In this study from Germany (1), the authors used data from the observational cohort study INTERCATH of 1014 patients (73% male, mean age 69 years) to analyse the association of modifiable risk factors (modRF) and high-sensitivity C-reactive protein (hsCRP) levels in stable coronary artery disease (CAD) patients. In addition, they aimed to define a potential target population for anti-inflammatory treatment when lifestyle risk factors are well controlled. Overweight (BMI >25 kg/m2), smoking, lack of physical activity (PA <1,5 h/week) and poor diet (<12 points of a Mediterranean diet score (MDS), range 0-28 points) were considered modRF. Based on the associations between modRF and hsCRP, the investigators calculated potential hsCRP levels for each patient, assuming optimal individual modRF.
Almost half of the patients (48%) had hsCRP > 2mg/l, and all modRF were significantly more common in these patients compared to those with hsCRP < 2mg/l, both in uni- and multivariable analyses. In patients with hsCRP > 2mg/l (hsCRP < 2mg/l) overweight was present in 76% (61%), lack of PA in 69% (57%), low MDS in 46% (37%) and smoking in 61% (54%). The association of BMI and hsCRP was the strongest of the modRF. Moreover, hsCRP increased significantly with the number of modRF present. Individual recalculation of hsCRP levels assuming optimised control of modRF showed that 38% of the patients with high hsCRP could achieve hsCRP < 2mg/l via lifestyle changes.
As atherosclerosis involves inflammation, it is discussed, but not decided, whether patients with a high inflammatory burden should be offered anti-inflammatory treatment in order to reduce cardiovascular events. This study provides important knowledge regarding the great potential for reducing the inflammatory burden by lifestyle change alone, and thereby minimising the size of the population who would need anti-inflammatory treatment.
The EAPC President, Martin Halle, has emphasised improvement of risk factors and in particular nutrition, as some of the key strategic focal points. The present study supports the need to focus on modifiable lifestyle improvement as an important contribution to cardiovascular disease prevention. High BMI seems to be the key variable for optimisation of inflammatory status in the present study, and the key factors to reduce BMI in overweight and obese subjects are healthy diet and physical activity, which is cheap and free of side-effects in contrast to anti-inflammatory treatment.