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Sonni Logan, RN, at work in the cardiac cath lab at Northridge Hospital Medical Center in Northridge, Calif.

For many years, a good cholesterol number has been akin to earning an A on the heart health report card. But today, cardiac screening is moving beyond cholesterol counts and lifestyle assessments to detect the risk of heart attack.

An emerging indicator of risk is CRP, or C-reactive protein, a sign of low-grade inflammation in coronary vessels that can signal heart disease risk even in seemingly healthy people.

While high cholesterol, high blood pressure, smoking, heredity, obesity, and a sedentary lifestyle are pegged as the prime risk factors for heart disease, nurses are finding highly sensitive CRP tests to be a valuable new tool in patient evaluations.

Increased levels of CRP, found in trace amounts in healthy people, are viewed by some clinicians as the key biomarker for the risk of heart attack, surpassing results obtained by testing total cholesterol, low density lipoprotein (LDL or “bad”) cholesterol, or homocysteine.

“If a patient has risk factors for heart disease — smoking, obesity, inactivity — and the cholesterol levels are non-favorable, well that’s four markers and it’s a high score,” says Teri Hernandez, RN, a clinical research nurse at the University of Colorado Health Sciences Center at Fitzsimons, Colo. “But if the CRP levels come in high, that means a lot more in telling me that the person needs to make changes.”

Detection and education

Early detection of coronary heart disease, the leading cause of death of both men and women, is a major goal of researchers, says Hernandez. Tests that signal cardiovascular dangers give nurses an opportunity to work with patients to reduce risk factors and increase longevity through heart-healthy lifestyle changes and medications.

At Southern California’s Northridge Hospital Medical Center, cardio CRP tests are often used to look for inflammatory symptoms, usually in conjunction with cholesterol screening, says Sonni Logan, RN, BSN, the clinical supervisor for the cardiac cath lab. While cardio CRP tests are fairly new and still somewhat questionable, they are a predictor of inflammation of coronary arteries and can indicate the risk of a heart attack even when cholesterol readings are normal, says Logan.

“One reason we jumped aboard is because high cholesterol levels are only present in half of the people who have heart attacks and we needed a more sensitive test to assess risk,” says Logan, adding that cardio CRP tests started at Northridge in 2001.

Logan’s been supervisor of the clinical cath lab for four years, after having spent 10 years in the ICU and 11 in the ER at Northridge. “Even in the ER and ICU I was always considered the heart nurse, so I came here with a lot of skills in that area,” says Logan. “It feels good to offer that experience to patients.”

Logan says patients coming to the cath lab are a captive audience and this gives nurses the opportunity to explain test results and impart heart-healthy advice. “We take the bull by the horns and say, ‘You’ve got issues here,’” she says. One risk factor reaching epidemic proportions locally and nationally is obesity and, regardless of test outcomes, overweight patients are urged to watch their diet and exercise more, she says.

“There’s an old adage: Just moderate,” says Logan. “Go up the stairs instead of taking the elevator. Take a parking space where you have to walk further. And stay away from fatty foods. They may add taste, but they don’t benefit your health.”

Hernandez, a nurse for 11 years, 10 in cardiovascular care, also recalls enjoying her role in educating patients in a cardiac rehab program at Baylor University Medical Center in Dallas. “I like to think that every patient would want to review their heart attack risk factors. I used to walk around with a big stack of pamphlets and articles. It was prime time for education.”

More study needed

Hernandez is now working toward a PhD at the Colorado teaching hospital campus, participating in two research projects involving CRP with Bob Eckel, MD, a professor of medicine in biophysics and physiology and the division of endocrinology, metabolism, and diabetes.

One study looked at the short-term effects of simvastatin (Zocor), a drug that lowers LDL cholesterol and can also lower CRP. In people with high lipid values, it took 14 days to bring CRP levels down. The second study looked at the effects of the statin on people with Type 2 diabetes, who also have a higher risk of heart events. Preliminary data shows lipid levels dropping significantly within two weeks, with positive results by day seven.

There are still no studies, however, that show lowering CRP reduces the risk of a heart attack, notes Hernandez. High levels of CRP are also caused by obesity, rheumatoid arthritis, diabetes, and cancer, which is one reason Hernandez doesn’t see CRP being effective as a stand-alone test. Also, for younger people and those with no family history of heart disease, a good cholesterol panel test score is usually an accurate predictor of low risk, she says.

For nurses seeking additional information about tests for heart disease, Hernandez recommends going to the American Heart Association’s position paper posted on its website, www.americanheart.org. The same site has a 13-page scientific paper by the AHA and Centers for Disease Control, “Markers of Inflammation and Cardiovascular Disease,” available for downloading.

Patricia Armstrong, RN, FNP, cardiac educator at Rogue Valley Medical Center in Medford, Ore., says CRP tests are rare in inpatient acute care settings because CRP is a predictor of an event that has already occurred. However, patients who have had a coronary event or stent are given statin medications if they can tolerate them, and these do reduce CRP levels.