Journal Information
Vol. 38. Issue 4.
Pages 279-280 (April 2019)
Download PDF
More article options
Vol. 38. Issue 4.
Pages 279-280 (April 2019)
Editorial comment
Open Access
C-Rreactive protein/albumin ratio in the assessment of risk for in-stent restenosis: Another small piece in the puzzle of vascular inflammation
A relação da proteína C-reativa/albumina na avaliação do risco de reestenose de stent: mais uma pequena peça novasto puzzle da inflamação vascular
Luís Bronzea,b,c,
Corresponding author
a Cardiologista, Marinha Portuguesa, Lisboa, Portugal
b Linha de Saúde, Centro de Investigação Naval (Cinav), Marinha Portuguesa, Lisboa, Portugal
c Professor Auxiliar, Mestrado Integrado de Medicina, Universidade da Beira Interior, Covilhã, Portugal
Article information
Full Text
Download PDF
Full Text

The study presented by Rencuzogullari et al. in this issue of the Journal1 is part of the large and important body of evidence on the role of inflammation in cardiovascular disease.2–5 The authors aimed to investigate the ability of the ratio between serum levels of two important acute-phase proteins, C-reactive protein (CRP) and albumin, to predict in-stent restenosis. There is already an extensive literature on the association between CRP and cardiovascular risk,6–8 but its ability to predict acute coronary syndromes is modest.9–11 A positive relationship between elevated serum CRP levels and in-stent restenosis, the clinical focus of the study under consideration, has also been established.12 At the same time, reduced serum concentrations of albumin have been related to increased cardiovascular risk.13,14 Furthermore, the CRP/albumin ratio has been associated with worse prognosis in cancer15 and can be used as a simple predictor of poor overall health.16

From a clinical standpoint, assessment of the combination of increased CRP and decreased albumin levels makes sense, seeing that these two molecules are involved in a range of complex and frequently interlinked processes ranging from inflammation to malnutrition, and so in theory the ratio between them should have considerable potential as a prognostic marker. However, Rencuzogullari et al. run a risk by attempting to associate this ratio with in-stent restenosis (a serious albeit uncommon complication of percutaneous revascularization17) since, like all indices of inflammatory markers used in cardiovascular assessment, it is non-specific.

The study is retrospective, reviewing around six years of data from a single institution. The population was of patients with ST-segment elevation myocardial infarction who underwent coronary angiography and percutaneous coronary intervention following standard indications. Of these, 448 who underwent repeat angiography due to recurrence of anginal symptoms were included in the study, of whom 25% (110/448) presented in-stent restenosis.

Unfortunately, the study did not use high-sensitivity CRP assays, which are firmly established in the literature as the gold standard for assessing vascular inflammation.18 The authors acknowledge that their use of an older test, which is less sensitive and more likely to be influenced by rises in CRP due to non-vascular causes, is a limitation to their study. Their results also include a wide range of laboratory results, from lipid profile to platelet count, as well as platelet distribution width, which is associated with myocardial infarction.19 The study thus has the characteristics of a general review of in-stent restenosis, even though drug-eluting stents, which were designed to be less prone to restenosis, were not used. This limitation was also pointed out by the authors.

The study concludes that the CRP/albumin ratio is a better predictor than CRP or albumin individually, at least in bare-metal stents. Overall, the work has merit, especially in the emphasis it places on the use of inflammatory parameters in clinical practice. However, despite recent successes in proof-of-concept trials,20 and although inflammation has been the focus of much productive and challenging basic and clinical research over the last twenty years, there is still some way to go before all the accumulated evidence can be brought to bear on daily clinical practice.21

To conclude, despite its limitations, the paper under consideration adds another small piece to the puzzle in this challenging area in which research continues apace, even though its conclusions need to be confirmed by further studies.

Conflicts of interest

The author has no conflicts of interest to declare.

I. Rencuzogullari, Y. Karabağ, M. Çağdaş, et al.
Assessment of the relationship between preporcedural C-reactive protein to albumin ratio and stent restenosis in patients with ST segment elevation myocardial infarction.
Rev Port Cardiol, 38 (2019),
R. Ross.
Atherosclerosis is an inflammatory disease.
Am Heart J, 138 (1999), pp. S419-S420
P. Libby, P.M. Ridker, A. Maseri.
Inflammation and atherosclerosis.
Circulation, 105 (2002), pp. 1135-1143
P. Libby.
Inflammation in atherosclerosis.
Nature, 420 (2002), pp. 868-874
G.K. Hansson, P. Libby, U. Schonbeck, et al.
Innate and adaptive immunity in the pathogenesis of atherosclerosis.
Circulation Res, 91 (2002), pp. 281-291
P. Libby, F. Crea.
Clinical implications of inflammation for cardiovascular primary prevention.
Eur Heart J, 31 (2010), pp. 777-783
E. Zakynthinos, N. Pappa.
Inflammatory biomarkers in coronary artery disease.
J Cardiol, 53 (2009), pp. 317-333
W. Koenig, M. Sund, M. Frohlich, et al.
C-Reactive protein, a sensitive marker of inflammation, predicts future risk of coronary heart disease in initially healthy middle-aged men: results from the MONICA (Monitoring Trends and Determinants in Cardiovascular Disease) Augsburg Cohort Study, 1984 to 1992.
Circulation, 99 (1999), pp. 237-242
A. Arbab-Zadeh, M. Nakano, R. Virmani, et al.
Acute coronary events.
Circulation, 125 (2012), pp. 1147-1156
J.C. Kaski, D.J. Fernandez-Berges, L. Consuegra-Sanchez, et al.
A comparative study of biomarkers for risk prediction in acute coronary syndrome – results of the SIESTA (Systemic Inflammation Evaluation in non-ST-elevation Acute coronary syndrome) study.
Atherosclerosis, 212 (2010), pp. 636-643
A.L. Catapano, I. Graham, G. De Backer, et al.
2016 ESC/EAS Guidelines for the Management of Dyslipidaemias.
Eur Heart J, 37 (2016), pp. 2999-3058
W.K. Jeong, M.H. Jeong, K.H. Kim, et al.
An elevated value of C-reactive protein is the only predictive factor of restenosis after percutaneous coronary intervention.
Korean J Intern Med, 18 (2003), pp. 154-160
S.C. Chien, C.Y. Chen, H.B. Leu, et al.
Association of low serum albumin concentration and adverse cardiovascular events in stable coronary heart disease.
Int J Cardiol, 241 (2017), pp. 1-5
S.C. Chien, C.Y. Chen, C.F. Lin, et al.
Critical appraisal of the role of serum albumin in cardiovascular disease.
Biomarker Res, 5 (2017), pp. 31
M. Kunizaki, T. Tominaga, K. Wakata, et al.
Clinical significance of the C-reactive protein-to-albumin ratio for the prognosis of patients with esophageal squamous cell carcinoma.
Mol Clin Oncol, 8 (2018), pp. 370-374
E. Fairclough, E. Cairns, J. Hamilton, et al.
Evaluation of a modified early warning system for acute medical admissions and comparison with C-reactive protein/albumin ratio as a predictor of patient outcome.
Clin Med, 9 (2009), pp. 30-33
P. Tyczynski, M.A. Karcz, L. Kalinczuk, et al.
Early stent thrombosis. Aetiology, treatment, and prognosis.
Postepy w kardiologii interwencyjnej=Advances in Interventional Cardiology, 10 (2014), pp. 221-225
K.K. Ray, C.P. Cannon, R. Cairns, et al.
Prognostic utility of apoB/AI, total cholesterol/HDL, non-HDL cholesterol, or hs-CRP as predictors of clinical risk in patients receiving statin therapy after acute coronary syndromes: results from PROVE IT-TIMI 22.
Arterioscl thromb Vasc Biol, 29 (2009), pp. 424-430
M. Cetin, E.M. Bakirci, E. Baysal, et al.
Increased platelet distribution width is associated with ST-segment elevation myocardial infarction and thrombolysis failure.
Angiology, 65 (2014), pp. 737-743
B. Ibanez, V. Fuster, CANTOS:.
A Gigantic Proof-of-Concept Trial.
Circ Res, 121 (2017), pp. 1320-1322
P. Libby, G.K. Hansson.
Taming immune and inflammatory responses to treat atherosclerosis.
J Am Coll Cardiol, 71 (2018), pp. 173-176

Please cite this article as: Bronze L. A relação da proteína C-reativa/albumina na avaliação do risco de reestenose de stent: mais uma pequena peça no vasto puzzle da inflamação vascular. Rev Port Cardiol. 2019;38:279–280.

Copyright © 2019. Sociedade Portuguesa de Cardiologia
Revista Portuguesa de Cardiologia (English edition)

Subscribe to our newsletter

Article options
en pt

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

By checking that you are a health professional, you are stating that you are aware and accept that the Portuguese Journal of Cardiology (RPC) is the Data Controller that processes the personal information of users of its website, with its registered office at Campo Grande, n.º 28, 13.º, 1700-093 Lisbon, telephone 217 970 685 and 217 817 630, fax 217 931 095, and email I declare for all purposes that the information provided herein is accurate and correct.