AHA Scientific Sessions 2026 Abstract · Nov 2, 2026
Elevated High-Sensitivity C-Reactive Protein as a Prescribing Trigger versus a Risk-Enhancing Factor Identifies Distinct Primary Prevention Populations for Statin Therapy
By Kramer E, Sha Z, Penmetcha A et al.
Background: Whether elevated high-sensitivity C-reactive protein (hs-CRP) should independently prompt statin initiation or refine treatment decisions among patients at borderline atherosclerotic cardiovascular disease (ASCVD) risk is unclear. The 2025 American College of Cardiology Scientific Statement on Inflammation supports statin initiation based on hs-CRP ≥3 mg/L alone, whereas the 2026 Joint Committee Guideline on Dyslipidemia recommends hs-CRP ≥2 mg/L to guide statin initiation among patients with borderline 10-year ASCVD risk (PREVENT score 3-<5%). Question: Does elevated hs-CRP as a standalone statin indication versus a risk-enhancing factor in borderline-risk patients identify groups with different risk profiles and ASCVD rates? Methods: We analyzed CARDIA (Coronary Artery Risk Development in Young Adults) participants without prior ASCVD and PREVENT 10-year ASCVD risk <5%. Participants were categorized into three groups: (1) hs-CRP-Driven Strategy (hs-CRP ≥3 mg/L); (2) Borderline-Risk Refinement Strategy (hs-CRP ≥2 mg/L and PREVENT 3-<5%); and (3) no statin indication under either strategy. The primary outcome was eight-year ASCVD (nonfatal myocardial infarction, coronary death, or fatal/nonfatal stroke). Multivariable logistic regression evaluated the association between hs-CRP and ASCVD, adjusting for variables used in the PREVENT calculation. Results: Among 2,149 individuals, 473 (22%) met statin criteria under the hs-CRP-Driven Strategy versus 92 (4.3%) under the Borderline-Risk Refinement Strategy; 1,638 (76.2%) had no statin indication under either strategy. The hs-CRP-Driven Strategy group was 70.0% female versus 32.6% in the Borderline-Risk Refinement Strategy group. Compared to individuals without a statin indication, both strategies identified patients with higher BMI, blood pressure, and triglycerides. The Borderline-Risk Refinement Strategy also identified patients with higher age, rates of diabetes and smoking, and LDL (Table 1). Overall, ASCVD occurred in 69 patients (3.2%): 2.6% with no statin indication, 4.4% in the hs-CRP-Driven Strategy, and 9.8% in the Borderline-Risk Refinement Strategy (Figure 1). After adjustment, hs-CRP was not independently associated with ASCVD (OR 1.06, 95% CI 0.94-1.19, p=0.32). Conclusion: Using elevated hs-CRP as a standalone statin indication identified five times more patients and a disproportionately more female population compared to using it to refine decisions in patients with borderline ASCVD risk. Despite higher ASCVD event rate in the Borderline-Risk Refinement Strategy group, hs-CRP was not independently associated with ASCVD after adjusting for conventional risk factors. Our findings illustrate how different strategies incorporating hs-CRP into recommendations may alter the statin prescribing burden, sex composition, and risk profile of patients selected for therapy.