Significance of C-reactive protein to albumin ratio and thrombus burden in acute coronary syndrome
DOI:
https://doi.org/10.15584/ejcem.2025.3.21Keywords:
acute coronary syndrome, albumin, C-reactive protein, thrombus burdenAbstract
Introduction and aim. Thrombus burden (TB) is a critical factor in the pathogenesis of acute coronary syndrome (ACS) pathogenesis with biomarkers such as C-reactive protein (CRP) and serum albumin that reflect systemic inflammatory and nutritional states. The CRP and albumin ratio (CAR) has emerged as a new composite marker, offering enhanced prognostic value. The aim of this study was to evaluate the association between CAR and TB in patients with ACS and to assess the predictive utility of CAR compared to CRP and albumin individually.
Material and methods. A hospital cross-sectional analytical study was conducted among 93 patients ages 18–60 years with ACS who underwent coronary angiography (CAG). CAR was calculated and its association with TB was analyzed.
Results. Of the participants, 9.7% had high tuberculosis. CAR, CRP, and albumin were significantly associated with TB (p<0.001). CAR showed the highest correlation (r=0.728) and perfect diagnostic accuracy (AUC=1), outperforming CRP (AUC=0.987) and albumin (AUC=0.030). High TB was significantly associated with the presentation of grade 1 TIMI and ST-elevated myocardial infarction (STEMI) presentation (p<0.05).
Conclusion. CAR is a reliable, accessible and independent biomarker for predicting TB in ACS, and its incorporation into standard clinical protocols could improve early risk stratification, therapeutic decision-making, and patient outcomes. More multicentric study are warranted to validate its broader clinical applicability.
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References
Makki N, Brennan TM, Girotra S. Acute coronary syndrome. J Intensive Care Med. 2015;30(4):186-200. doi: 10.1177/0885066613503294
Singh A, Museedi AS, Grossman SA. Acute Coronary Syndrome. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459157/. Accessed Jan 2, 2025.
Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published correction appears in Circulation. 2014;129(23):e650]. Circulation. 2014;129(23):2440-2492. doi: 10.1161/
CIR.0000000000000029
Tanboga IH, Topcu S, Aksakal E, et al. Determinants of Angiographic Thrombus Burden in Patients With ST-Segment Elevation Myocardial Infarction. Clin Appl Thromb. 2013;20(7):716-722. doi: 10.1177/1076029613483169
Jebari-Benslaiman S, Galicia-García U, Larrea-Sebal A, et al. Pathophysiology of Atherosclerosis. Int J Mol Sci. 2022;23(6):3346. doi: 10.3390/ijms23063346
Sianos G, Papafaklis MI, Serruys PW. Angiographic thrombus burden classification in patients with ST-segment elevation myocardial infarction treated with percutaneous coronary intervention. J Invasive Cardiol. 2010;22(10B):6B-14B.
Wiviott SD, Braunwald E, McCabe CH, et al. Prasugrel versus Clopidogrel in Patients with Acute Coronary Syndromes. N Engl J Med. 2007;357(20):2001-2015. doi: 10.1056/nejmoa0706482
Bhatt DL, Eagle KA, Ohman EM, et al. Comparative De terminants of 4-Year Cardiovascular Event Rates in Stable Outpatients at Risk of or With Atherothrombosis. JAMA. 2010;304(12):1350. doi: 10.1001/jama.2010.1322
Tian J, Dauerman H, Toma C, et al. Prevalence and Characteristics of TCFA and Degree of Coronary Artery Stenosis. J Am Coll Cardiol. 2014;64(7):672-680. doi: 10.1016/j.jacc.2014.05.052
Batty M, Bennett MR, Yu E. The Role of Oxidative Stress in Atherosclerosis. Cells. 2022;11(23):3843. doi: 10.3390/cells11233843
Acet H, Güzel T, Aslan B, et al. Predictive Value of C-Reactive Protein to Albumin Ratio in ST-Segment Elevation Myocardial Infarction Patients Treated With Primary Percutaneous Coronary Intervention. Angiology. 2020;72(3):244-251. doi: 10.1177/0003319720963697
Cheng L, Meng Z, Wang Q, et al. The Usefulness of C-Reactive Protein to Albumin Ratio in the Prediction of Adverse Cardiovascular Events in Coronary Chronic Total Occlusion Undergoing Percutaneous Coronary Intervention. Front Cardiovasc Med. 2021;8:731261-731261. doi: 10.3389/fcvm.2021.731261
Al Tameemi WF, Alkhazraji NA. Assessment of C-Reactive Protein/Serum Albumin Ratio in Relation to Acute Presentation and Early Outcome of Patients with Acute Coronary Syndrome. J Biosci Med. 2023;11(02):239-253. doi: 10.4236/jbm.2023.112019
Akkaya S, Cakmak U. Association between C-Reactive Protein to Albumin Ratio and Multi-Vessel Coronary Artery Disease in Patients with Stable Coronary Artery Disease. J Pers Med. 2024;14(4):378. doi: 10.3390/jpm14040378
Ridker PM, MacFadyen JG, Everett BM, et al. Relationship of C-reactive protein reduction to cardiovascular event reduction following treatment with canakinumab: a secondary analysis from the CANTOS randomised controlled trial. Lancet Lond Engl. 2018;391(10118):319-328. doi: 10.1016/S0140-6736(17)32814-3
Yi M, Wu L, Ke X. Prognostic Value of High-Sensitivity C-Reactive Protein in In-Stent Restenosis: A Meta-Analysis of Clinical Trials. J Cardiovasc Dev Dis. 2022;9(8):247. doi: 10.3390/jcdd9080247
Duman H, Çinier G, Bakırcı EM, et al. Relationship Between C-Reactive Protein to Albumin Ratio and Thrombus Burden in Patients With Acute Coronary Syndrome. Clin Appl Thromb Off J Int Acad Clin Appl Thromb. 2019;25:1076029618824418-1076029618824418. doi: 10.1177/1076029618824418
Kaplangoray M, Toprak K, Aslan R, et al. High CRP-albumin ratio is associated high thrombus burden in patients with newly diagnosed STEMI. Medicine (Baltimore). 2023;102(41):e35363-e35363. doi: 10.1097/MD.0000000000035363
Liuzzo G, Biasucci LM, Gallimore JR, et al. The Prognostic Value of C-Reactive Protein and Serum Amyloid A Protein in Severe Unstable Angina. N Engl J Med. 1994;331(7):417-424. doi: 10.1056/nejm199408183310701
Caetano C, Valente A, Silva FJ, et al. Effect of an intradialytic protein-rich meal intake in nutritional and body composition parameters on hemodialysis patients. Clin Nutr ESPEN. 2017;20:29-33. doi: 10.1016/j.clnesp.2017.04.003
Arques S. Human serum albumin in cardiovascular diseases. Eur J Intern Med. 2018;52:8-12. doi: 10.1016/j.ejim.2018.04.014
Cui X, Jia Z, Chen D, et al. The prognostic value of the C-reactive protein to albumin ratio in cancer: An updated meta-analysis. Medicine (Baltimore). 2020;99(14):e19165-e19165. doi: 10.1097/MD.0000000000019165
Tsai CM, Yu HR, Tang KS, et al. C-Reactive Protein to Albumin Ratio for Predicting Coronary Artery Lesions and Intravenous Immunoglobulin Resistance in Kawasaki Disease. Front Pediatr. 2020;8:607631-607631. doi: 10.3389/fped.2020.607631
Antman EM, Cohen M, Bernink PJLM, et al. The TIMI Risk Score for Unstable Angina/Non–ST Elevation MI. JAMA. 2000;284(7):835. doi: 10.1001/jama.284.7.835
Scarparo P, van Gameren M, Wilschut J, et al. Impact of thrombus burden on long-term clinical outcomes in patients with either anterior or non-anterior ST-segment elevation myocardial infarction. J Thromb Thrombolysis. 2022;54(1):47-57. doi: 10.1007/s11239-021-02603-3
Souteyrand G, Amabile N, Combaret N, et al. Invasive management without stents in selected acute coronary syndrome patients with a large thrombus burden: a prospective study of optical coherence tomography guided treatment decisions. EuroIntervention. 2015;11(8):895-904. doi: 10.4244/EIJY14M07_18
Özkan U, Gürdoğan M, Öztürk C, et al. Systemic Immune-Inflammation Index: A Novel Predictor of Coronary Thrombus Burden in Patients with Non-ST Acute Coronary Syndrome. Medicina (Mex). 2022;58(2):143. doi: 10.3390/medicina58020143
Kaptoge S, Seshasai SRK, Gao P, et al. Inflammatory cytokines and risk of coronary heart disease: new prospective study and updated meta-analysis. Eur Heart J. 2014;35(9):578-589. doi: 10.1093/eurheartj/eht367
Blake GJ, Ridker PM. C-reactive protein and other inflammatory risk markers in acute coronary syndromes. J Am Coll Cardiol. 2003;41(4):S37-S42. doi:10.1016/s0735-1097(02)02953-4
Armstrong EJ, Morrow DA, Sabatine MS. Inflammatory biomarkers in acute coronary syndromes: part I: introduction and cytokines. Circulation. 2006;113(6):e72-75. Doi: 10.1161/CIRCULATIONAHA.105.595520
Abbate R, Cioni G, Ricci I, et al. Thrombosis and acute coronary syndrome. Thromb Res. 2012;129(3):235-240. doi: 10.1016/j.thromres.2011.12.026
Rao SV, O’Donoghue ML, Ruel M, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2025;151(13):e771-e862. doi: 10.1161/CIR.0000000000001309
Khandkar C, Madhavan MV, Weaver JC, et al. Atherothrombosis in Acute Coronary Syndromes—From Mechanistic Insights to Targeted Therapies. Cells. 2021;10(4):865. doi: 10.3390/cells10040865
Kume T, Uemura S. Clinical impact of thrombus burden in patients with ST-segment elevation myocardial infarction. Coron Artery Dis. 2016;27(3):165. doi: 10.1097/MCA.0000000000000344
Grech ED, Ramsdale DR. Acute coronary syndrome: unstable angina and non-ST segment elevation myocardial infarction. BMJ. 2003;326(7401):1259-1261. doi: 10.1136/bmj.326.7401.1259
Basit H, Malik A, Huecker MR. Non–ST-Segment Elevation Myocardial Infarction. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK513228/ Accessed March 22, 2025.
Ma L, Li Y, Pei J, et al. Elevated Glucose on Admission Was an Independent Risk Factor for 30-Day Major Adverse Cardiovascular Events in Patients with STEMI but Not NSTEMI. Rev Cardiovasc Med. 2024;25(2):46. doi: 10.31083/j.rcm2502046
Coşkun G, Ozde C, Kayapinar O, et al. The Relationship of Coronary Thrombus Burden and Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Score in Patients With ST-Segment Elevation Myocardial Infarction. Clin Appl Thromb. 2024;30:10760296241237232. doi: 10.1177/10760296241237232
Suleiman M, Aronson D, Reisner SA, et al. Admission C-reactive protein levels and 30-day mortality in patients with acute myocardial infarction. Am J Med. 2003;115(9): 695-701. doi: 10.1016/j.amjmed.2003.06.008
Casas JP, Shah T, Hingorani AD, et al. C-reactive protein and coronary heart disease: a critical review. J Intern Med. 2008;264(4):295-314. doi: 10.1111/j.1365-2796.2008.02015.x
Oduncu V, Erkol A, Karabay CY, et al. The prognostic value of serum albumin levels on admission in patients with acute ST-segment elevation myocardial infarction undergoing a primary percutaneous coronary intervention. Coron Artery Dis. 2013;24(2):88-94. doi: 10.1097/MCA.0b013e32835c46fd
Cheng CW, Lee CW, Chien SC, et al. Serum Albumin was Associated with a Long Term Cardiovascular Mortality among Elderly Patients with Stable Coronary Artery Disease. Acta Cardiol Sin. 2024;40(1):87-96. doi: 10.6515/ACS.202401_40(1).20230825A
Yang LJ, Feng YX, Li T, et al. Serum albumin levels might be an adverse predictor of long term mortality in patients with acute myocardial infarction. Int J Cardiol. 2016:223:647-648. doi: 10.1016/j.ijcard.2016.08.251.
Söğüt Ö, Akdemir T, Can MM. Prognostic value of the C-reactive protein to albumin ratio in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Turk J Med Sci. 2021;51(3):1281-1288. doi: 10.3906/sag-2003-188
Wang W, Ren D, Wang CS, et al. Prognostic Efficacy of High-Sensitivity C-Reactive Protein to Albumin Ratio in Patients with Acute Coronary Syndrome. Biomark Med. 2019;13(10):811-820. doi: 10.2217/bmm-2018-0346
Askin L, Tanriverdi O, Tibilli H, et al. Prognostic value of C-reactive protein/albumin ratio in ST-segment elevation myocardial infarction. Interv Med Appl Sci. 2019;11(3):168-171. doi: 10.1556/1646.11.2019.20
Ranzani OT, Zampieri FG, Forte DN, et al. C-reactive protein/albumin ratio predicts 90-day mortality of septic patients. PloS One. 2013;8(3):e59321. doi: 10.1371/journal.pone.0059321
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