Inflammation Now Predicts Heart Disease More Strongly Than Cholesterol Author: Brandon Ballinger Date: September 29, 2025 --- Key Update from the American College of Cardiology (ACC) Chronic inflammation doubles the risk of heart disease. Inflammation, specifically measured by high-sensitivity C-reactive protein (hs-CRP), is now recognized as a Standard Modifiable Risk Factor (SMuRF) for heart disease. ACC recommends universal screening of hs-CRP for both primary and secondary prevention along with cholesterol testing. Measuring inflammation is critical, as "clinicians will not treat what they do not measure." --- Inflammation (hs-CRP) vs Cholesterol in Predicting Heart Disease Traditionally, LDL cholesterol (or ApoB) has been the focus of cardiovascular risk. Recent evidence shows hs-CRP is a stronger predictor of heart disease than LDL cholesterol. Cholesterol has become a "victim of its own success" due to widespread statin use lowering LDL, leaving residual risk largely driven by non-SMuRF markers like inflammation. In patients on statins or without traditional risk factors ("SMuRF-less"), inflammation remains a key driver of cardiovascular events. Other factors (blood pressure, insulin resistance, kidney function) contribute additionally. --- What Can You Do to Lower Inflammation? Clinical Trials Summary | Trial | Drug (Class) | Outcome | |--------------|-------------------------------|-----------------------------------------| | JUPITER | Rosuvastatin (statin) | Reduced CV events in people with high hs-CRP despite normal LDL | | COLCOT | Colchicine | Reduced recurrent CV events | | LoDoCo2 | Colchicine | Reduced CV events in stable CAD | | CANTOS | Canakinumab (anti–IL-1β) | Reduced major adverse CV events (MACE), but expensive with infection risk | | ATTACH, ACCLAIM, CIRT, CLEAR SYNERGY, GISSI-HF, CORONA, OPT-CHF, DCMP, RENEWAL | Various anti-inflammatories (TNF inhibitors, methotrexate, corticosteroids) | Generally no significant benefit | Effective Strategies to Reduce Inflammation Statins: Lower risk even when LDL is normal, especially with elevated hs-CRP. Colchicine: FDA-approved (0.5 mg/day) adjunct for secondary prevention in stable ASCVD; avoid with severe kidney/liver disease. Canakinumab: Reduces events but costly and increases infection risk. Lifestyle: Anti-inflammatory diets (Mediterranean, DASH), exercise, smoking cessation, and weight management lower hs-CRP and cardiovascular risk. --- Understanding hs-CRP Levels <1 mg/L: Optimal (low inflammation, lower risk) 1–3 mg/L: Moderate risk >3 mg/L: High risk of cardiovascular events --- Other Inflammatory Biomarkers IL-6, fibrinogen, neutrophil-to-lymphocyte ratio, EPA/AA ratio, serum amyloid A also predict cardiovascular risk. However, once hs-CRP is measured, additional markers add little incremental value. --- Additional Insights from the ACC Article Imaging biomarkers (CT, PET, MRI) can detect vascular inflammation but aren't ready for routine clinical use. Bempedoic acid, a new cholesterol-lowering drug, also reduces hs-CRP; long-term effects are under study. Residual inflammatory risk remains even in patients with well-controlled LDL on statins. Universal hs-CRP screening is now recommended for everyone at risk or with known heart disease. New IL-6 inhibitors are under investigation as future anti-inflammatory treatments for heart disease. --- Measuring Your Inflammation hs-CRP blood tests are widely available and inexpensive. Recommended routinely by ACC for both at-risk individuals (primary prevention) and those with established heart disease (secondary prevention). Empirical Health offers a Comprehensive Health Panel that includes hs-CRP, ApoB,