there is increasing evidence that higher levels of high sensitivity c - reactive protein ( hs - crp ) is a marker of inflammation and a potential independent predictor of cardiovascular disease , as it may play a role in the development of atherosclerosis , adversely affecting mortality.1)2 ) rate of obesity is increasing globally where studies have shown association of body weight as assessed by body mass index ( bmi ) with clinical outcomes after percutaneous coronary intervention ( pci ) in acute myocardial infarction ( ami ) patients.3 ) previous reports have also indicated that hs - crp level is correlated with bmi and fat distribution.4)5 ) the mechanism for elevation of plasma hs - crp in obese subjects could be through a high production of cytokines , e.g. , interleukin-1 ( il-1 ) , interleukin-6 ( il-6 ) and tumor necrosis factor- ( tnf- ) , by excess adipose tissue which could induce high hs - crp production in liver.4 ) curently there is no data available evaluating the relationship between higher baseline hs - crp levels , body mass index ( bmi ) status , and adverse outcomes in patients with ami undergoing pci .
therefore , in the present study we attempted to assess the association between baseline hs - crp level and 12-month clinical outcomes in patients with ami .
this retrospective study was carried out at the heart center of chonnam national university hospital , korea . the permission to carry out
the study had been sought from the hospital authorities ( irb no.05 - 49 ) and informed consent obtained from the patients .
patient medical documents were used to obtain the demographic data , clinical characteristics and relevant laboratory results .
patients were enrolled in the registry after admission to participating hospitals with a suspected diagnosis of ami .
the korea acute myocardial infarction registry ( kamir ) is a prospective , multicenter , observational registry designed to examine current epidemiology in hospital management and outcome of patients with ami in korea .
the registry included 52 community and university hospitals capable of primary pci with one - year clinical follow up .
data was collected at each site by a well - trained study coordinator based on a standardized protocol.6 - 8 ) a total of 10974 consecutive patients with ami ( both st - segment elevation mi and non - st - segment elevation mi ) undergoing pci from november 2005 to september 2008 were assessed in this study .
patients with unknown bmi ( n=395 ) and missing hs - crp ( n=2405 ) data were excluded from this study ; hence the total study population was 8174 patients .
the aim was to evaluate the impact of baseline hs - crp on 12-month clinical outcomes according to bmi status .
then , according to bmi categories suggested by the world health organization for asian population , the total study population was divided into three groups that included 1 ) overweight / obese ( bmi 23 kg / m , n=5647 ) , 2 ) normal - weight ( bmi 18.5 to 22.9 kg / m , n=2246 ) and 3 ) underweight ( bmi < 18.5 kg / m , n=281).9 ) each group was then stratified into quartiles based on their hs - crp levels . a final diagnosis of ami was made by the european society of cardiology / american college of cardiology ( esc / acc ) diagnostic criteria for ami.10 ) bmi was calculated as weight ( kg ) divided by height squared ( m ) .
diabetes mellitus ( dm ) was defined as requiring the use of oral hypoglycaemic agent or insulin to lower blood glucose levels .
hypertension was defined as patient systolic blood pressure > 140 mm hg and/or diastolic blood pressure > 90 mm hg at rest , over a series of repeated measurements , or after treatment with anti - hypertensive medications . for diabetics and patients with chronic renal disease
, hypertension was defined as systolic blood pressure 130 mm hg and/or diastolic blood pressure 80 mm hg .
hyperlipidemia was defined as patient total cholesterol level > 200 mg / dl or treatment with a lipid - lowering agent .
coronary artery disease ( cad ) was defined as patient having a history of myocardial infarction ( mi ) revascularization procedure , or obstructive cad .
blood samples were centrifuged and serum was removed and stored at a temperature of -700 until the assay for sugar and proteins was performed .
absolute creatine kinase - mb levels were determined by radioimmunoassay ( dade behring , inc . ,
cardiac specific troponin i levels were measured using a paramagnetic particle , chemiluminescent immunoenzymatic assay ( beckham , coulter , inc . ,
twelve - hour fasting serum levels of total cholesterol , triglyceride , and low and high density lipoprotein - cholesterol were measured by standard enzymatic methods . blood sample for hs - crp
was obtained on admission and was analyzed turbidimetrically with sheep antibodies against human crp ; this has been validated against the dade behring method .
overweight / obese quartiles were : first quartile < 0.2 mg / dl , n=1370 , second quartile 0.2 to < 0.82 mg / dl , n=1451 , third quartile 0.82 to < 4.08 mg / dl , n=1413 and fourth quartile 4.08 mg / dl , n=1413 .
normal - weight quartiles were : first quartile < 0.2 mg / dl , n=548 , second quartile 0.2 to < 0.92 mg / dl , n=575 , third quartile 0.92 to < 5.23 , n=563 mg / dl and fourth quartile 5.23 mg / dl , n=563 .
underweight quartiles were : first quartile < 0.31 mg / dl , n=70 , second quartile 0.31 to < 1.54 mg / dl , n=70 , third quartile 1.54 to < 8.76 mg / dl , n=71 and fourth quartile 8.76 mg / dl , n=70 .
two - dimensional echocardiography was performed in all patients and left ventricular ejection fraction ( lvef ) was assessed using a modified simpson 's biplane method .
the morphology in coronary angiography was classified by criteria from the american college of cardiology / american heart association ( acc / aha).11 ) the degree of coronary flow was classified by thrombolysis in myocardial infarction ( timi ) score .
the presence of left main coronary artery stenosis was defined as a luminal stenosis 50% .
multivessel disease was defined as the presence of a lesion with > 50% diameter stenosis in a non - infarct related coronary artery .
successful pci was defined as timi flow 3 with residual stenosis 50% in the infarct related artery .
in - hospital complications included atrio - ventricular block , bradycardia , ventricular tachycardia / ventricular fibrillation , atrial fibrillation , no reflow , dissection , cardiogenic shock , acute renal failure , metabolic acidosis / lactic acidosis .
major advense cardiac event ( mace ) were defined as all - cause death , recurrent mi , or repeat revascularization .
the primary endpoint of this study was all - cause mortality at 12-month clinical follow up .
all data were recorded on a standardized , electronic , web based registry at http://www.kamir.or.kr .
continuous variables were presented as the meansd ; comparisons were conducted by one - way anova test .
discrete variables were presented as percentages and frequencies ; comparisons were conducted by chi - square statistics .
cox regression analysis was performed to identify a model with independent predictive factors including determination of a hazard ratio and its 95% confidence interval ( ci ) for each variable in the model .
cox analysis was performed to identify variables that most affected the hazard ratio of hs - crp , with a cut off at p<0.20 for entry into the model .
the korea acute myocardial infarction registry ( kamir ) is a prospective , multicenter , observational registry designed to examine current epidemiology in hospital management and outcome of patients with ami in korea .
the registry included 52 community and university hospitals capable of primary pci with one - year clinical follow up .
data was collected at each site by a well - trained study coordinator based on a standardized protocol.6 - 8 )
a total of 10974 consecutive patients with ami ( both st - segment elevation mi and non - st - segment elevation mi ) undergoing pci from november 2005 to september 2008 were assessed in this study .
patients with unknown bmi ( n=395 ) and missing hs - crp ( n=2405 ) data were excluded from this study ; hence the total study population was 8174 patients .
the aim was to evaluate the impact of baseline hs - crp on 12-month clinical outcomes according to bmi status .
then , according to bmi categories suggested by the world health organization for asian population , the total study population was divided into three groups that included 1 ) overweight / obese ( bmi 23 kg / m , n=5647 ) , 2 ) normal - weight ( bmi 18.5 to 22.9 kg / m , n=2246 ) and 3 ) underweight ( bmi < 18.5 kg / m , n=281).9 ) each group was then stratified into quartiles based on their hs - crp levels .
a final diagnosis of ami was made by the european society of cardiology / american college of cardiology ( esc / acc ) diagnostic criteria for ami.10 ) bmi was calculated as weight ( kg ) divided by height squared ( m ) .
diabetes mellitus ( dm ) was defined as requiring the use of oral hypoglycaemic agent or insulin to lower blood glucose levels .
hypertension was defined as patient systolic blood pressure > 140 mm hg and/or diastolic blood pressure > 90 mm hg at rest , over a series of repeated measurements , or after treatment with anti - hypertensive medications . for diabetics and patients with chronic renal disease
, hypertension was defined as systolic blood pressure 130 mm hg and/or diastolic blood pressure 80 mm hg .
hyperlipidemia was defined as patient total cholesterol level > 200 mg / dl or treatment with a lipid - lowering agent .
coronary artery disease ( cad ) was defined as patient having a history of myocardial infarction ( mi ) revascularization procedure , or obstructive cad .
blood samples were centrifuged and serum was removed and stored at a temperature of -700 until the assay for sugar and proteins was performed .
absolute creatine kinase - mb levels were determined by radioimmunoassay ( dade behring , inc . ,
cardiac specific troponin i levels were measured using a paramagnetic particle , chemiluminescent immunoenzymatic assay ( beckham , coulter , inc . ,
twelve - hour fasting serum levels of total cholesterol , triglyceride , and low and high density lipoprotein - cholesterol were measured by standard enzymatic methods . blood sample for hs - crp
was obtained on admission and was analyzed turbidimetrically with sheep antibodies against human crp ; this has been validated against the dade behring method .
overweight / obese quartiles were : first quartile < 0.2 mg / dl , n=1370 , second quartile 0.2 to < 0.82 mg / dl , n=1451 , third quartile 0.82 to < 4.08 mg / dl , n=1413 and fourth quartile 4.08 mg / dl , n=1413 .
normal - weight quartiles were : first quartile < 0.2 mg / dl , n=548 , second quartile 0.2 to < 0.92 mg / dl , n=575 , third quartile 0.92 to < 5.23 , n=563 mg / dl and fourth quartile 5.23 mg / dl , n=563 .
underweight quartiles were : first quartile < 0.31 mg / dl , n=70 , second quartile 0.31 to < 1.54 mg / dl , n=70 , third quartile 1.54 to < 8.76 mg / dl , n=71 and fourth quartile 8.76 mg / dl , n=70 .
two - dimensional echocardiography was performed in all patients and left ventricular ejection fraction ( lvef ) was assessed using a modified simpson 's biplane method .
the morphology in coronary angiography was classified by criteria from the american college of cardiology / american heart association ( acc / aha).11 ) the degree of coronary flow was classified by thrombolysis in myocardial infarction ( timi ) score .
the presence of left main coronary artery stenosis was defined as a luminal stenosis 50% .
multivessel disease was defined as the presence of a lesion with > 50% diameter stenosis in a non - infarct related coronary artery .
successful pci was defined as timi flow 3 with residual stenosis 50% in the infarct related artery .
in - hospital complications included atrio - ventricular block , bradycardia , ventricular tachycardia / ventricular fibrillation , atrial fibrillation , no reflow , dissection , cardiogenic shock , acute renal failure , metabolic acidosis / lactic acidosis .
major advense cardiac event ( mace ) were defined as all - cause death , recurrent mi , or repeat revascularization .
the primary endpoint of this study was all - cause mortality at 12-month clinical follow up .
all data were recorded on a standardized , electronic , web based registry at http://www.kamir.or.kr .
spss 17.0 for windows ( spss , inc . , chicago , il , usa ) was used for all analyses .
continuous variables were presented as the meansd ; comparisons were conducted by one - way anova test .
discrete variables were presented as percentages and frequencies ; comparisons were conducted by chi - square statistics .
cox regression analysis was performed to identify a model with independent predictive factors including determination of a hazard ratio and its 95% confidence interval ( ci ) for each variable in the model .
cox analysis was performed to identify variables that most affected the hazard ratio of hs - crp , with a cut off at p<0.20 for entry into the model .
a total of 8,174 ami patients , mean age=62.712.4 years and 76% male gender ( n=6217 ) , were stratified into quartiles based on their hs - crp level to study their 12-month clinical outcomes .
twelve - month all - cause death and 12-month composite of mace increased as the value of hs - crp increased from 1st to 4th quartile .
cox proportional hazard analysis showed 12-month mortality to be highest in patients of 4th quartile { hr=2.80 ( 1.335 - 5.873 ) , p=0.006 } followed by 3rd quartile { hr=2.495 ( 1.186 - 5.248 ) , p=0.016}. it was statistically significant among hs - crp quartiles ( p=0.045 ) .
independent factors for 12-month mortality were age greater than 60 years , in - hospital complications , killip class > 1 , use of statin , heart rate > 100 beats / min , n - terminal pro - b - type natriuretic peptide ( nt - probnp ) > 3000 pg / ml , left ventricular ejection fraction ( lvef ) < 55% and creatinine clearance < 60 min / ml ( data not provided ) . as the 12-month mortality was statistically borderline significant among hs - crp quartiles in the total study population , we sought to further evaluate this finding by dividing the total study population into three groups based on their bmi .
overweight and obese patients were grouped together as there was no baseline significant difference in their 12-month all - cause mortality ( p=0.076 , data not provided ) .
baseline clinical characteristics and laboratory findings of this group are presented in table 1 and 2 respectively .
overweight / obese patients with higher hs - crp ( i.e. , 2nd , 3rd and 4th quartiles ) were older , more often female , had higher killip classes , heart rate and nt - probnp ; and had lower blood pressure , lvef and creatinine clearance .
they were associated with higher incidence of dm , hypertension , cad , heart failure and cerebrovascular disease .
as per past regular medication history , 7.15% of the patients at the time of admission were on statin ( n=404 ) .
multivessel involvement , acc / aha lesion type c , and pre - pci timi flow grade 0 were observed to increase with an increase in hs - crp .
pci success rate decreased and in - hospital complication rate increased with increasing hs - crp .
table 4 shows the clinical outcomes during the 12-month follow - up . in - hospital
death , composite mace at 1 month and 12 months , and mortality at 1 month and 12 months were more frequent with increasing hs - crp levels .
twelve - month mortality increased as the value of hs - crp increased ; 2.0% ( n=27 ) in 1st , 2.5% ( n=37 ) in 2nd , 4.4% ( n=62 ) in 3rd and highest 6.6% ( n=94 ) in the 4th quartile .
cox proportional hazard model was implemented to identify the independent predictors of mortality at the 12-month clinical follow - up .
serum hs - crp quartiles showed significant association with 12-month mortality when adjusted for age and gender ( p<0.001 ) .
with quartile 1 as a reference , the risk of 12-month mortality was higher in the 3rd quartile { 2.153 ( 1.369 - 3.384 ) , p=0.001 } and 4th quartile { 3.268 ( 2.129 - 5.016 ) , p<0.001}. after adjustment with multiple covariates , 12-month mortality was highest in patients within the 4th quartile compared to other patients { hazard ratio ( hr ) 2.382 ( 1.079 - 5.259 ) , p=0.032 } though statistical significance was not achieved ( p=0.172 ) .
independent factors for 12-month mortality were old age ( > 60 years ) , heart rate > 100 beats / min , lvef < 55% , creatinine clearance < 60 min / ml and in - hospital complications .
the variables included in cox model were age , male gender , heart rate , systolic blood pressure , smoking history , history of hypertension , diabetes mellitus , coronary artery disease , cerebrovascular disease and heart failure , lvef , killip classes > 1 , glucose , total cholesterol , triglyceride , creatinine clearance , nt - probnp , left main and multivessel involvement , pre - timi flow grade 0 , post - timi flow grade 3 , acc / aha lesion type c , pci success rate , in - hospital complications and use of statin .
patients were also stratified into quartiles based on hs - crp level to evaluate their 12-month clinical outcomes .
patients with higher hs - crp were found to be older ( p<0.001 ) , with increased heart rate ( p=0.015 ) and higher killip classes ( p=0.002 ) .
they had more association with diabetes mellitus ( p=0.019 ) , hypertension ( p=0.049 ) , heart failure ( p=0.001 ) and peripheral vascular disease ( p=0.001 ) .
creatinine clearance , lvef and high - density lipoprotein cholesterol decreased with higher hs - crp ( p<0.001 , p<0.001 and p=0.001 respectively ) .
total cholesterol , triglyceride and low density lipoproteincholesterol ( ldl - c ) were also significant among quartiles ( p<0.001 , p=0.001 and p=0.001 respectively ) .
they were more associated with acc / aha lesion type c , multivessel involvement , pre - timi flow grade 0 and in - hospital complications .
twelve - month composite of mace ( p=0.009 ) and all - cause death ( p<0.001 ) increased as the value of hs - crp increased from 1st to 4th quartile .
cox proportional hazard model showed 12-month mortality to be statistically insignificant among hs - crp quartiles in this group ( p=0.681 ) .
the variables included in the model were age , dm , hypertension , hyperlipidemia , heart failure , peripheral vascular disease , smoking history , clinical presentation st - elevation mi , total cholesterol , triglyceride , creatinine clearance , nt - probnp , systolic blood pressure , heart rate , in - hospital complications , killip class > 1 , lvef < 55% , pre - procedure timi grade 0 flow , acc / aha lesion type c , multivessel involvement , and use of statin .
patients from this study were additionally divided into quartiles based on hs - crp level to study their 12-month clinical outcomes .
the variables included in the model were age , systolic blood pressure , lvef < 55% , glucose , total cholesterol , ldl - c , creatinine clearance , nt - probnp , smoking history , heart failure , post - procedure timi grade 3 , pci success rate , and in - hospital complications .
age , nt - probnp , killip class > 1 and in - hospital complications increased with increasing levels of hs - crp ( p=0.006 , p<0.001 , p=0.009 and p=0.032 respectively ) , while creatinine clearance decreased with rising level of hs - crp ( p=0.001 ) .
systolic blood pressure , lvef , total cholesterol and post - timi flow grade iii were statistically significant among the quartiles ( p=0.043 , p=0.023 , p=0.038 and p=0.002 respectively ) .
twelve - month composite of mace increased as the value of hs - crp increased from 1st to 4th quartile , but it was statistically insignificant ( p=0.382 ) , and twelve - month all - cause death showed no association among quartiles ( p=0.079 ) .
cox proportional hazard model showed 12-month mortality to be statistically insignificant among hs - crp quartiles in this group as well ( p=0.760 ) .
1 shows adjusted survival curves of 12-month mortality in hs - crp quartiles in ( a ) total study population , ( b ) overweight / obese group , ( c ) normal - weight group and ( d ) underweight group .
baseline clinical characteristics and laboratory findings of this group are presented in table 1 and 2 respectively .
overweight / obese patients with higher hs - crp ( i.e. , 2nd , 3rd and 4th quartiles ) were older , more often female , had higher killip classes , heart rate and nt - probnp ; and had lower blood pressure , lvef and creatinine clearance . they were associated with higher incidence of dm , hypertension , cad , heart failure and cerebrovascular disease .
as per past regular medication history , 7.15% of the patients at the time of admission were on statin ( n=404 ) .
multivessel involvement , acc / aha lesion type c , and pre - pci timi flow grade 0 were observed to increase with an increase in hs - crp .
pci success rate decreased and in - hospital complication rate increased with increasing hs - crp .
table 4 shows the clinical outcomes during the 12-month follow - up . in - hospital
death , composite mace at 1 month and 12 months , and mortality at 1 month and 12 months were more frequent with increasing hs - crp levels .
twelve - month mortality increased as the value of hs - crp increased ; 2.0% ( n=27 ) in 1st , 2.5% ( n=37 ) in 2nd , 4.4% ( n=62 ) in 3rd and highest 6.6% ( n=94 ) in the 4th quartile .
cox proportional hazard model was implemented to identify the independent predictors of mortality at the 12-month clinical follow - up .
serum hs - crp quartiles showed significant association with 12-month mortality when adjusted for age and gender ( p<0.001 ) .
with quartile 1 as a reference , the risk of 12-month mortality was higher in the 3rd quartile { 2.153 ( 1.369 - 3.384 ) , p=0.001 } and 4th quartile { 3.268 ( 2.129 - 5.016 ) , p<0.001}. after adjustment with multiple covariates , 12-month mortality was highest in patients within the 4th quartile compared to other patients { hazard ratio ( hr ) 2.382 ( 1.079 - 5.259 ) , p=0.032 } though statistical significance was not achieved ( p=0.172 ) .
independent factors for 12-month mortality were old age ( > 60 years ) , heart rate > 100 beats / min , lvef < 55% , creatinine clearance < 60 min / ml and in - hospital complications .
the variables included in cox model were age , male gender , heart rate , systolic blood pressure , smoking history , history of hypertension , diabetes mellitus , coronary artery disease , cerebrovascular disease and heart failure , lvef , killip classes > 1 , glucose , total cholesterol , triglyceride , creatinine clearance , nt - probnp , left main and multivessel involvement , pre - timi flow grade 0 , post - timi flow grade 3 , acc / aha lesion type c , pci success rate , in - hospital complications and use of statin .
patients were also stratified into quartiles based on hs - crp level to evaluate their 12-month clinical outcomes .
patients with higher hs - crp were found to be older ( p<0.001 ) , with increased heart rate ( p=0.015 ) and higher killip classes ( p=0.002 ) .
they had more association with diabetes mellitus ( p=0.019 ) , hypertension ( p=0.049 ) , heart failure ( p=0.001 ) and peripheral vascular disease ( p=0.001 ) .
creatinine clearance , lvef and high - density lipoprotein cholesterol decreased with higher hs - crp ( p<0.001 , p<0.001 and p=0.001 respectively ) .
total cholesterol , triglyceride and low density lipoproteincholesterol ( ldl - c ) were also significant among quartiles ( p<0.001 , p=0.001 and p=0.001 respectively ) .
they were more associated with acc / aha lesion type c , multivessel involvement , pre - timi flow grade 0 and in - hospital complications .
twelve - month composite of mace ( p=0.009 ) and all - cause death ( p<0.001 ) increased as the value of hs - crp increased from 1st to 4th quartile .
cox proportional hazard model showed 12-month mortality to be statistically insignificant among hs - crp quartiles in this group ( p=0.681 ) .
the variables included in the model were age , dm , hypertension , hyperlipidemia , heart failure , peripheral vascular disease , smoking history , clinical presentation st - elevation mi , total cholesterol , triglyceride , creatinine clearance , nt - probnp , systolic blood pressure , heart rate , in - hospital complications , killip class > 1 , lvef < 55% , pre - procedure timi grade 0 flow , acc / aha lesion type c , multivessel involvement , and use of statin .
patients from this study were additionally divided into quartiles based on hs - crp level to study their 12-month clinical outcomes .
the variables included in the model were age , systolic blood pressure , lvef < 55% , glucose , total cholesterol , ldl - c , creatinine clearance , nt - probnp , smoking history , heart failure , post - procedure timi grade 3 , pci success rate , and in - hospital complications .
age , nt - probnp , killip class > 1 and in - hospital complications increased with increasing levels of hs - crp ( p=0.006 , p<0.001 , p=0.009 and p=0.032 respectively ) , while creatinine clearance decreased with rising level of hs - crp ( p=0.001 ) .
systolic blood pressure , lvef , total cholesterol and post - timi flow grade iii were statistically significant among the quartiles ( p=0.043 , p=0.023 , p=0.038 and p=0.002 respectively ) .
twelve - month composite of mace increased as the value of hs - crp increased from 1st to 4th quartile , but it was statistically insignificant ( p=0.382 ) , and twelve - month all - cause death showed no association among quartiles ( p=0.079 ) .
cox proportional hazard model showed 12-month mortality to be statistically insignificant among hs - crp quartiles in this group as well ( p=0.760 ) .
1 shows adjusted survival curves of 12-month mortality in hs - crp quartiles in ( a ) total study population , ( b ) overweight / obese group , ( c ) normal - weight group and ( d ) underweight group .
this study demonstrated that higher baseline hs - crp level ( 4.08 mg / dl ) in overweight / obese ami patients showed significant association with 12-month all - cause mortality independent of other prognostic markers . over the past few years , it has become increasingly clear that inflammation plays a pivotal role in cardiovascular disease , and increased circulating inflammation markers may be predictive of cardiovascular events.12)13 ) among the inflammation markers available , hs - crp is one of the independent predictors of cardiovascular events.14)15 ) adiposity is an inflammatory condition and il-6 , tnf- and hs - crp levels are positively correlated with adipocyte size.4)15)16 ) these cytokines induce insulin resistance in adipose cells by inhibiting insulin signaling.17)18 ) crp along with il-6 and other cytokines / adipokines could be deleterious on the arterial wall since it has been found to directly promote endothelial cell inflammation and atherosclerotic processes.19)20 ) thus , the link between adiposity , plaque accumulation / progression / rupture and atherothrombotic events , especially ami , might be explained by higher levels of systemic inflammation and their chronic effect on coronary atherosclerosis over time .
marsik et al.2 ) report that patients with crp concentrations > 5 mg / l at the time of hospital admission had a 50% to 330% increase in risk of death from any cause .
this increase in risk was present in both short - term and long - term follow - ups , and rose in magnitude as concentrations of crp increased to >
another study by koenig et al.1 ) deals with the issue of hs - crp as a predictor of death in the monitoring of trends and determinants in cardiovascular disease .
after adjustment for age , smoking , hypertension , hyperlipidemia , diabetes , obesity and socioeconomic markers , those with baseline hs - crp concentrations > 3 mg / l had a 2-fold increase in risk of total mortality .
some studies have shown that higher bmi is associated with higher crp concentrations even among young adults 17 to 39 years of age .
these findings suggest a state of low - grade systemic inflammation in obese patients.21 ) as previously reported by sutter et al.22 ) it is known that increased levels of hs - crp are greatly associated with extensive tissue destruction or infarct size . in such situations with more severe inflammation and extensive tissue damage ,
the relationship between adverse outcomes and crp level might be considered independent from bmi status .
the present study shows that hs - crp concentrations in the obese rise with increasing age , diabetes mellitus , hypertension , coronary artery disease , heart failure and cerebrovascular disease reaffirming data from earlier studies.23 - 25 ) a prospective study by bruci et al.26 ) on 329 patients with myocardial infarction at the time of admission showed crp to be associated with a strong , positive graded increase in the risk of heart failure and death independently of known risk indicators .
ninety - four patients ( 29% ) were in killip class greater than 1 at presentation , and greater killip class was associated with increased crp .
interestingly , a study in cairo by fareed et al . noted that patients with hs - crp -17 mg / l were prone to heart failure ( at this value sensitivity=88% , specificity=51.2% ) .
our findings are in agreement with a recently published report that showed a trend to decreasing values of lvef in relation to higher crp levels.27 ) the significant relationship between crp and lvef suggests the implication of inflammatory mechanisms in left ventricular dysfunction and in the pathogenesis of congestive heart failure , independently of the underlying atherosclerotic burden .
angiographic findings of multivessel involvement , frequency of acc / aha lesion type c and subsequently higher pre - timi grade 0 flow , lower procedure success rate and higher complications support the previous study findings on acute coronary syndrome that demonstrated multiple complex stenoses with high plaque burden suggesting a pan - coronary involvement.28 ) this study showed a negative relation of smoking with hs - crp in the overweight / obese subset .
the mechanism whereby smoking is related to crp concentration is unclear , but it may be multi - factorial , involving bronchial injury , endothelial activation and systemic inflammation.29 ) use of a statin is a negative predictor of 12-month mortality in total study population
. however , there was no significant association of statin use and hs - crp levels in higher bmi patients though earlier studies have shown that statin reduces hs - crp levels.30)31 ) this could be due to relatively small number of patients on a statin at the time of admission ( 7.15% ) or unavailability of follow - up hs - crp data in our registry . moreover , in anglo - scandinavian cardiac outcomes trial : lipid lowering arm trial neither baseline nor on - treatment crp provided useful information about the efficacy of statin treatment to reduce cardiovascular events beyond ldl - c reduction.32 ) this study should be interpreted in the light of the following limitations .
this is not a randomized trial , but a retrospective evaluation on a large - scale multi - center registry .
blood samples for hs - crp were obtained at the time of admission , hence higher levels of hs - crp in our study may not be associated with myocardial necrosis.33 ) the time of onset and size of the myocardial infarction may also increase the hs - crp levels .
however , we did not determine the serial changes in hs - crp concentration after ami .
other inflammatory markers , such as il-6 , tnf- or lipoprotein - associated phospholipase a2 ( lp - pla2 ) that could have added more robust evidence of other inflammatory pathways associated with poor outcome were not a part of this study .
extreme variations in hs - crp levels that could have made a difference in standard deviation in each group have not been excluded from this study .
higher baseline hs - crp level ( 4.08 mg / dl ) in overweight / obese ami patients showed significant association with 12-month all - cause mortality independent of other prognostic markers .
we suggest further long term evaluation with serial changes in hs - crp concentration after ami and other inflammation markers to clearly elucidate its role in more diverse population .
this is not a randomized trial , but a retrospective evaluation on a large - scale multi - center registry .
blood samples for hs - crp were obtained at the time of admission , hence higher levels of hs - crp in our study may not be associated with myocardial necrosis.33 ) the time of onset and size of the myocardial infarction may also increase the hs - crp levels .
however , we did not determine the serial changes in hs - crp concentration after ami .
other inflammatory markers , such as il-6 , tnf- or lipoprotein - associated phospholipase a2 ( lp - pla2 ) that could have added more robust evidence of other inflammatory pathways associated with poor outcome were not a part of this study .
extreme variations in hs - crp levels that could have made a difference in standard deviation in each group have not been excluded from this study .
higher baseline hs - crp level ( 4.08 mg / dl ) in overweight / obese ami patients showed significant association with 12-month all - cause mortality independent of other prognostic markers .
we suggest further long term evaluation with serial changes in hs - crp concentration after ami and other inflammation markers to clearly elucidate its role in more diverse population .
 background and objectivesserum high sensitivity c - reactive protein ( hs - crp ) is a marker of inflammation and may lead to the development of atherosclerosis , adversely affecting mortality . 
 the aim of this study was to evaluate the relationship between baseline hs - crp level and 12-month clinical outcomes in patients with acute myocardial infarction ( ami ) undergoing percutaneous coronary intervention ( pci ) according to their body mass index ( bmi ) status.subjects and methodsusing data from the korea acute myocardial infarction registry from november 2005 to september 2008 , a total of 8174 consecutive ami patients were studied . 
 cox proportional hazard model revealed that higher baseline levels of hs - crp was associated with 12-month all - cause mortality ( p=0.045 ) . to further understand this association 
 , patients were divided into 3 groups based on their body mass index : 1 ) overweight / obese , 2 ) normal weight , and 3 ) underweight patients . then each group was stratified into quartiles based on their hs-crp.resultsin overweight / obese patients , cox model showed significant association of hs - crp with 12-month mortality when adjusted for age and gender ( p<0.001 ) , however , after adjustment with multiple covariates , mortality was highest in the 4th quartile { hr 2.382 , ( 1.079 - 5.259 ) , p=0.032 } though statistically insignificant ( p=0.172 ) . 
 we observed no significant association of serum hs - crp with 12-month mortality in normal weight ( p=0.681 ) and underweight ( p=0.760 ) patients.conclusionhigher baseline hs - crp level ( 4.08 mg / dl ) in overweight / obese ami patients showed significant association with 12-month all - cause mortality independent of other prognostic markers . 