C-Reactive Protein and Heart Failure after Myocardial Infarction in the Community

doi:10.1016/j.amjmed.2006.07.039

The American Journal of Medicine

Volume 120, Issue 7, July 2007, Pages 616-622

https://doi.org/10.1016/j.amjmed.2006.07.039 Get rights and content

Abstract

Background

There is a paucity of data on the prognostic role of C-reactive protein (CRP) measured after myocardial infarction. We prospectively examined the association of CRP with heart failure and death among patients with myocardial infarction in the community.

Methods and Results

All Olmsted County residents who had a myocardial infarction meeting standardized criteria were prospectively enrolled to measure CRP on admission and followed for heart failure and death. A total of 329 consecutive patients (mean age 69 ± 16 years, 52% men) were enrolled. At 1 year, 28% of patients experienced heart failure and 20% died. There was a strong positive graded association between CRP and the risk of developing heart failure, as well as dying over the period of follow-up (P < .001). Compared with patients in the first tertile, patients in the third tertile of the CRP distribution had a markedly increased risk of heart failure and death independently of age, sex, troponin T, Q wave, comorbidity, previous myocardial infarction, and recurrent ischemic events (adjusted hazard ratio 2.47 [95% confidence interval, 1.27-4.82] for heart failure and 3.96 [95% confidence interval, 1.78-8.83] for death).

Conclusions

These prospective data indicate that among contemporary community subjects with myocardial infarction, heart failure and death remain frequent complications. CRP is associated with a large increase in the risk of heart failure and death, independently of age, sex, myocardial infarction severity, comorbidity, previous myocardial infarction, and recurrent ischemic events. These data suggest that inflammatory processes may play a role in the development of heart failure and death after myocardial infarction independently of other conventional prognostic indicators.

Section snippets

Study Population

Olmsted County, Minnesota, is relatively isolated from other urban centers, and nearly all medical care in virtually every specialty is delivered to residents by a few providers,²⁰ which include the Mayo Clinic and its affiliated hospitals; the Olmsted Medical Center and its affiliated community hospital; local nursing homes; and a few private practitioners. Each provider in the community uses 1 medical record, whereby all medical information for each individual is in a single file. Through the

Results

We included 329 subjects with a mean age of 69 ± 16 years; 52% were men, 269 patients had definite myocardial infarction, and 60 patients had probable myocardial infarction. CRP was measured a median of 6.1 hours (25th-75th percentile 1.2-11.0 hours) after symptom onset. The median CRP was 5.7 mg/L (25th-75th percentile 2.0-31.0 mg/L). The baseline characteristics were examined according to the tertiles of the distribution of CRP (Table 1). Tertile 1 includes patients with CRP less than 3 (n =

Discussion

Heart failure and death remain frequent after myocardial infarction, as shown in this contemporary, geographically defined cohort of patients with rigorously ascertained myocardial infarction. CRP measured on hospital admission for myocardial infarction is associated with a strong, positive graded increase in the risk of heart failure and death independently of known prognostic factors. Because CRP was not associated with conventional measures of myocardial infarction size (Q waves, ST

Conclusion

These prospective data indicate that in the community, heart failure and death remain frequent after myocardial infarction. CRP is associated with a large increase in the risk of heart failure and death independently of other risk predictors. These data suggest that inflammatory processes play an independent role in the development of heart failure and death after myocardial infarction. Thus, CRP may assist in risk stratification after myocardial infarction.

Acknowledgments

We thank the following individuals for their support with data collection, data entry and analysis, and article preparation: Kay A. Traverse, RN, Susan Stotz, RN, and Kristie K. Shorter. We are grateful to Ellen Koepsell, RN, study manager.

References (50)

F.A. Spencer et al.
Twenty year trends (1975-1995) in the incidence, in-hospital and long-term death rates associated with heart failure complicating acute myocardial infarction: a community-wide perspective
J Am Coll Cardiol
(1999)
D.A. Morrow et al.
C-reactive protein is a potent predictor of mortality independently of and in combination with troponin T in acute coronary syndromes: a TIMI 11A substudyThrombolysis in Myocardial Infarction
J Am Coll Cardiol
(1998)
S.K. James et al.
Troponin and C-reactive protein have different relations to subsequent mortality and myocardial infarction after acute coronary syndrome: a GUSTO-IV substudy
J Am Coll Cardiol
(2003)
G. Berton et al.
C-reactive protein in acute myocardial infarction: association with heart failure
Am Heart J
(2003)
H.K. Yip et al.
Level of high-sensitivity C-reactive protein is predictive of 30-day outcomes in patients with acute myocardial infarction undergoing primary coronary intervention
Chest
(2005)
M. Suleiman et al.
Admission C-reactive protein levels and 30-day mortality in patients with acute myocardial infarction
Am J Med
(2003)
J.S. Gottdiener et al.
Predictors of congestive heart failure in the elderly: the Cardiovascular Health Study
J Am Coll Cardiol
(2000)
V. Bodi et al.
Multimarker risk strategy for predicting 1-month and 1-year major events in non-ST-elevation acute coronary syndromes
Am Heart J
(2005)
C. Heeschen et al.
Predictive value of C-reactive protein and troponin T in patients with unstable angina: a comparative analysisCAPTURE Investigators. Chimeric c7E3 AntiPlatelet Therapy in Unstable angina REfractory to standard treatment trial
J Am Coll Cardiol
(2000)
L.J. Melton
History of the Rochester Epidemiology Project
Mayo Clin Proc
(1996)

V.L. Roger et al.

Coronary disease surveillance in Olmsted County objectives and methodology

J Clin Epidemiol

(2002)

M.E. Charlson et al.

A new method of classifying prognostic comorbidity in longitudinal studies: development and validation

J Chron Dis

(1987)

K.D. Lindsted et al.

Healthy volunteer effect in a cohort study: temporal resolution in the Adventist health study

J Clin Epidemiol

(1996)

A.S. Gabriel et al.

IL-6 levels in acute and post myocardial infarction: their relation to CRP levels, infarction size, left ventricular systolic function, and heart failure

Eur J Intern Med

(2004)

M. Suleiman et al.

Early inflammation and risk of long-term development of heart failure and mortality in survivors of acute myocardial infarction predictive role of C-reactive protein

J Am Coll Cardiol

(2006)

P. Knuefermann et al.

The role of innate immune responses in the heart in health and disease

Trends Cardiovasc Med

(2004)

J.S. Zebrack et al.

Should C-reactive protein be measured routinely during acute myocardial infarction?

Am J Med

(2003)

P.G. Steg et al.

Predischarge C-reactive protein and 1-year outcome after acute coronary syndromes

Am J Med

(2006)

S. De Servi et al.

C-reactive protein increase in unstable coronary disease cause or effect?

J Am Coll Cardiol

(2005)

M.R. Cusack et al.

Systemic inflammation in unstable angina is the result of myocardial necrosis

J Am Coll Cardiol

(2002)

J.E. Moller et al.

Wall motion score index and ejection fraction for risk stratification after acute myocardial infarction

Am Heart J

(2006)

R.J. Gibbons et al.

The quantification of infarct size

J Am Coll Cardiol

(2004)

V.L. Roger et al.

Trends in the incidence and survival of patients with hospitalized myocardial infarction, Olmsted County, Minnesota, 1979 to 1994

Ann Intern Med

(2002)

J.P. Hellermann et al.

Incidence of heart failure after myocardial infarction: is it changing over time?

Am J Epidemiol

(2003)

U.C. Guidry et al.

Temporal trends in event rates after Q-wave myocardial infarction: the Framingham Heart Study

Circulation

(1999)

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Interleukin-1 blockade with anakinra reduces C-reactive protein (CRP) levels and prevents heart failure (HF) events after ST-segment myocardial infarction (STEMI). The effectiveness of anakinra according to the degree of systemic inflammation in STEMI has not been addressed.
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: Supported in part by grants from the Public Health Service and the National Institutes of Health (AR30582, R01 HL 59205, R01 HL 72435) and by an American Heart Association Postdoctoral Greater Midwest Fellowship Award to Dr Bursi. Dr Roger is an Established Investigator of the American Heart Association.

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AJM Theme Issue: Diabetes/MetabolismClinical research studyC-Reactive Protein and Heart Failure after Myocardial Infarction in the Community

Abstract

Background

Methods and Results

Conclusions

Section snippets

Study Population

Results

Discussion

Conclusion

Acknowledgments

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

Chest

Am J Med

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

Mayo Clin Proc

J Clin Epidemiol

J Chron Dis

J Clin Epidemiol

Eur J Intern Med

J Am Coll Cardiol

Trends Cardiovasc Med

Am J Med

Am J Med

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

Trends in the incidence and survival of patients with hospitalized myocardial infarction, Olmsted County, Minnesota, 1979 to 1994

Ann Intern Med

Incidence of heart failure after myocardial infarction: is it changing over time?

Am J Epidemiol

Temporal trends in event rates after Q-wave myocardial infarction: the Framingham Heart Study

Circulation

AJM Theme Issue: Diabetes/Metabolism
Clinical research study
C-Reactive Protein and Heart Failure after Myocardial Infarction in the Community