Inflammation triggers heart attacks Study finds condition is top trigger, worse than cholesterol 

NBC NEWS AND NEWS SERVICES 

Nov. 14 � Simmering, painless inflammation deep within the body is the single most powerful trigger of heart attacks, worse even than high cholesterol, a landmark study concludes. 

November 14 � A test that�s just as simple as the one that measures cholesterol appears to be a better predictor of heart disease. NBC�s Robert Bazell reports. 

BARBARA MURPHY, a retired nurse, worries about heart disease. �My grandmother died in her 60s. My mother also had a heart attack and had high blood pressure most of her life,� she said. Murphy had her cholesterol tested � and it�s normal. But a new study shows that a cholesterol test may not be enough. The study, published in Thursday�s New England Journal of Medicine, followed almost 28,000 women for eight years. Fully 77 percent of those who had heart attacks or strokes had cholesterol in the normal range and 45 percent were in the ideal range. �That means we�re missing very large numbers of individuals at risk and I think a great opportunity to do a better job identifying the high risk patients,� said study author Dr. Paul Ridker of Brigham and Women�s Hospital in Boston. 

What is the opportunity? A separate blood test that measures something called C-reactive protein, or CRP, a measure of inflammation deep within the body. The study found that the CRP test actually did a better job of predicting heart disease risk than cholesterol. Those with high levels of inflammation are twice as likely as those with high cholesterol to die from heart attacks and strokes. The lowest risk was in women whose CRP readings were below one-half milligram per liter of blood. It more than doubled when readings went over about three. Advertisement 

The two tests together did the best job of all. �In other words, individuals who have both these abnormalities are at very high risk. Individuals without either of them have relatively low risk,� Ridker said. 

�INFLAMMATION HYPOTHESIS� Over the past five years, Ridker has built the case for the �inflammation hypothesis.� With his latest study, many believe the evidence is overwhelming that inflammation is a central factor in cardiovascular disease. �I don�t think it�s a hypothesis anymore. It�s proven,� said Dr. Eric Topol, chief of cardiology at the Cleveland Clinic. Doctors believe inflammation has many possible sources. Often, the fatty buildups that line the blood vessels become inflamed as white blood cells invade in a misguided defense attempt. Fat cells are also known to turn out these inflammatory proteins. Other possible triggers include high blood pressure, smoking and lingering low-level infections, such as chronic gum disease. Inflammation is thought to weaken the fatty buildups, or plaques, making them more likely to burst. A piece of plaque can then lead to a clot that can choke off the blood flow and cause a heart attack. 

TESTING GUIDELINES DEBATED 

For the first time, Ridker�s study establishes what level of CRP should be considered worrisome, so doctors can make sense of patients� readings. However, experts are still divided over which patients to test and how to treat them if their CRP readings are high. Some, such as Dr. Richard Milani of the Ochsner Clinic in New Orleans, recommend a CRP check for virtually anyone getting a cholesterol test. �If I have enough concern to check a patient�s cholesterol, it seems naive not to include an inexpensive test that would give me even more information,� he said. Others are reluctant to test people at low outward risk. Dr. Sidney Smith, research director of the American Heart Association, said CRP testing is likely to be most helpful in guiding the care of the 40 percent of U.S. adults already considered at intermediate risk of heart attacks because of other conditions, such as age, obesity and high blood pressure. In March, the heart association and the Centers for Disease Control and Prevention held a meeting of 50 experts to review the evidence and make recommendations on CRP testing. Although it hoped to be finished this month, the committee went back to the drawing board after learning last week of Ridker�s latest results. A skeptical editorial in the journal by Dr. Lori Mosca of Columbia University questioned the need for widespread testing, at least until more studies are done to show that lowering CRP actually saves lives. 

REDUCING RISKS The good news is that there is treatment when the CRP test indicates inflammation. Cholesterol-lowering drugs called statins can reduce the inflammation and so does a daily dose of aspirin. Barbara Murphy�s CRP test was high, indicating a heart disease risk even with her normal cholesterol. She is now on statins and a strict diet. �It probably has saved my life,� she said. The CRP test is already on the market, costs about $10 and many doctors believe it could

save thousands of lives a year by identifying those at highest risk for America�s No. 1 killer. 

How to lower inflammation levels 

You've heard it before: Eat sensibly and get some exercise. But new findings on the dangers of inflammation offer still another reason to shape up. Doctors say that both inactivity and obesity increase inflammatory proteins that can trigger heart attacks. People can substantially lower their levels of these proteins simply by improving their living habits. Even modest changes help, though studies show that vigorous exercise and a strict diet can cut inflammation levels in half in just three months. Some research suggests that moderate alcohol consumption and fish oil are good for inflammation levels. So too are giving up smoking and keeping blood pressure under control. A variety of drugs may also do the trick, though many think more research is needed before doctors actually begin prescribing them to lower inflammation. The list of medications includes statins, aspirin and Plavix, a common blood thinner. 

Source: Associated Press 

NBC�s Robert Bazell and The Associated Press contributed to this report.