symptomatology and were randomized to a control group or one of two treatment groups: (1) those eligible to receive selected interventions to reduce blood cholesterol, weight, cigarette smoking, alcohol abuse, and evaluation of depression and dementia at community health centers or (2) those who could receive similar interventions in physicians' offices. There were 3884 participants in the study (1312 in the hospital-based group, 1347 in the physician-intervention group, and 1225 in the control group), with a mean age of 71 years. Overall, 56.8% were women, and all were white, characteristic of the rural community in which they were recruited. There were no substantial differences in outcome or changes in risk factors during the study across the three groups, and therefore their data have been pooled.

Follow-up of the participants was primarily through annual telephone interviews and review of both part A and part B Medicare utilization records. Deaths were ascertained through the Medicare entitlement records. Death certificates were obtained to determine the causes of death. Hospital discharge diagnoses were determined from Medicare part A data. No independent review of the hospital records was included in the study. Case subjects came from the 77% of the participants who were without a prior history of CHD at baseline. Two end points have been included in the study to define a case: (1) incident MI (ICD code 410) as the primary discharge diagnosis on the hospital discharge form and no hospitalization for CVD during the baseline year of the study (n=73; a report from the CHS has shown previously that ICD code 410 as the primary hospital discharge diagnosis is usually verified as MI16 ) and (2) death attributed to CHD (n=92). During the 3 years of follow-up, 21 (28.4%; 9 women, 12 men) of the MI case subjects died and have been included with the death end point, leaving 53 (28 women, 25 men) surviving MI case subjects. Control subjects were matched by sex and age, had no history of MI or angina pectoris at their baseline interview, and did not die and had no hospitalization for MI or angina pectoris during the 3-year follow-up.

Laboratory Methods
CRP was measured by use of an enzyme-linked immunosorbent assay developed at the CHS central blood laboratory.19 It is a colorimetric competitive immunoassay that uses purified protein and polyclonal anti-CRP antibodies. The interassay coefficient of variation is 5.5%. The samples from the case subjects and matched control subjects were assayed together by a technician who was blinded to the case-control status of the samples. Measurement of fibrinogen by a modified clot-rate assay and all other assay methods have been described previously.20

Statistical Methods
Mean CRP levels in case and control subjects, adjusted for age, were obtained from ANOVA procedures. Because the distribution of CRP levels was skewed to the right, the distribution was log-normalized, and the transformed values were used for analyses. For ease of interpretation, means and standard deviations of untransformed values are reported. The analyses were stratified or adjusted on the matching factors. Quartiles (CHS) or quintiles (RHPP) of CRP were defined on the basis of the distribution of CRP levels among the control subjects. In the CHS analysis, we estimated the OR for CVD events for subjects in the upper quartile of CRP levels compared with subjects in the combined lower quartiles using conditional logistic regression to account for the matching factors. In the RHPP analysis, CRP values were divided into quintiles, and distribution of case and control subjects by quintile was evaluated by calculating the OR and CIs using Cornfield's method, comparing the fifth quintile of CRP with the remaining four quintiles.21


* Results
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*Results
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The baseline characteristics of CHS case and control subjects are shown in Table 1Down. Case subjects (n=146) had a higher prevalence of hypertension, higher systolic blood pressure, and lower HDL cholesterol than control subjects (n=146). Triglyceride levels were also significantly higher for case subjects than for control subjects. There were 89 men and 57 women in each of the case and control groups.


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Table 1. Baseline Characteristics of Case and Control Subjects: CHS, 1989

Because we matched subjects on the basis of subclinical disease, the prevalences of selected markers of subclinical disease by CHS criteria were similar among the case and control subjects (all comparisons were nonsignificant at P>.05; Table 2Down).


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Table 2. Comparison of Measures of Subclinical Disease Among Case and Control Subjects: CHS

In women, the mean CRP levels were significantly higher for case subjects than for control subjects, with the major difference being confined to those with subclinical disease (Table 3Down). For men with or without subclinical disease, there were no differences in mean CRP levels. The CRP levels were higher for participants with subclinical disease at baseline than for those without, except in the female control group.


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Table 3. Age-Adjusted Mean Baseline Measures of CRP Among Participants in the CHS by Presence of Subclinical Disease: Case and Control Subjects

In women, case subjects with subclinical disease had higher CRP levels than control subjects at every time point from baseline blood sample (Fig 1Down). In general, the levels of CRP declined for case subjects with duration of follow-up (except for the last time point, at 24 months), with little change for control subjects, so that the difference in CRP between case and control subjects for women with subclinical disease was greater for more proximate case-control comparisons. These differences were not present for men or for the few female case subjects who did not have subclinical disease. In fact, it appeared that CRP levels in subclinical disease–free women with clinical events early in the study were actually lower than in the corresponding case subjects with clinical events later in the study.



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Figure 1. Mean age-adjusted baseline CRP values stratified on length of follow-up in women. Mean values for CRP were calculated for women in the CHS in groups either with subclinical disease (SD) or with no subclinical disease (NSD), stratified on the length of time from baseline to the clinical event. Mean values were calculated separately for case and control subjects.

The distribution of case and control subjects by quartiles was further evaluated by sex and for presence or absence of subclinical disease (Table 4Down). There were no significant associations in men. However, there was approximately a 2.3-fold (CI=0.9 to 6.1) increased risk of incident CHD among women with subclinical disease in the highest quartile versus the combined lower quartiles. There was no linear relationship with risk for quartiles 1 through 3, indicating that the increased risk was primarily in women in the upper quartile.


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Table 4. Distribution of Case and Control Subjects in Quartiles of CRP Stratified by Sex and Presence of Subclinical CVD

The higher OR for CHD among women with subclinical disease was primarily limited to those with MI (Table 5Down). The OR comparing the upper versus the lower quartiles was 4.50 (CI=0.97 to 20.8). For men, the OR for MI was 1.75 (CI=0.51 to 5.98). The overall OR for men and women combined with incident MI was 2.67 (CI=1.04 to 6.81; P=.04). A formal test for interaction with gender gave a value of P=.33. If the association of CRP with MI is truly weaker in men than in women, we did not have enough power to detect it.


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Table 5. Distribution of CRP Quartiles in Women by Presence of Subclinical Disease and Clinical Outcome

There were six control subjects and seven case subjects among the women who reported current cigarette smoking at baseline. After excluding these individuals, the unmatched OR for total incident CHD for women (highest quartile of CRP compared with the lower three quartiles) was 3.3, similar to the analysis of smokers and nonsmokers combined.

In previous reports, lower levels of albumin and higher levels of fibrinogen (both inflammation-sensitive proteins, like CRP) have also been associated with increased risk of CHD.22 23 The mean levels of albumin adjusted for age, sex, subclinical disease, and length of follow-up were 4.03 g/dL among 148 control subjects and 3.99 g/dL among 148 case subjects. The distribution of albumin for female case and control subjects with subclinical disease was not different: 15 of 41 female control subjects and 16 of 41 female case subjects had albumin levels in the lowest quartile.

Fibrinogen was correlated with CRP (r=.52) in the CHS (Tracy et al, manuscript submitted). However, mean fibrinogen levels (adjusted for age, sex, subclinical disease, and length of follow-up) were only slightly higher for case subjects (319.9 mg/dL) than control subjects (315.0 mg/dL). There was no difference in distribution of fibrinogen levels among the 41 female case subjects and their matched control subjects with subclinical disease: 8 control subjects and 10 case subjects had fibrinogen levels in the upper quartile of the distribution (345 to 570 mg/dL). There was, however, a tendency for higher fibrinogen values to be associated with risk of MI: 13 control subjects and 22 MI case subjects distributed in the upper quartile of fibrinogen, yielding an OR for upper quartile compared with lower three quartiles of 2.00 (CI=0.90 to 4.45; P=.09). This tendency was found for both men and women with subclinical disease, with a combined OR of 2.33 (CI=0.90 to 6.07; P=.08) for MI.

CHS participants with both CRP and fibrinogen in the upper quartile had a 2.20-fold (CI=0.76 to 6.33; P=.13) risk of MI compared with those in the lower three quartiles. Participants with prevalent subclinical disease at baseline and both fibrinogen and CRP in the upper quartile had a 3.33-fold (CI=0.92 to 12.11; P=.05) increased risk of MI. Participants who had either fibrinogen or CRP in the upper quartile had a 2.37-fold (CI=1.04 to 5.42; P=.03) risk of MI, and if they had prevalent subclinical disease at baseline, the risk was 3.0 (CI=1.09 to 8.25; P=.02). There was no consistent association between CRP, fibrinogen, and MI for participants without subclinical disease at baseline.

We confirmed these results by performing a similar analysis in the RHPP, although without matching on the basis of subclinical CVD. In our sample, there were 145 case subjects (80 men, 65 women) and 146 control subjects (one case subject's serum was lost) including 55 CHD deaths in men and 37 in women.

Comparing mean log-adjusted CRP values between case and control subjects, the only significant differences (P=.03) were in women: case subjects, 7.3 mg/L; control subjects, 2.9 mg/L. In women, the distribution of CRP was skewed toward higher levels, especially for case subjects (Fig 2Down). The OR for women, quintile 5 versus 1 through 4 of CRP, for total case subjects compared with control subjects was 2.7 (95% CI=1.10 to 6.69), and for CHD deaths, the OR was 3.74 (95% CI=1.36 to 10.4). For men, the ORs were 2.0 (CI=0.82 to 4.87) for total CHD and 1.4 (CI=0.50 to 3.95) for CHD deaths.



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Figure 2. Percent distribution of CRP in women in the RHPP. The percent of case subjects and percent of control subjects that fall within each CRP class are shown; the actual number of subjects in each class is shown above the appropriate bar.


* Discussion
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up arrowResults
*Discussion
down arrowReferences

Subclinical CVD, as defined in the CHS, was a strong, independent predictor of subsequent clinical CVD over a 2.4-year follow-up.11 12 The current study extended these findings by examining whether CRP was associated with incident CVD even when case and control subjects were matched for the presence or absence of subclinical disease. The strengths of the present study are the quality of sample collection and the use of a central laboratory,20 the clear definitions and adjudication of events,12 the rich CHS data set that includes variables allowing us to define subclinical disease, and the matching design, which takes subclinical disease into account. The major weakness of the present study is the relatively small number of case and control subjects, which necessitates caution in the interpretation of the results. However, we were able to confirm our results in a separate but similar study, the RHPP.

Among the elderly with subclinical disease, CRP was a risk factor for CVD, primarily MI. The association of CRP with MI was apparently stronger among women than men. However, we could not detect a statistically significant interaction with sex, leaving open the question of whether there is a difference in the elderly in the association of CRP with events. In support of an answer in the affirmative, we have observed the same apparently sex-specific association in the RHPP analysis.

Although we found a significant association of CRP with CVD events, there was no trend for increased risk in the lower three quartiles of CRP, with the increased risk limited to those in the highest quartile. In both the case and control subjects, however, only seven subjects had values >10 mg/L, the generally accepted cutoff for clinical significance for CRP. Of these, only two were women. For individuals without clinical CVD, a CRP value that represents clinical "inflammation" is less important with respect to CVD risk than is a CRP value that, although <10> an important role for chronic, low-level "inflammation."24

In our study, the association of CRP and risk of disease was time dependent. The CRP levels were higher and the differences between case and control subjects greater the closer the proximity of the case event to the time of blood collection, especially for subjects with subclinical disease. This finding suggests the hypothesis that elevated CRP is associated with the short-term process leading to the clinical event, including changes in the arterial wall and/or in clotting status. In support of this hypothesis, CRP has been shown to elaborate the protein responsible for initiating arterial thrombosis, tissue factor.8

This study is limited by the relatively small numbers of case and control subjects, and it included only baseline CRP measurements. However, CRP was significantly associated with risk even after subclinical disease status was taken into consideration, and higher CRP levels in close proximity to the clinical event among individuals with subclinical disease were the most predictive of events. These results suggest that recent elevations of CRP might be the strongest predictor of short-term clinical events and that the changes in the levels of CRP over time before an MI may be an even stronger predictor of the risk of incident CVD.

In the follow-up of the MRFIT, high CRP levels were a strong predictor of subsequent CHD deaths among middle-aged (35 to 57 years old) cigarette-smoking men after a relatively long follow-up of no less than 12 years and up to 17 years.4 Unfortunately, there was no opportunity to examine the relationship of CRP to more proximal events in the MRFIT. The fact that baseline CRP levels were related to chronologically distant events in MRFIT and chronologically close events in CHS suggests potentially important differences in the relationship of inflammation to CHD at different times in the natural history of this disease.

In the CHS, the association of CRP and clinical disease was not changed by excluding current cigarette smokers. The same findings were noted in the RHPP (data not shown). However, there were too few events in either study among individuals who were never cigarette smokers to determine whether CRP was an independent risk factor in older, lifelong never-smokers.

The fact that the strongest relationship between CRP and risk of CVD in the present study was in those with subclinical disease is consistent with previous studies2 23 in which a strong relationship was observed in individuals with existing clinical CVD. The role of inflammation in CVD is currently being investigated in a variety of studies. It is possible that injury or inflammation of arteries and pulmonary disease may increase the risk of infection with Chlamydia TWAR or other similar agents, which may themselves increase the risk of CVD.25 26 27 28 29 30 31 The prevalence of Chlamydia TWAR infection is higher among smokers and has been linked to both increased prevalence of atherosclerosis and clinical CVD.

We have suggested the possibility that CRP and other inflammation-sensitive proteins are primarily related to changes in plaque morphology and possibly to rupture and acute thrombosis.32 33 If true, this would be consistent with the relationship of CRP to clinical disease being primarily limited to individuals who already have moderate to extensive subclinical atherosclerosis or clinical CVD. In the present study, we observed a similar association with incident disease for fibrinogen and albumin as we observed for CRP, although the association for fibrinogen did not reach statistical significance. This result, in addition to the strong association of acute-phase proteins, such as fibrinogen, with subclinical disease,34 is consistent with a model in which the pathophysiological progression is from atherosclerosis to subclinical disease to ruptured plaque to thrombosis and MI.7 35 36 37 It would also suggest that with the use of epidemiological data, it may be difficult to determine any causal relationship of an acute inflammatory marker with risk of CHD because such a marker would be a measure of underlying vascular disease.

If the results of our study are confirmed in other analyses, the measurement of CRP as a risk factor for MI in individuals with subclinical disease has important implications. For example, in the CHS we found that the risk of CHD was 2.5-fold higher in women with subclinical disease than in women without subclinical disease.12 The addition of CRP in the highest quartile to the women with subclinical disease may raise this risk for CHD by another 2.5-fold (see Fig 1Up, Table 4Up) and for MI {approx}4.5-fold (Table 5Up). The incidence of total CHD was {approx}3.8% for those with subclinical disease and 1.5% for those with no subclinical diseases.12 A further increase by 2.5-fold would increase the overall incidence for women with subclinical disease to {approx}9.5%. This is similar to that for men, 8.2%,13 or {approx}4% per year of follow-up. Approximately 50% of women without clinical disease have subclinical disease at baseline, and 25% would be in the upper quartile of CRP. The use of CRP may aid in the identification of the 12.5% of elderly women who are at high risk of future events.


* Selected Abbreviations and Acronyms

CHD = coronary heart disease
CHS = Cardiovascular Health Study
CI = confidence interval
CRP = C-reactive protein
CVD = cardiovascular disease
ICD = International Classification of Diseases
MI = myocardial infarction
MRFIT = Multiple Risk Factor Intervention Trial
OR = odds ratio
RHPP = Rural Health Promotion Project


* Acknowledgments

This work was supported by a grant from the National Heart, Lung, and Blood Institute, RO1 HL-46696 (Dr Tracy), and by NHLBI contracts NO1-HC-85079 through NO1-HC-85086. Dr Cushman was supported by USPHS training grant T3207594. We also thank the investigators and staff of the Cardiovascular Health Study: Bowman Gray School of Medicine of Wake Forest University, Forsyth County, NC—Gregory L. Burke, Alan Elster, Walter H. Ettinger, Curt D. Furberg, Edward Haponik, Gerardo Heiss, Dalane Kitzman, H. Sidney Klopfenstein, Margie Lamb, David S. Lefkowitz, Mary F. Lyles, Maurice B. Mittelmark, Cathy Nunn, Ward Riley, Grethe S. Tell, James F. Toole, and Beverly Tucker; Bowman Gray School of Medicine, Forsyth County, NC (electrocardiogram reading center)—Kris Calhoun, Harry Calhoun, Farida Rautaharju, Pentti Rautaharju, and Loralee Robertson; University of California, Davis—William Bommer, Charles Bernick, Andrew Duxbury, Mary Haan, Calvin Hirsch, Paul Kellerman, Lawrence Laslett, Marshall Lee, Virginia Poirier, John Robbins, Marc Schenker, and Nemat Borhani; The Johns Hopkins University, Baltimore, Md—M. Jan Busby-Whitehead, Joyce Chabot, George W. Comstock, Linda P. Fried, Joel G. Hill, Steven J. Kittner, Shiriki Kumanyika, David Levine, Joao A. Lima, Neil R. Powe, Thomas R. Price, Jeff Williamson, Moyses Szklo, and Melvyn Tockman; The Johns Hopkins University, Baltimore, Md (MRI reading center)—R. Nick Bryan, Carolyn C. Meltzer, Douglas Fellows, Melanie Hawkins, Patrice Holtz, Michael Kraut, Grace Lee, Larry Schertz, Earl P. Steinberg, Scott Wells, Linda Wilkins, and Nancy C. Yue; University of Pittsburgh, Pa—Diane G. Ives, Charles A. Jungreis, Laurie Knepper, Lewis H. Kuller, Elaine Meilahn, Peg Meyer, Roberta Moyer, Anne Newman, Richard Schulz, Vivienne E. Smith, and Sidney K. Wolfson; University of California, Irvine, (baseline echocardiography reading center)—Hoda Anton-Culver, Julius M. Gardin, Margaret Knoll, Tom Kurosaki, and Nathan Wong; Georgetown Medical Center, Washington, DC (follow-up echocardiography reading center)—John Gottdiener, Eva Hausner, Stephen Kraus, Judy Gay, Sue Livengood, Mary Ann Yohe, and Retha Webb; Geisinger Medical Center, Danville, Pa (ultrasound reading center)—Daniel H. O'Leary, Joseph F. Polak, and Laurie Funk; Respiratory Sciences, University of Arizona at Tucson—Paul Enright; University of Washington, Seattle (coordinating center)—Alice Arnold, Annette L. Fitzpatrick, Bonnie K. Lind, Richard A. Kronmal, Bruce M. Psaty, David S. Siscovick, Lynn Shemanski, Lloyd Fisher, Will Longstreth, Patricia W. Wahl, David Yanez, Paula Diehr, and Maryann McBurnie; and NHLBI Project Office, Bethesda, Md—Diane E. Bild, Teri A. Manolio, Peter J. Savage, Patricia Smith, and Rachel Solomon.

Received May 28, 1996; accepted October 9, 1996.


* References
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up arrowAbstract
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up arrowResults
up arrowDiscussion
*References

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Angiotensin-Converting Enzyme Inhibitor Use Is Associated With Reduced Plasma Concentration of C-Reactive Protein in Patients With First-Ever Ischemic Stroke
Stroke, December 1, 2003; 34(12): 2922 - 2929.
[Abstract] [Full Text] [PDF]


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HypertensionHome page
M. Di Napoli and F. Papa
Association Between Blood Pressure and C-Reactive Protein Levels in Acute Ischemic Stroke
Hypertension, December 1, 2003; 42(6): 1117 - 1123.
[Abstract] [Full Text] [PDF]


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CirculationHome page
P. M Ridker and on behalf of the JUPITER Study Group
Rosuvastatin in the Primary Prevention of Cardiovascular Disease Among Patients With Low Levels of Low-Density Lipoprotein Cholesterol and Elevated High-Sensitivity C-Reactive Protein: Rationale and Design of the JUPITER Trial*
Circulation, November 11, 2003; 108(19): 2292 - 2297.
[Full Text] [PDF]


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CirculationHome page
M. Schillinger, M. Exner, J. Amighi, W. Mlekusch, S. Sabeti, H. Rumpold, O. Wagner, and E. Minar
Joint Effects of C-Reactive Protein and Glycated Hemoglobin in Predicting Future Cardiovascular Events of Patients With Advanced Atherosclerosis
Circulation, November 11, 2003; 108(19): 2323 - 2328.
[Abstract] [Full Text] [PDF]


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Arterioscler. Thromb. Vasc. Bio.Home page
D.J. Brull, N. Serrano, F. Zito, L. Jones, H.E. Montgomery, A. Rumley, P. Sharma, G.D.O. Lowe, M.J. World, S.E. Humphries, et al.
Human CRP Gene Polymorphism Influences CRP Levels: Implications for the Prediction and Pathogenesis of Coronary Heart Disease
Arterioscler. Thromb. Vasc. Biol., November 1, 2003; 23(11): 2063 - 2069.
[Abstract] [Full Text] [PDF]


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Arch Intern MedHome page
A. B. Newman, A. M. Arnold, B. L. Naydeck, L. P. Fried, G. L. Burke, P. Enright, J. Gottdiener, C. Hirsch, D. O'Leary, and R. Tracy
"Successful Aging": Effect of Subclinical Cardiovascular Disease
Arch Intern Med, October 27, 2003; 163(19): 2315 - 2322.
[Abstract] [Full Text] [PDF]


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J. Epidemiol. Community HealthHome page
P Jousilahti, V Salomaa, V Rasi, E Vahtera, and T Palosuo
Association of markers of systemic inflammation, C reactive protein, serum amyloid A, and fibrinogen, with socioeconomic status
J. Epidemiol. Community Health, September 1, 2003; 57(9): 730 - 733.
[Abstract] [Full Text] [PDF]


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Arterioscler. Thromb. Vasc. Bio.Home page
P. Holvoet, T. B. Harris, R. P. Tracy, P. Verhamme, A. B. Newman, S. M. Rubin, E. M. Simonsick, L. H. Colbert, and S. B. Kritchevsky
Association of High Coronary Heart Disease Risk Status With Circulating Oxidized LDL in the Well-Functioning Elderly: Findings From the Health, Aging, and Body Composition Study
Arterioscler. Thromb. Vasc. Biol., August 1, 2003; 23(8): 1444 - 1448.
[Abstract] [Full Text] [PDF]


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CirculationHome page
J. J. Cao, C. Thach, T. A. Manolio, B. M. Psaty, L. H. Kuller, P. H.M. Chaves, J. F. Polak, K. Sutton-Tyrrell, D. M. Herrington, T. R. Price, et al.
C-Reactive Protein, Carotid Intima-Media Thickness, and Incidence of Ischemic Stroke in the Elderly: The Cardiovascular Health Study
Circulation, July 15, 2003; 108(2): 166 - 170.
[Abstract] [Full Text] [PDF]


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Arterioscler. Thromb. Vasc. Bio.Home page
G. Luc, J.-M. Bard, I. Juhan-Vague, J. Ferrieres, A. Evans, P. Amouyel, D. Arveiler, J.-C. Fruchart, and P. Ducimetiere
C-Reactive Protein, Interleukin-6, and Fibrinogen as Predictors of Coronary Heart Disease: The PRIME Study
Arterioscler. Thromb. Vasc. Biol., July 1, 2003; 23(7): 1255 - 1261.
[Abstract] [Full Text] [PDF]


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Arch Intern MedHome page
I. M. van der Meer, M. P. M. de Maat, A. J. Kiliaan, D. A. M. van der Kuip, A. Hofman, and J. C. M. Witteman
The Value of C-Reactive Protein in Cardiovascular Risk Prediction: The Rotterdam Study
Arch Intern Med, June 9, 2003; 163(11): 1323 - 1328.
[Abstract] [Full Text] [PDF]


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Arch Intern MedHome page
G. D. Slade, E. M. Ghezzi, G. Heiss, J. D. Beck, E. Riche, and S. Offenbacher
Relationship Between Periodontal Disease and C-Reactive Protein Among Adults in the Atherosclerosis Risk in Communities Study
Arch Intern Med, May 26, 2003; 163(10): 1172 - 1179.
[Abstract] [Full Text] [PDF]


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J Am Coll CardiolHome page
J. Cosin-Sales, C. Pizzi, S. Brown, and J. C. Kaski
C-reactive protein, clinical presentation, and ischemic activity in patients with chest pain and normal coronary angiograms
J. Am. Coll. Cardiol., May 7, 2003; 41(9): 1468 - 1474.
[Abstract] [Full Text] [PDF]


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Psychosom. Med.Home page
M. Danner, S. V. Kasl, J. L. Abramson, and V. Vaccarino
Association Between Depression and Elevated C-Reactive Protein
Psychosom Med, May 1, 2003; 65(3): 347 - 356.
[Abstract] [Full Text] [PDF]


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CirculationHome page
J. D. Curb, R. D. Abbott, B. L. Rodriguez, P. Sakkinen, J. S. Popper, K. Yano, and R. P. Tracy
C-Reactive Protein and the Future Risk of Thromboembolic Stroke in Healthy Men
Circulation, April 22, 2003; 107(15): 2016 - 2020.
[Abstract] [Full Text] [PDF]


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J Am Coll CardiolHome page
L. F. Fried, M. G. Shlipak, C. Crump, A. J. Bleyer, J. S. Gottdiener, R. A. Kronmal, L. H. Kuller, and A. B. Newman
Renal insufficiency as a predictor of cardiovascular outcomes and mortality in elderly individuals
J. Am. Coll. Cardiol., April 16, 2003; 41(8): 1364 - 1372.
[Abstract] [Full Text] [PDF]


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Clin. Chem.Home page
E. S. Ford, W. H. Giles, G. L. Myers, and D. M. Mannino
Population Distribution of High-Sensitivity C-reactive Protein among US Men: Findings from National Health and Nutrition Examination Survey 1999-2000
Clin. Chem., April 1, 2003; 49(4): 686 - 690.
[Full Text] [PDF]


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Arterioscler. Thromb. Vasc. Bio.Home page
A. D. Pradhan, N. R. Cook, J. E. Buring, J. E. Manson, and P. M. Ridker
C-Reactive Protein Is Independently Associated With Fasting Insulin in Nondiabetic Women
Arterioscler. Thromb. Vasc. Biol., April 1, 2003; 23(4): 650 - 655.
[Abstract] [Full Text] [PDF]


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Arterioscler. Thromb. Vasc. Bio.Home page
T. H. Schindler, B. Hornig, P. T. Buser, M. Olschewski, N. Magosaki, M. Pfisterer, E. U. Nitzsche, U. Solzbach, and H. Just
Prognostic Value of Abnormal Vasoreactivity of Epicardial Coronary Arteries to Sympathetic Stimulation in Patients With Normal Coronary Angiograms
Arterioscler. Thromb. Vasc. Biol., March 1, 2003; 23(3): 495 - 501.
[Abstract] [Full Text] [PDF]


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J Am Coll CardiolHome page
G. J. Blake and P. M. Ridker
C-reactive protein and other inflammatory risk markers in acute coronary syndromes
J. Am. Coll. Cardiol., February 19, 2003; 41(4_Suppl_S): 37S - 42S.
[Abstract] [Full Text] [PDF]


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ChestHome page
P. L. Enright, M. A. McBurnie, V. Bittner, R. P. Tracy, R. McNamara, A. Arnold, and A. B. Newman
The 6-min Walk Test: A Quick Measure of Functional Status in Elderly Adults
Chest, February 1, 2003; 123(2): 387 - 398.
[Abstract] [Full Text] [PDF]


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Arch SurgHome page
M. A. Zimmerman, C. H. Selzman, C. Cothren, A. C. Sorensen, C. D. Raeburn, and A. H. Harken
Diagnostic Implications of C-Reactive Protein
Arch Surg, February 1, 2003; 138(2): 220 - 224.
[Abstract] [Full Text] [PDF]


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CirculationHome page
P. M Ridker
Clinical Application of C-Reactive Protein for Cardiovascular Disease Detection and Prevention
Circulation, January 28, 2003; 107(3): 363 - 369.
[Full Text] [PDF]


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CirculationHome page
T. A. Pearson, G. A. Mensah, R. W. Alexander, J. L. Anderson, R. O. Cannon III, M. Criqui, Y. Y. Fadl, S. P. Fortmann, Y. Hong, G. L. Myers, et al.
Markers of Inflammation and Cardiovascular Disease: Application to Clinical and Public Health Practice: A Statement for Healthcare Professionals From the Centers for Disease Control and Prevention and the American Heart Association
Circulation, January 28, 2003; 107(3): 499 - 511.
[Full Text] [PDF]


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CirculationHome page
P. M Ridker, J. E. Buring, N. R. Cook, and N. Rifai
C-Reactive Protein, the Metabolic Syndrome, and Risk of Incident Cardiovascular Events: An 8-Year Follow-Up of 14 719 Initially Healthy American Women
Circulation, January 28, 2003; 107(3): 391 - 397.
[Abstract] [Full Text] [PDF]


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CirculationHome page
M. S. Beattie, M. G. Shlipak, H. Liu, W. S. Browner, N. B. Schiller, and M. A. Whooley
C-Reactive Protein and Ischemia in Users and Nonusers of {beta}-Blockers and Statins: Data From the Heart and Soul Study
Circulation, January 21, 2003; 107(2): 245 - 250.
[Abstract] [Full Text] [PDF]


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Arch Intern MedHome page
B. Thorand, H. Lowel, A. Schneider, H. Kolb, C. Meisinger, M. Frohlich, and W. Koenig
C-Reactive Protein as a Predictor for Incident Diabetes Mellitus Among Middle-aged Men: Results From the MONICA Augsburg Cohort Study, 1984-1998
Arch Intern Med, January 13, 2003; 163(1): 93 - 99.
[Abstract] [Full Text] [PDF]


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CirculationHome page
M. G. Shlipak, L. F. Fried, C. Crump, A. J. Bleyer, T. A. Manolio, R. P. Tracy, C. D. Furberg, and B. M. Psaty
Elevations of Inflammatory and Procoagulant Biomarkers in Elderly Persons With Renal Insufficiency
Circulation, January 7, 2003; 107(1): 87 - 92.
[Abstract] [Full Text] [PDF]


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Arterioscler. Thromb. Vasc. Bio.Home page
R. A. Hegele, M. E. Kraw, M. R. Ban, B. A. Miskie, M. W. Huff, and H. Cao
Elevated Serum C-Reactive Protein and Free Fatty Acids Among Nondiabetic Carriers of Missense Mutations in the Gene Encoding Lamin A/C (LMNA) With Partial Lipodystrophy
Arterioscler. Thromb. Vasc. Biol., January 1, 2003; 23(1): 111 - 116.
[Abstract] [Full Text] [PDF]


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CirculationHome page
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Int J EpidemiolHome page
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In the Elderly, Interleukin-6 Plasma Levels and the -174G>C Polymorphism Are Associated With the Development of Cardiovascular Disease
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NEJMHome page
P. M. Ridker, N. Rifai, L. Rose, J. E. Buring, and N. R. Cook
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StrokeHome page
K. Winbeck, H. Poppert, T. Etgen, B. Conrad, and D. Sander
Prognostic Relevance of Early Serial C-Reactive Protein Measurements After First Ischemic Stroke
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JAMAHome page
A. D. Pradhan, J. E. Manson, J. E. Rossouw, D. S. Siscovick, C. P. Mouton, N. Rifai, R. B. Wallace, R. D. Jackson, M. B. Pettinger, and P. M Ridker
Inflammatory Biomarkers, Hormone Replacement Therapy, and Incident Coronary Heart Disease: Prospective Analysis From the Women's Health Initiative Observational Study
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Arterioscler. Thromb. Vasc. Bio.Home page
A. R. Brasier, A. Recinos III, and M. S. Eledrisi
Vascular Inflammation and the Renin-Angiotensin System
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G.J. Blake and P.M. Ridker
C-reactive protein and prognosis after percutaneous coronary intervention
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