Why You Should Ask Your Doctor About HS-CRP

If you have high cholesterol but no other cardiac disease risks, ask your doctor about the High Sensitivity C-Reactive Protein (HS-CRP) test.

The HS-CRP test is an important predictor of heart disease risk. Actually, as explained in Why You Should Ask For Advanced Lipid Testing, if you are concerned about heart disease risk, you might want to ask your doctor about three key tests: HS-CRP, ApoB and LDL Pattern Type. (While they’re separate tests, all are included in one single Advanced Lipid Panel blood test.)

The HS-CRP test in particular predicts heart disease risk by measuring inflammation in the blood vessels. That the HS-CRP blood test is an excellent predictor of heart disease risk has been widely established. A page on the National Institute of Health about HS-CRP states, “Evidence supporting the hypothesis that elevated CRP levels contributes to increased cardiovascular risk is now available from at least six major prospective studies…”

The HS-CRP is particularly relevant for women. WebMD’s Heart Disease and C-Reactive Protein (CRP) Testing article explains that in the large Harvard Women’s Health study (WHS), “results of the CRP test were more accurate than cholesterol levels in predicting heart problems. Twelve different markers of inflammation were studied in healthy, postmenopausal women. After three years, CRP was the strongest predictor of risk. Women in the group with the highest CRP levels were more than four times as likely to have died from coronary disease, or to have suffered a nonfatal heart attack or stroke compared to those with the lowest levels. This group was also more likely to have required a cardiac procedure such as angioplasty (a procedure that opens clogged arteries with the use of a flexible tube) or bypass surgery than women in the group with the lowest levels.”

That said, if you are already taking a statin or being treated for high blood pressure, the HS-CRP test might not be appropriate. According to Dr. Andrew Weil’s What is elevated C-reactive protein? article, “CRP levels don’t appear to help predict the risk of heart disease in patients already being treated for risks such as high blood pressure or high LDL (“bad”) cholesterol. A 2010 analysis of British data on 4,853 patients found that C-reactive protein levels didn’t yield any more information about the risk of heart disease than LDL (“bad”) cholesterol levels or high blood pressure in patients who already were being treated with a cholesterol-lowering statin drug or with medication to lower blood pressure.”  However, it goes on to say that, “Other physicians, including Dr. Weil, think that all adults should have an hs-CRP test whenever their cholesterol is tested.”

A powerful statement.

My cardiologist appears to agree; at my visit on Christmas Eve, he ordered an advanced lipid panel and an HS-CRP test. There was a mixup on the advanced lipid panel prescription (more on that in another post) so I don’t yet have those results, but I was delighted to see that my HS-CRP test came back with even lower risk than last year.

I was surprised at this result, but apparently should not have been. With a bit of research I found that HS-CRP should be measured over time, as there is high variability in this test. According to the Mayo Clinic, “C-reactive protein (CRP) is an acute-phase reactant and has high intraindividual variability. Therefore, a single test for high-sensitivity CRP (hs-CRP) may not reflect an individual patient’s basal hs-CRP level. Repeat measurement may be required to firmly establish an individual’s basal hs-CRP concentration. The lowest of the measurements should be used as the predictive value.”  I saw this in my own results: in December 2014 my HS-CRP level was 0.8 and in December 2015 it was 0.3.

As both of my HS-CRP measurements are below 1.0 mg/L, that puts me at “lower relative cardiovascular risk” according to the goals printed at the bottom of my test results.  Here are the guidelines:

HS-CRP Guidelines

Do you know your heart disease risk as measured by HS-CRP? If you fall into the category of those for whom the HS-CRP test is a good predictor of heart disease risk (meaning, you aren’t already being treated for heart disease or you have an inflammatory disease), ask your doctor about this simple blood test and get more insight into your heart disease risk.

 

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Why You Should Ask For Advanced Lipid Testing

Controversies in Cardiovascular Medicine is the intriguing title of a 2009 article in the American Heart Association’s Circulation publication.

Stop laughing – cholesterol research can be intriguing!  I’d label the situation frustrating more than intriguing, but here’s what is going on.

The controversy is essentially that advanced lipid testing (explained in Cholesterol Tests Your Doctor Hasn’t Told You About) has been around for 50 years and is a better predictor of cardiovascular disease risk than standard cholesterol blood tests, and yet these ‘advanced’ tests are still not widely prescribed.

In fact, the ‘standard’ cholesterol blood panels (total cholesterol, LDL and HDL) often inaccurately portray risk for many people: those, for example, with normal cholesterol levels who heart attacks. And yet, standard lipid testing is still the norm.  It’s kind of crazy.

As explained in the Circulation article:

“Standard tests of low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) misidentify coronary heart disease (CHD) risk status in a substantial portion of the population. Tests of apolipoprotein concentrations are superior to standard LDL-C tests, and it can be argued that they should replace standard lipoprotein cholesterol testing.”

The Circulation article goes on to explain that the advanced testing used to be difficult and expensive – but this testing is now more widely available:

“Advanced lipoprotein tests that were previously available only from university research laboratories are now provided by several commercial laboratories.”

Indeed, since Berkeley Heart Lab (which was one of very few offering advanced lipid testing years ago) was bought first by Celera Corp in 2007 and then by Quest Diagnostics in 2011, it is now far easier — and inexpensive — to get advanced lipid testing!

And yet, it’s not widely prescribed.  Sigh.

I just had an advanced lipid panel done in December 2014. It wasn’t easy to get (my internist said not necessary; it wasn’t until I had to see cardiologist for sudden high blood pressure that he agreed it was a good idea). But I’m glad I did because I now have a much better understanding of my personal cardiac disease risk.

Here’s what I learned – and below these key points is some further info about test results that may be pertinent as you consider ASKING FOR advanced lipid testing:

  • My total cholesterol is ‘high’ at 266 and my LDL cholesterol is ‘high’ at 159
  • I have elevated ApoB (score of 123) which contributes to higher cardiac disease risk. But that is offset by other test results.
  • My LDL pattern is type A, which is optimal.  This is the fluffy kind that doesn’t stick to the arteries like the smaller, denser, more dangerous Type B LDL cholesterol.
  • My C-Reactive Protein score of 0.8 is also considered optimal / low risk.

Total and LDL Cholesterol: I find it frustrating that the lab reports still characterize my Total 266 and LDL cholesterol of 159 as ‘abnormal’ or ‘high’ (meaning, high ‘risk’) even though the November 2013 cholesterol guidelines say these scores are not, indeed, high or risky or need treatment. (The new guidelines indicate risk when  LDL>190, along with other factors).

Why do the lab reports not match the new guidelines?  This is inane.

ApoB: I am concerned about my elevated ApoB.  I wrote about apolipoprotein (ApoB) testing and explained why many believe it’s a better predictor of cardiac risk than LDL and total cholesterol testing in ApoB and Cardiovascular Risk.  So this is something I need to keep track of. Interestingly, the lab report says my score is ‘high’ risk and yet, when I dug further, I found a table that showed my personal target is probably <130 (see blog post for details).  Frustration #2 that there are not clear standards.

LDL Pattern Type: The type of LDL cholesesterol you have matters. As explained in the Physican’s Weekly article In The LDL World, Size Matters, roughly half of all people who have heart attacks have ‘normal’ cholesterol levels.  That’s because small sized LDL (Pattern B) can puncture the walls of the arteries and cause plaque buildup – so even ‘normal’ amounts can be dangerous.  If you have high LDL but it’s the Pattern A type which is big and fluffy, that cholesterol bounces off arterial walls so causes less plaque buildup and is thus less dangerous even if you have a ‘lot’ of it.

While I have the preferred / less dangerous Pattern A LDL cholesterol, I found in researching that Pattern B can be modified: if you have Pattern B, you can get it to change to pattern A with diet and exercise!  Which is great.  But that leads me to wonder whether just because I have pattern A now means it sticks (sorry, pun intended) or if it can change to pattern B.  I intend to stay with my lo-co diet and exercise plan, just wondering if I risk changing to Pattern B if I’m not careful. I need to check in with my cardiologist on this.

C Reactive Protein: I was relieved to find my C Reactive Protein score was low. As explained in a Circulation article from 2003 entitled C Reactive Protein: A Simple Test to Help Predict Risk of Heart Attack and Stroke, the C Reactive Protein test is an important measure in assessing cardiac risk. “When measured with new “high sensitivity” CRP assays, levels of CRP less than 1, 1 to 3, and greater than 3 mg/L (milligrams per liter) discriminate between individuals with low, moderate, and high risk of future heart attack and stroke…  Evidence also indicates that individuals with high CRP levels are at increased risk of developing diabetes.”

Now that the Advanced Lipid testing has provided a more in-depth look at my cardiac disease risk, I understand why my cardiologist feels that my 266 Total cholesterol is not terribly concerning. And doesn’t need treatment.

So if you, like me, want a far clearer understanding of your personal risk of cardiac disease, you should ask your doctor to order Advanced Lipid Testing, including scores for:

  • Advanced Lipid Panel Reflex Direct LDL (measures direct LDL and provides the info on particle pattern, number and size)
  • ApoB
  • C-Reactive Protein – the high sensitivity test

Sad to say you’ll probably have to ask your doctor to order Advanced Lipid Testing – he or she is NOT likely to order these tests unless you ask. Which is a shame.

Because as the Circulation article concludes, these tests have been around for 50+ years, are now easily and widely available, and they pick up risk that typical cholesterol panel testing might miss:

“One advantage of ALTs is the greater insight they provide clinicians into individual patient disorders often masked by standard lipid tests considered to be within “normal” ranges.”

It’s important to ask, because advanced lipid testing might reveal that although your cholesterol is not high, you are still at risk. This testing is easy, cheap and could save your life. It will provide you with a more in depth understanding of your cardiac disease risk.

It’s a simple, important question. Ask about advanced lipid panel testing the next time you see your doctor.

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Cholesterol Results 2014

So I finally bucked up and got my cholesterol tested in November and the results were surprising.  First of all, my cholesterol – after a year of reasonably careful eating and a lot more exercise, but no Metamucil or Fish Oil pills – actually moved in the right direction.

Details in a second.

Not only that, my new cardiologist (again, more in a sec on why I needed to finally see a cardiologist) actually called my cholesterol results “enviable.”

Enviable, people.

This shocked me. Especially because I gave up on the fish oil pills which apparently now, in a total turnaround from past belief, don’t help much with cholesterol. (It’s frustratingly difficult to keep up with what’s recommended –  and what is no long considered effective – for managing cholesterol without statins.)

That said, in the face of a genetic predisposition toward high cholesterol, I’ve managed through diet and exercise to avoid cholesterol medication.  Though truth be told, that’s more likely due to the American Heart Association’s 2013 revised Guidelines For Managing Blood Cholesterol than anything I’ve done… if the Guidelines hadn’t been revised, I’d probably still be having the statin conversation with my doctor.

In any case, here are my exciting (ha ha) cholesterol results.

My overall cholesterol is UP and now measures 246 – which used to be considered high but is apparently now not so big a deal.  Not a big deal, I guess, because my LDL (bad) cholesterol keeps falling (“goal” is less than 130 and mine is now 123) and my HDL (good) cholesterol keeps rising (“goal” is higher than 46 and mine shot up to 95).

NOTE: I put “goal” in quotes because these goals are no longer really in line with the new Guidelines; I find it fascinating that they are still reported as “goal” when the only goal according to the new guidelines is LDL (bad) cholesterol over 190 along with other heart disease risk factors that have nothing to do with cholesterol results.  Bizarre that this is still ‘outdated’ a year later.  Or maybe not bizarre, just sad.

In any case, I’m excited about the results.  Here’s a chart for those who prefer graphs.  If that’s not you, skip to cardiologist discussion 2 paragraphs below!

KLS Chol Trend Thru 2014

You’ll see the red line of total cholesterol is still high and rising – but no one seems worried about that, since the green line of LDL (bad) cholesterol is falling along with the purple triglyceride line … and because the blue line of HDL (good) cholesterol is rising.

Things certainly do change – I’m so glad I never started on a statin back in 2010-2011 when my numbers looked like a statin was in order.

Now, on to cardiologist.  My cholesterol results were surprising – and nicely so. But at same blood test I found I am positive for a blood clotting disorder, so that was a major bummer.  It’s not treated – and not dangerous unless you take hormones (which of course I was) so that had to stop immediately.

And then it turns out my blood pressure has risen quite dramatically.

Likely the stress of this past year – along with wondering and worrying about the blood clotting disorder.  Hence my doctor-referred trip to the cardiologist.

So my new cardiologist and primary care doctor are sorting out how to deal with my (hopefully short-lived) blood pressure issue … and on the plus side, I really liked the new cardiologist.  And when we discussed cardiac risk and my cholesterol trends and family history, he also thought that getting a handle on what my cardiac risk really looks like is a good idea.  So I had two more blood tests – and YAY – these are the very tests I’ve written about thinking made sense for me in Cholesterol Tests Your Doctor Hasn’t Told You About.  Finally!

So I had blood tests for both C Reactive Protein (CRP is a measure of inflammation in the body and high levels have been associated with heart disease) and also a full lipid analysis that will measure LDL density, ApoB and more.  I am really relieved to finally be getting a handle on cardiac risk.  Lastly, am debating about getting a Coronary Calcium test done – it’s a CT test so there’s radiation involved (and Aetna denied coverage) so I’ll likely wait until the blood test results come back to decide.

So on plus side, my cholesterol tests are now ‘enviable’ but am waiting for the blood test results to come back and really help hone in on cardiac disease risk. Oh, and trying to figure out how to get my blood pressure back to normal.

So I’ll end 2014 with a question for you: how’s your cholesterol? And, um, blood pressure? If you don’t know, please resolve in 2015 to have them checked.

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Cholesterol Treatment – Guidelines Pocket Cards for Doctors

Did you know that any old person (and by ‘any old’ I mean a regular, non-doctor person, not any OLD person!) can purchase the American Heart Association’s “guidelines pocket cards” meant to keep doctors up to date on latest treatment protocols/recommendations?

On the American Heart Association website, these pocket cards are described as:

“These quick reference tools provide instant access to current AHA/ASA and ACCF/AHA guidelines in a clear, concise format – available in print and in the Guideline Central Mobile app for iPhone, iPad and Android.”

AHAlogo_lifeiswhy-logoFor months, I have been wondering whether there have been any updates or changes to the November 2013 Cholesterol Guidelines – and how doctors are following – or not – the new guidelines. (More info about the 2013 guidelines here: The NEW guidelines for cholesterol-lowering statin meds).

To me, there’s been a startling dearth of information about how treatment of high cholesterol has changed – or not – since these guidelines were issued. So I was pleased to stumble upon these pocket guidelines for doctors – updated with the latest recommendations.  For just $8.99 I downloaded the cholesterol pocket guidelines and found them largely unchanged since the new guidelines were issued in November 2013.

Which is good, I guess.

That said, one new thing I learned from this pocket guide is that there are established goals for the more in-depth cholesterol tests like C-Reactive Protein and Coronary Artery Calcium – both tests I think I might benefit from.

While my $8.99 purchase would NOT let me print (grr), I was able to grab some text via the handy iPhone app. Love that.

So if you would like a peak at the ‘pocket guidelines’ your doctor may well use when considering how to treat your high cholesterol, read on. Fair warning: it’s, um, quite detailed and uses acronyms (it is, after all, for doctors) so I’ve included a simple glossary for some of the medical terms.

Here goes – what follows is the ‘key points’ section of the doctor ‘pocket guide’ for treating high cholesterol:

TITLE: Cholesterol Adult Management

KEY POINTS

  • Encourage adherence to a heart-healthy lifestyle. A healthy diet, regular aerobic physical activity, smoking cessation and maintenance of a healthy weight are critical components of ASCVD risk reduction. Control hypertension and diabetes, when present.
  • Statin therapy is recommended for adults in groups demonstrated to benefit. ASCVD risk reduction clearly outweighs the risk of adverse events based on a strong body of evidence in 4 groups:
    • Secondary prevention in individuals with clinical ASCVD
    • Primary prevention in individuals age ≥ 21 years with primary elevations of LDL-C ≥ 190 mg/dL
    • Primary prevention in individuals with diabetes 40 to 75 years of age who have LDL-C 70 to 189 mg/dL
    • Primary prevention in individual without diabetes and with estimated 10-year ASCVD risk ≥ 7.5%, 40 to 75 years of age who have LDL-C 70 to 189 mg/dL
  • Statins have an acceptable margin of safety when used in properly selected individuals and appropriately monitored. If no baseline abnormality, monitoring of hepatic transaminases is not routinely needed. CK should not be routinely measured unless there is a personal or family history of muscle problems. You may need to discontinue and then restart the statin to determine the cause of muscle symptoms.
  • Engage in a clinician-patient discussion before initiating statin therapy, especially for primary prevention. Discuss the potential for ASCVD event reduction, adverse effects, drug–drug interactions, and patient preferences. Additional factors may be considered when a risk-based decision is uncertain.
    • These include LDL-C ≥ 160 mg/dL, family history of premature ASCVD, hs-CRP ≥ 2.0 mg/L, CAC ≥ 300 Agatson units, ABI < 0.9; lifetime risk of ASCVD.
  • Use the newly developed Pooled Cohort Equations for estimating 10-year ASCVD risk. Calculating the estimated 10-year ASCVD risk should be the start of the clinician-patient discussion and should not automatically lead to statin initiation.
    • For other ethnic groups, use the equations for non-Hispanic whites, although these estimates may underestimate the risk for persons from some race/ethnic groups, especially American Indians, some Asian Americans (e.g., of south Asian ancestry), and some Hispanics (e.g., Puerto Ricans), and may overestimate the risk for others, including some Asian Americans (e.g., of east Asian ancestry) and some Hispanics (e.g., Mexican Americans).
  • Initiate the appropriate intensity of statin therapy to reduce ASCVD risk.
  • Evidence is inadequate to support treatment to specific LDL-C or non–HDL-C treatment goals. “Treating to goal” may result in treatment with less-than-optimum statin intensity or adding unproven nonstatin therapy.
  • Regularly monitor patients for adherence to lifestyle and appropriate intensity of statin therapy. Obtain a fasting lipid panel before and after initiating statin or other drug therapy.
  • Nonstatin drug therapy may be considered in selected individuals.”

Going Lo-Co GLOSSARY:

  • ASCVD -atherosclerotic cardiovascular disease
  • Hypertension – high blood pressure
  • Statin Therapy – treatment with statin drugs, like Lipitor
  • Individuals with clinical ASCVD  – people with cardiovascular disease or who have had a ‘cardiac event’ like a heart attack
  • LDL-C – level of LDL cholesterol in the blood
  • 10 year ASCVD risk – risk of a cardiac event in 10 years, as measured by the calculator issued with the November 2013 guidelines.  More here: Going LoCo Calculator Post
  • hs-CRP – measure of “C-Reactive Protein” which is a marker for inflammation
  • CAC – coronary artery calcium which measures the thickness of fatty accumulation in the arteries and is used to predict heart disease risk

While managing cholesterol down to a specific goal is no longer the treatment standard, that doesn’t mean you shouldn’t be tracking your cholesterol and managing non-dangerous/risky high cholesterol with lifestyle choices. And remember, if your LDL cholesterol is at/over 190 mg/dL or you have other risks, discuss a statin with your doctor.

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New Cholesterol Guidelines – An App For That

The American Heart Association and the America College of Cardiology released completely new, totally different guidelines for the treatment of high blood cholesterol back in November 2013.

As explained in my post, The NEW Guidelines For Cholesterol-Lowering Statin Meds, in broad strokes the new guidelines state that if you are in one of the following four groups you have elevated heart disease risk and should take statins:

  1. those who already have cardiovascular disease
  2. anyone with LDL (bad) cholesterol of 190 mg/dL or higher
  3. anyone between 40 and 75 years of age who has Type 2 diabetes
  4. people between 40 and 75 who have an estimated 10-year risk of cardiovascular disease of 7.5 percent or higher.

To determine your personal 10-year risk of cardiac disease, the new guidelines included an online calculator * … and now that a few months have passed, there’s even AN APP FOR THAT (links to the app are on the online calculator webpage – or search ‘ASCVD Risk” in iTunes store). I downloaded the app for my iPhone and it’s quite handy as it saves your data and also provides articles about key topics like ‘diet and physical activity recommendations,’ and ‘common cardiovascular terms,’ and the like – right in the app.
* NOTE – if the link does not work, check for an updated link on my RESOURCES page.

One of the more interesting topics I found inside the app (in the Patients’ Blood Cholesterol Management Recommendations tab) discussed additional blood tests. After reviewing with your doctor your ‘lifetime risk estimate’ based on the inputs in the calculator/app, the article stated there were three additional tests your doctor may want to order:  Coronary Artery Calcium (CAC), High-Sensitivity C-Reactive Protein (CRP) and Ankle-Branchial Index (ABI).

The Coronary Artery Calcium test was one my doctor had talked with me about a few years ago. She asked me to find out whether anyone in my family (all of whom take a statin to manage high cholesterol) had had a Coronary Artery Calcium test done, and if so, what the results were. I failed at that. Apparently, I need to email all my cousins and aunts and uncles.  Today.

As I wrote about in Cholesterol Tests Your Doctor Hasn’t Told You About, the C-Reactive Protein test is a test (along with apo-B) that I would really like done to truly understand my cardiac risk. CRP is a measure of inflammation in the body and high levels have been associated with heart disease.  But my doctor declined to order either test for me back a year or two ago – said with my just-over-220 total cholesterol levels, I didn’t need these tests.

The Ankle-Branchial Index I’ve never heard of before. According to the ASCVD Risk app, ABI measures “the ratio of the blood pressure in the ankle compared to blood pressure in the arm, which can predict peripheral artery disease (PAD).”

So I will have to ask my doctor again about Coronary Artery Calcium, CRP, apo-B and ABI testing. I feel sure she won’t agree to this testing because my newly calculated lifetime risk is far below the 7.5% risk that indicates statin medication is needed.

That said, these tests are at least mentioned within the new guidelines, while others, like Non-HDL cholesterol are now no longer viewed as vital to determining cardiac disease risk and treatment plans. So even though my risk is low under the new guidelines and I am no longer in the group that should be taking statins, I want to ask about whether these tests might provide further insight into cardiac risk.

If you haven’t read about the new guidelines or found the new online calculator intimidating, download the new app.* Knowing your cardiac risk before you talk to your doctor will give you more confidence to ask questions about your risk of cardiac disease at your next appointment.

* You can’t use the calculator/app if you already have cardiac disease or take statins. If that’s you, best bet is to talk with your doctor about what the new guidelines mean for you and/or if a change in your statin medication is warranted.

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