Elkind M, Luna J, McClure L, Zhang Y, Coffey C, Roldan A, et al. C-Reactive Protein as a Prognostic Marker After Lacunar Stroke: Levels of Inflammatory Markers in the Treatment of Stroke Study. Stroke. 2014
VIVEK RAI, MD
There is evidence provided by basic and clinical research that inflammation plays an important role in atherosclerosis and cardiovascular disease. Several studies have demonstrated utility of high sensitivity assay for C-reactive protein (hsCRP) as a marker of future risk of coronary artery disease. The relationship of hsCRP with risk of recurrent stroke is not very clear at present. There are some studies with focus on first ever stroke that have looked at hsCRP as a prognostic marker but there are few that have studied it for secondary prevention of ischemic stroke.
Elkind and colleagues report the results of Levels of Inflammatory Markers in Treatment of Stroke (LIMITS) trial that was an ancillary study nested within Secondary Prevention of Small Subcortical Strokes (SPS3). Of the total population enrolled in SPS3, 1244 were enrolled in LIMITS. Within this group, there were 83 recurrent ischemic strokes and 115 major vascular events (stroke, myocardial infarction, vascular death). hsCRP was measured during the subacute phase (median time after stroke 60 days). There was an increased risk of recurrent stroke in those with hsCRP>4.86 mg/L (unadjusted HR 2.54, 95%CI 1.30-4.96). The risk remained high (adjusted HR 2.32, 95%CI 1.15-4.68) even after adjustment for traditional risk factors (smoking, statin use, hypertension, diabetes etc) and demographics (age, sex, race). There was no linear relationship with hsCRP levels and no interaction with randomized anti-platelet treatment.
This study provides evidence that hsCRP predicts risk of recurrent ischemic stroke after a recent lacunar stroke. Although there was prognostic value of hsCRP in this study, it could not predict response to dual anti-platelet use. It is unclear at this time if this prognostic information can be used to alter the treatment regimen to provide better secondary prevention measures that would drive the risk of recurrent stroke further down. It will be interesting to see whether hsCRP can be used to stratify patients for research in future, especially secondary prevention treatment trials.