Why doctors should reconsider ordering a CRP to screen patients for heart disease

The CRP, or C-reactive protein, is a test that many doctors use to screen for heart disease.

And indeed, studies have associated an elevated level with an increased risk of coronary artery disease. But there is little data showing that reducing the CRP level saves lives. That hasn’t stopped both doctors and patients from inappropriately ordering the test.

Although not expensive by itself, it serves as a gateway to more intense, and expensive, testing, like stress tests or cardiac catheterizations. Patients at borderline risk for heart disease, who have an elevated CRP level, are often placed on cholesterol medications.

As we inch closer to mandating medical decisions be based on the evidence, it’s interesting to note that the foremost authority, namely, the USPSTF, doesn’t recommend widespread use of the CRP to screen for heart disease.

In their latest recommendations, here’s what they state: “The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to assess the balance of benefits and harms of using the nontraditional risk factors discussed in this statement to screen asymptomatic men and women with no history of CHD to prevent CHD events . . . The nontraditional risk factors included in this recommendation are high-sensitivity C-reactive protein (hs-CRP), ankle–brachial index (ABI), leukocyte count, fasting blood glucose level, periodontal disease, carotid intima–media thickness (carotid IMT), coronary artery calcification (CAC) score on electron-beam computed tomography (EBCT), homocysteine level, and lipoprotein(a) level.”

Will patients accept the fact that there’s not enough evidence to support indiscriminate ordering of the CRP? Will doctors hold off on a test that potentially can inflate health spending for little value?

Health reformers, who generally espouse medical decision making based on empirical evidence, had better hope so.

As an aside, Gary Schwitzer laments the silence of mainstream media on the issue. MedPage Today’s Peggy Peck also shares her thoughts.

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  • christophil M.D.

    Well read physicians already know the data but patients are about to get a dose of reality. No more trendy tests, now that’s reform!

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    I am wary of may of these surrogate tests that are easy for physicians to respond to, but may not help actual patients. The ESR is another example of a test that is often overused. “Wow! The ESR is 80, this guy must be sick!” The fever, abdominal pain and elevated WBC should have convinced us of this already.

  • Dr. C

    Testing for test’s sake only engenders more worry and uncertainty. Healthy lifestyle practices are abundantly more worthwhile than trendy tests.

  • http://advancedmediterraneandiet.com/blog/ Steve Parker, M.D.

    The JUPITER study from about a year ago showed a health benefit to using Crestor in middle-aged healthy people with elevated hs-CRP. The problem is, to prevent just one death, heart attack, or stroke over the course of two years, you have to treat 120 people with the drug. So 119 people are subjected to cost ($3.45/day for the pill), risk, and hassle . . . with no benefit.

    I’m not sure it’s worth it.

    -Steve

    Reference: http://advancedmediterraneandiet.com/blog/?p=88

  • Phillip Duncan, MD

    If used appropriately hs-CRP can be a very useful tool in achieving the types of lifestyle changes necessary to reduce risk. If a doc uses the information inappropriately to justify unnecessary procedures then it’s not the fault of the test. The bottomline is we need to use our tools appropriately, whether that be lab tests, imaging or invasive procedures.