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Are Heart Disease and Stroke Preventable?
 

Heart disease and stroke used to be diseases for people that are older, overweight or obese, stressed, physical inactive, and for those who smoke, have hypertension (high blood pressure) or family history of cardiovascular disease. But there is a growing number of victims, who cared about their health: not overweight and exercised regularly, died of heart attack or stroke in their mid-50s or even younger.

Traditionally, it is believed that heart attack and stroke occur because high low-density lipoprotein cholesterol (LDL) or the so-called bad cholesterol causes accumulation of fatty build-ups inside arteries that supply blood to the brain and heart. Yet, about half of all stroke and heart attack do occur in people who are apparently healthy and who have low or normal LDL level.

Fortunately, there is a way to help people who are likely victims of cardiovascular events. Doctors are now recommending testing of high-sensitivity C-Reactive Protein (hsCRP) for those who are at intermediate risk of a heart attack and are not sure if they should take statins or not to lower their lipid level.

Being a marker of inflammation, hsCRP predicts cardiovascular disease independent of LDL levels. hsCRP is a protein produced by the body when there is inflammation caused by an injury or infection. Elevating value of hsCRP has been shown to be an independent predictor of the risk of developing heart attack or stroke, even in people with normal LDL level.

In 2008, the findings of JUPITER trial were presented at the American Heart Association meeting and published in the ‘New England Journal of Medicine’. It reported that those patients with normal LDL level and who had no heart disease but with elevated hsCRP could actually benefit from treatment with rosuvastatin (a statin drug), under the brand of ‘Crestor’. The statin lowered the LDL level by 50 percent, which reduced stroke and heart attack, and improved overall survival rate. Previously, no evidence had suggested lowering LDL level in these patients could be beneficial.

JUPITER trial was aimed to evaluate if statins could reduce heart attack and stroke in people with normal LDL level. It began in 2003 and was directed by researchers from Brigham and Women’s Hospital in the United States. 17,802 patients who had no evidence of heart disease but had high hsCRP level were involved in the trial.

Rosuvastatin is a cholesterol-lowering medication that blocks the production of bad cholesterol in the body. It reduces level of LDL and triglycerides in the blood, while increasing level of HDL (high-density lipoprotein) or the so-called good cholesterol. In the Jupiter trial, it significantly reduced the relative risk of heart attack by 54 percent, stroke by 48 percent, and arterial revascularization by 46 percent.

Most health experts, however, do not think that hsCRP test is meant for the majority of people because it will not help people who already have high cholesterol and most certainly require treatment, and those who are at low risk. Instead, the test is relevant for those with borderline cholesterol results and cholesterol levels closed to the boundaries for treatment but not yet commence.

A new and large study of 3,404 Chinese, Malays and Asian-Indians conducted in Singapore showed that about a third of Singapore's population who have low LDL level and do not qualify for statin therapy have elevated hsCRP. These people are likely to be older, female, and are Malay or Asian-Indian, and are also more likely to be obese, have high level of blood pressure, triglyceride, and insulin resistance, and lower HDL.

Large waist circumference and smoking were identified as 2 of the independent and modifiable risk factors for elevated hsCRP. Obesity does result in higher CRP, and so is cardiovascular risk.

In Singapore, it is recommended that assessment of cardiovascular risk should first be taken based on the formula that has been developed by the Ministry of Health. Those at intermediate risk (between 5 and 20 percent risk of heart attack in the next 10 years) and have elevated hsCRP are advised to have treatment with a statin, though it does not have to be rosuvastatin.

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