Inflammation and lipids in coronary pathology. Risk factors, triggering causes or therapeutic targets?

The search for new risk markers of cardiovascular (CV) risk is continuous, aimed to improve its estimate. Among them, the measurement of C-reactive protein (CRP) levels seems the most promising one. CV risk evaluation systems as Reynolds score, integrating CPR dosage to classic risk factors, were shown to improve the detection of subjects at higher risk, who deserve a more effective CV prevention. The use of CRP as a guide in primary prevention was tested for the first time in the JUPITER study, a large randomized trial comparing rosuvastatin 20 mg and placebo. Admission criteria were based on the presence of an inflammatory status only (CRP >2 mg/l), aside from CV risk factors (LDL <130 mg/dl). Rosuvastatin 20 mg, compared to placebo, significantly reduced composite primary endpoint (CV mortality, myocardial infarction, ischemic stroke, hospitalization for unstable angina and myocardial revascularization). These results confirmed the continuous relationship between decreased cholesterol level and clinical benefit also in primary prevention. The high prevalence of metabolic syndrome in this study population confirmed the link between this condition and the presence of an inflammatory status, and the high incidence of events occurred in the placebo group suggests an important role of CRP in the detection of subjects at higher CV risk. The greatest reduction of CV events was seen in the subgroup of patient who achieved the "double target" of both decreased lipids and inflammation marker, similarly to PROVE IT-TIMI 22 in secondary prevention. The presence of an inflammatory status may allow the detection of more vulnerable patients, where statin treatment may result in a greater benefit, as both LDL cholesterol and inflammatory status are reduced, and clinical CV events are consequently decreased.