THE PROGNOSTIC VALUE OF C-REACTIVE PROTEIN AND SERUM AMYLOID-A PROTEIN IN SEVERE UNSTABLE ANGINA

Background. The pathogenesis of unstable angina is poorly understood, and predicting the prognosis is problematic. Evidence suggests that there may be active inflammation, possibly in the coronary arteries, in this syndrome. We therefore studied the prognostic value of measurements of the circulating acute-phase reactants C-reactive protein and serum amyloid A protein, which are sensitive indicators of inflammation. Methods. We measured C-reactive protein, serum amyloid A protein, creatine kinase, and cardiac troponin T in 32 patients with chronic stable angina, 31 with severe unstable angina, and 29 with acute myocardial infarction. Results. At the time of hospital admission, creatine kinase and cardiac troponin T levels were normal in all the patients, but the levels of C-reactive protein and serum amyloid A protein were greater than or equal to 0.3 mg per deciliter (exceeding the 90th percentile of the normal distribution) in 4 of the patients with stable angina (13 percent), 20 of the patients with unstable angina (65 percent), and 22 of the patients with acute myocardial infarction (76 percent). The 20 patients with unstable angina who had levels of acute-phase reactants greater than or equal to 0.3 mg per deciliter had more ischemic episodes in the hospital than those with levels <0.3 mg per deciliter (mean [+/-SD] number of episodes per patient, 4.8+/-2.5 vs. 1.8+/-2.4; P = 0.004); 5 patients subsequently had a myocardial infarction, 2 died, and 12 required immediate coronary revascularization. In contrast, no deaths or myocardial infarction occurred among the 11 patients with levels of acute-phase reactants <0.3 mg per deciliter, and only 2 of them required coronary revascularization. Among the patients admitted with a diagnosis of acute myocardial infarction, unstable angina preceded infarction in 14 of the 22 patients (64 percent) with levels of acute-phase reactants greater than or equal to 0.3 mg per deciliter but in none of the 7 patients with levels <0.3 mg per deciliter. Conclusions. Elevation of C-reactive protein and serum amyloid A protein at the time of hospital admission predicts a poor outcome in patients with unstable angina and may reflect an important inflammatory component in the pathogenesis of this condition.