IJCS | Volume 32, Nº2, March/April 2019

122 Milano et al. C-reactive protein as a predictor of mortality Int J Cardiovasc Sci. 2019;32(2)118-124 Original Article older than 70 years, 14 whereas 74.4% of the deaths attributed to this condition occur in patients older than 70 years. 15 There are many possible reasons for this. Elderly population has more severe coronary artery disease, receive less adequate treatment than younger individuals, and presents later at the hospital after the onset of infarction symptoms. 16 Regarding sex distribution, our results demonstrate a higher proportion of females among thosewho died (40%) comparing to survivors (29.6%, p = 0.51). Several studies have already shown that female sex is independently associated with early mortality after STEMI. 13 The present study also demonstrates a strong, positive association between hs-CRP obtained on admission and in-hospital mortality. In the early phase of AMI, CRP levels are probably a reaction to the inflammatory response following myocardial ischemia and not to chronic vascular inflammation. 17-20 It allows CRP levels to be a simple marker of the magnitude of the inflammatory response tomyocardial ischemia, potentially providing prognostic information regarding the risk of death. 8,9 Therefore, measurement of CRP can offer a strategy for risk stratification and management of patients at the highest risk for adverse outcomes. 21-23 Besides myocardial necrosis and ischemia, other kinds of tissue damage could cause CRP elevation in patients with AMI, such as atherosclerotic mass, underlying inflammatory process and circulating proinflammatory cytokines. 24 There have been several studies on the prognostic value of hs-CRP in AMI. High sensitivity CRP has been shown to be associated with hospital outcomes, such as death, myocardial infarction and angina, 4,25-31 suggesting it to be a useful biomarker in risk assessment of patients with acute coronary syndrome. Raposeiras-Roubín et al., 32 also evaluated the prognostic value of hs-CRP, showing that a higher level of hs-CRP is a predictor of in-hospital cardiac events in acute MI, independently of the GRACE (Global Registry of Acute Coronary Events) risk score. Tanveer et al., 33 analyzed 190 patients with STEMI to investigate the relationship between hs‑CRP level and complications of myocardial infarction. However, there were no significant differences in hs‑CRP values between patientswhodiedandwho survivedduringhospitalization. Suleiman et al., 7 reported that patients with AMI with higher CRP levels on admission were older, had higher baseline creatinine levels and were at increased risk of long-term development of heart failure. Schiele et al., 34 showed an independent predictive role of CRP in patients with acute coronary syndrome; those in the highest quartile of CRP showed increasedmortality rates at 30 days of follow‑up. In recent years, there has been an attempt to predict the risk of early adverse events in patients with STEMI. In order to stratify STEMI patients according to this risk, risk scores have been created with a strong prognostic capacity, such as the GRACE risk score. Inflammatory markers can add prognostic information to these scoring systems even in the current era of high-sensitivity cardiac troponin assays. 35 AMI is associated with an extensive myocardial inflammation, which leads to a systemic inflammatory response. 6,36 Our results demonstrate that hs-CRP can measure inflammatory response to tissue injury after a STEMI, providing a means for assessing short-term prognosis and the risk of death. The present study also has some limitations, because it is a retrospective study and it could not establish a cut-off point for CRP level in relation to mortality. This study can help us better understand the prognostic significance of hs-CRP levels over the AMI spectrum, however further studies are needed to elucidate the inflammatory process due to myocardial ischemia. Conclusions Our results demonstrate a strong, positive association between high-sensitivity C-reactive protein obtained on admission and in-hospital mortality after STEMI. Moreover, in-hospital mortality is tightly associatedwith elderly patients. These findings suggest that hs-CRP levels canmeasure inflammatory response to myocardial ischemia after STEMI, providing prognostic information regarding the risk of death. Therefore, CRP on admission of patients with STEMI is a strong univariate predictor of mortality. Author contributions Conception and design of the research: Milano SM, Lenci GL, Bordim A, Moura Junior OV. Acquisition of data: Milano SM, Bordim A, Moura Junior OV. Analysis and interpretation of the data: Milano SM, Lenci GL, BordimA, Moura Junior OV. Writing of the manuscript: