Clinical Geriatrics

One of the major health concerns for older persons is their potential risk for serious cardiovascular events, a risk that rises dramatically with increasing age.1^1,2 For example, the average annual rate of first major cardiovascular events rises from 7 per 1000 men at ages 35-44 years to 68 per 1000 men at ages 85-94; comparable rates occur in women 10 years later in life.³

Coronary heart disease (CHD) is more prevalent in the elderly, with over 83% of cardiovascular disease deaths in the United States occurring in individuals age 65 years or older.⁴ Individuals in the sixth decade of life or older have a considerably higher absolute risk of an acute coronary event.³ Most persons in this age group will have a 10% or greater risk of a cardiovascular event over their next 10 years of life.² The challenge for the primary care physician is to identify those older patients who are at greatest risk and target them for closer monitoring and aggressive treatment. Standard risk models cannot identify all those at risk.⁵ However, given the high incidence of cardiovascular events in this age group, a relatively small increase in predictive ability could significantly improve the physician’s ability to identify high-risk patients.⁶ Furthermore, even when identified, patients at high risk may perceive themselves as healthy and decline treatment. Can newer risk factors be useful in further assessing and effectively illustrating the risk?

We are thoroughly familiar by now with the standard risk factors for cardiovascular disease and their utility for predicting risk. The Framingham risk calculator, in particular, can be a very useful tool for assessing 10-year cardiovascular risk.² Over the last 30 years, elevated cholesterol—particularly low-density lipoprotein cholesterol (LDL-C)—has been proven to be a key marker of cardiovascular risk, and lowering LDL-C by the use of statins is recognized as a potent preventive tool. The National Cholesterol Education Program (NCEP) has published an update to its 2001 guidelines for the diagnosis and treatment of high blood cholesterol, recommending even lower levels of LDL-C as an option for patients at highest risk of cardiovascular disease.⁷ It should be noted, however, that LDL-C may be less reliable as a predictor of cardiovascular events in elderly persons.² The Framingham risk score, too, is generally less accurate in older persons because of competing health issues, and for persons over age 80 years it cannot even be calculated.

We may consider using additional risk factors to help identify high-risk patients who may be candidates for more aggressive treatment. By 1981, 246 risk factors for CHD had been identified.8 Most of these have proven to be of little help to the clinician or the patient, however, because they fail to identify a significant number of patients who present with active disease. In contrast, several newer risk factors deserve our consideration. The most promising of these is C-reactive protein (CRP), a continuing focus of attention and the subject of recent studies specific to older men and women.^6,9,10

What Is C-Reactive Protein?
Our understanding of the pathogenesis of atherosclerosis has advanced enormously in the past decade. Atherosclerosis is now considered to be an inflammatory disease.^11,12 C-reactive protein is an acute phase reactant that signals acute systemic inflammation.