For decades, heart disease risk assessment has heavily focused on cholesterol levels, but a growing body of research suggests a more comprehensive approach is needed. New recommendations from the American College of Cardiology (ACC) now advocate for worldwide screening of C-reactive protein (CRP) alongside conventional cholesterol tests, signaling a potential paradigm shift in cardiovascular care. This biomarker, which indicates inflammation within the body, may offer a more accurate prediction of heart attacks and strokes-and could lead to more effective prevention strategies for the nationS leading cause of death.
Why Inflammation, Measured by C-Reactive Protein, May Be a Better Predictor of Heart Disease Than “Bad” Cholesterol
For decades, assessing cardiovascular risk has centered on cholesterol levels, but emerging research suggests that chronic, low-grade inflammation plays a central role in heart attacks and strokes. A biomarker indicating this inflammation may offer more relevant insights into a person’s risk.
Cardiovascular diseases are the leading cause of death in the United States. Following research in the 1950s that established a link between diet, cholesterol, and heart disease, risk assessment has largely relied on measuring cholesterol levels in the blood through routine tests.
However, over the past two decades, evidence has accumulated indicating that C-reactive protein (CRP), a biomarker signaling low-grade inflammation, is a better predictor of cardiovascular risk than cholesterol alone. This finding is prompting a re-evaluation of how heart disease risk is assessed and managed, potentially leading to more effective preventative strategies.
In September, the American College of Cardiology (ACC) published new recommendations for universal screening of C-reactive protein in all patients, alongside cholesterol evaluation. This guidance reflects the growing recognition of inflammation’s importance in cardiovascular health.
C-reactive protein is produced by the liver in response to infections, tissue injury, chronic inflammatory conditions associated with autoimmune diseases, and metabolic disorders like obesity and diabetes. Essentially, it’s a marker of inflammation – of the immune system being activated – within the body and can be easily measured through a blood test.
A level below 1 milligram per deciliter indicates minimal inflammation and is associated with cardiovascular protection, while values above 3 milligrams per deciliter signal increased inflammation and a higher risk of heart disease. Approximately 52% of Americans have elevated levels of this marker.
Studies show that C-reactive protein more accurately predicts heart attacks and strokes than “bad” cholesterol, or LDL (low-density lipoprotein), or another commonly measured, genetically inherited marker, lipoprotein(a).
One study found that the predictive value of C-reactive protein for heart disease is comparable to that of blood pressure.
Inflammation is involved in all stages of the formation of plaque in the arteries, a process called atherosclerosis, which can lead to heart attack and stroke.
When a blood vessel is damaged – for example, by high blood sugar or cigarette smoke – immune cells enter the area and engulf particles of cholesterol from the blood, forming a fatty plaque within the vessel wall.
This process unfolds slowly, over decades, until substances released by the immune system can crack or rupture the cap covering the plaque. At that point, a blood clot forms that can block the vessel, interrupting circulation and leading to a heart attack or stroke. Thus, cholesterol is only part of the mechanism, with the immune system involved in every stage of the disease.
Lifestyle significantly influences C-reactive protein levels. Dietary fiber from legumes, vegetables, nuts, and seeds, as well as foods like berries, olive oil, green tea, chia seeds, and flaxseeds, have been associated with lower levels of the marker. Weight loss and regular physical activity also reduce C-reactive protein.
While cholesterol is no longer considered the most important predictor of cardiovascular risk, it remains relevant. It’s not just the amount of LDL cholesterol that matters, but also the number of particles carrying it. A higher number of particles means a greater risk.
The apolipoprotein B test, which measures the number of these particles, provides a better estimate of risk than total LDL cholesterol.
Apolipoprotein B levels are influenced by diet, exercise, and weight, while fiber, nuts, and omega-3 fatty acids are associated with lower particle levels, and increased sugar consumption with higher numbers.
Lipoprotein(a), a protein associated with cholesterol particles, is another marker that estimates cardiovascular risk more accurately than cholesterol, as it promotes the retention of cholesterol within atherosclerotic plaque. Unlike other factors, lipoprotein(a) levels are genetically determined, are not influenced by lifestyle, and require measurement only once in a lifetime.
Overall, heart disease results from the interaction of multiple risk factors throughout life, and prevention goes beyond simply following a cholesterol-free diet. Knowing the levels of LDL cholesterol, C-reactive protein, apolipoprotein B, and lipoprotein(a) provides a more complete picture of risk and can support the long-term adoption of fundamental cardiovascular prevention measures.
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