How important is inflammation as a residual cardiovascular risk factor? The knowledge, perception, and management.

1. Occupation^*

physician

resident/fellow

physician’s assistant

nurse

public health specialist

academic

researcher

other medical profession

2. Specialty^*

Cardiology

Family medicine

Emergency medicine

General/Internal medicine

Neurology

Surgery

Anesthesiology

Dermatology

Orthopedics and traumatology

Endocrinology

Diabetology

Gastroenterology

Nephrology

Ophthalmology

Other

3. Gender^*

Female

Male

I prefer not to respond

4. Age^*

20-29

30-39

40-49

50-59

60-69

70-79

80-89

90-100

5. Domicile^*

village

city <50 thousand inhabitants

city 50-100 thousand inhabitants

city 100-500 thousand inhabitants

city >500 thousand inhabitants

6. Country: ^*

7. In your opinion, inflammation is one of the main pathophysiological mechanisms of atherosclerosis?^*

Yes

Yes, together with lipid disorders.

I don’t know

8. The main pro-inflammatory cytokines involved in the pathogenesis of atherosclerosis include ^*

(you can select more than one answer)

IL-1β

IL-2

IL-5

IL-6

IL-8

IL-10

IL-12

IL-18

TNF-α

IFN-γ

Vascular adhesion molecules

Red blood cell distribution width (RDW)

9. hsCRP, considering existing knowledge, should be considered as a risk enhancer or independent CVD risk factor?^*

We still do not have enough data to definitely answer this question, however it seems to be a causal CVD risk factor.

Based on the available evidence, it should be considered as a risk enhancer for primary prevention and risk factor for secondary prevention patients.

hsCRP should be always considered as an independent risk factor.

hsCRP does not significantly increase the risk of CVD.

10. Do you routinely measure hsCRP levels in your patients to clarify their individual cardiovascular risk?^*

Yes, routinely.

Rarely (in less than 1/3 of my patients)

Very rarely (in less than 1/10 of my patients)

I am not able to perform this type of test

11. Do you have possibility of measuring inflammatory biomarkers in your practice? ^*

Unfortunately, no, but I think it is important.

I do not consider this as important to improve risk estimation.

Yes, but only CRP.

Yes, hsCRP is a routine parameter to measure.

Yes, CRP, hsCRP, and even IL-6

I use other inflammatory biomarkers to define the risk.

I do not think it is important to measure inflammatory biomarkers before we have targeted drugs.

12. What is the difference between CRP and hsCRP? ^*

There is none; the difference is only related to commercial names.

I do not know.

There is a difference, but it does not have any effect on its risk predictive role.

hsCRP is measured using nephelometric quantitative determination, and CRP with two-reagent immunoturbidimetric system.

A standard CRP test (used to evaluate advanced inflammation) is expected to have a min. starting range of 5 mg/L, whereas an hsCRP test (a marker of low-grade vascular inflammation) is supposed to have a measuring range <1.0 mg/L - 10 mg/L.

13. What are the approved hsCRP ranges (reference intervals) to stratify the risk of CVD?^*

I do not know, but I guess there are none.

There is still an ongoing discussion, but the existing recommendations suggest: < 1.00 mg/L, 1-3 mg/L, and >3 mg/L for low, moderate (average) and high-risk categories.

There is still an ongoing discussion, but the existing recommendations suggest: < 1.00 mg/L, 1-5 mg/L, and >5 mg/L for low, moderate (average) and high-risk categories.

The existing recommendations suggest: < 1.00 mg/L, 1-10 mg/L, and >10 mg/L for low, moderate (average) and high-risk categories.

14. Elevated hsCRP should be treated to reduce residual CVD risk. Mark the correct sentence.^*

We still do not have any effective therapy for elevated hsCRP.

The only effective and approved therapy to reduce hsCRP in CVD patients is canakinumab.

Statins, colchicine, bempedoic acid are currently the drugs that might effectively reduce elevated levels of hsCRP, while waiting for the inflammation-targeted therapies.

We should reduce general CVD risk, there is no need to reduce hsCRP with dedicated therapy.

15. Which of the following conditions do you think are residual factors of ASCVD?^*

(you can select more than one answer)

LDL-C >= 100 mg/dl (2.5 mmol/l)

hsCRP >= 2 mg/l

Thrombotic disorders

TG >= 150 mg/dl (1.7 mmol/l)

Lp(a) >= 50 mg/dl (125 nmol/l)

Increased HbA1c and/or impaired fasting glucose

16. Which of the following drugs have documented anti-inflammatory effects?^*

(you can select more than one answer)

Statins

Ezetimibe

Bempedoic acid

Apabetalone

Niacin

Canakinumab

Methotrexate

Colchicine

PCSK9 targeted therapy (PCSK9Is and inclisiran)

17. Which of the following nutraceuticals (natural products) have documented anti-inflammatory effects?^*

(you can select more than one answer)

Curcumin

Garlic

Lupin

Flavonoids

Monacolin K

Soy

Coffee

Tea

Omega-6 fatty acids

Omega-3 fatty acids

Bergamot

Berberine

18. Among statins, the strongest anti-inflammatory properties are characterized by:^*

Rosuvastatin

Atorvastatin

Simvastatin

Fluvastatin

Pitavastatin

Statins have no significant anti-inflammatory effect

19. Are there any biomarkers of inflammation with the causal effect on CVD risk?^*

There is multiple data, including MR studies that confirm a causal link between hsCRP and CVD risk.

The only causal link exists for IL-1B, what was confirmed in the CANTOS trial.

There is no causal relation between CRP and CVD risk but there is some data suggesting that such a link may exist for IL-6.

Many studies targeting TNF-alfa suggested such a causal link.

20. If you are assessing the inflammatory profile in your patients, in the event of an elevated hsCRP (>= 2 mg/l):^*

I recommend using nutraceuticals with proven anti-inflammatory effects

I optimize/intensify lifestyle changes and background CVD therapies

I am monitoring the patient

No intervention is necessary.

I immediately start colchicine (based on the recommendations and indications).

How important is inflammation as a residual cardiovascular risk factor? The knowledge, perception, and management.

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