Elevated C-reactive Protein (CRP)

[Paleowoman]

When I saw my cardiologist just over a month ago I complained about some left sided chest pains I was getting intermittently, every few weeks lasting two to three days, pain around sternum and into left side of chest and up into shoulder blade, making breathing painful, and more painful when I lie down. The cardio did some blood tests for inflammation. I had an echo, which was okay apart from some 'minor' heart damage (paradoxical septal movement) that is common after cardiac surgery. When I asked at follow up about the blood tests he told me they were normal.

I got lab copies of the tests a few days ago and saw that the C-Reactive Protein level was raised at 15.9 (lab ref range 0 - 10), but the ESR was normal and blood count normal too. I contacted the cardiologist and asked him if I should see my GP in view of the raised CRP. He said I could if I wished (I'm not a doctor) to see if the levels have recovered, but he didn't think it was significant. I am sure he is only thinking of my heart since he is a cardiologist. I have several other things wrong with me (diabetes, small airways disease and now tendon pains or arthritis in my toes and fingers), as well as the continuing intermittent chest pains and feeling breathless, and plain not like I was pre-surgery. The cardio didn't comment on my chest pains after the blood test and the echo.

I am having routine blood tests via my GP on Friday week but CRP is not one of the tests. My problem is that I don't know whether to bother my GP with this and ask him to add the CRP to the list of tests or whether I should just wait until I see him at the beginning of October when I have a routine appointment for the results of Friday week's tests.

I find very little information about CRP - I mean I do find info but it's not clear what a raised level like I have means. I did not have an infection at the time of the test.

Has anyone else had a raised CRP ?

 

[epstns]

I've never had elevated CRP (that I'm aware of), but I would probably call the GP and at least ask to have that added to your blood work prior to the office visit. Then you can discuss any changes and the meaning of the numbers with the doc.

I know sometimes we have test results that are outside the "normal" range, but they may or may not have any meaning to our health. I know I have one that I continue to watch with my GP, but for the last 4 or 5 years it has been stable but just above the lab range. As long as it is stable and I have no apparently related issues, we just watch it.

 

[newmitral]

Hi Paleogirl,

Has anyone else had a raised CRP ?

An elevated C-reactive protein level is a non-specific indicator of inflammation somewhere in your body. Since you say you have other known issues that could be causing low level inflammation, and your sedimentation rates were normal, my (non-medical) opinion is that your cardiologist is probably correct, and there is no cause for worry. But it can't hurt to mention your concern to your GP at your next routine appointment and get his opinion on whether further follow-up testing would be appropriate.

I had an elevated C-Reactive Protein level as one of my symptoms when I had endocarditis, and the doctors were running tons of tests trying to find out what was wrong before they figured it out. In my case, the C-reactive Protein level was a whopping 108, so your level of 16 seems like a fairly minor elevation by comparison.

Hope this helps to put your mind at rest.

 

[Paleowoman]

Thanks Steve and newmitral !

I know that my small airways disease is inflammatory and I am using a steroid preventer inhaler to reduce the inflammation - there probably still is some inflammation as I cough every day - maybe the elevated CRP could easily be that. I'll check with the GP - I wish the cardiologist had mentioned this in his letter to the GP instaed of leaving it up to me ! I know my endo would have remakred on any tests he did, even if normal or non significant - like my urea level has been well over normal for seven years but endo says that's allright.

 

[pellicle]

Hi, as the others have said CRP is an indicator of infections. There is a background CRP level which can be between 2 and 10. Anything between that level is not worthy of note. There is always something attacking your that your body is doing something about, and so an elevated CRP alone does not mean there is any harm. When it gets up to the 100 sort of levels and for extended times its an indicator that something is amiss.

The thing is that CRP in itself does not assist in diagnosing what is the infection that the body is fighting. It could be from a nick or scrape or it could be from your gums.

When its known what (for instance in my own case) is the infection then the CRP provides a good way to monitor its progress (or its retreat). My last CRP reading showed 5 and my infection specialist said that was an indicator that my infection is not visible to the immune system (but may be hiding somewhere we just don't know yet).

some reading
http://en.wikipedia.org/wiki/C-reactive_protein#Diagnostic_use

 

[Garserin]

My totally unscientific mind can't figure out if crp levels are measured the same way in Europe and the US. Does anyone know?

 

[Paleowoman]

My totally unscientific mind can't figure out if crp levels are measured the same way in Europe and the US. Does anyone know?

They must be measured the same as I'm in Europe and the lab reference range for normal levels of CRP is the same as it is in US, i.e. 0 to 10 mg/L

 

[Paleowoman]

I saw my GP today, not specifically about the CRP but of course I mentioned it. I showed him the print out results and, yes, he does want to add CRP to my list of blood tests that I'm having later this week. He said that the CRP could be raised like that just due to "residual inflammation" in my sternum ! That might be that pain along sternum/left ribs I've been getting recently ? Still, CRP is very non site specific.

 

[ski girl]

When I had acute endocarditis my CRP was about 400! From memory it's not a very specific test so they really only get concerned when it's VERY high.

 

[Paleowoman]

Hi Ski Girl - yes I know my level isn't very high, but normally CRP is supposed to be practically undetectable, so having a level, even just a bit high above lab reference range shows some inflammation is going on. When it is very high like yours was that shows that infection is going on - I had no symptoms of infection. I have an inflammatory airways disease so it may be something to do with that, maybe the steroid I take is not fully effective ? I certainly am coughing more recently. Or it may be related to the pain I am getting from time to time in my sternum, particularly when I breathe in. My GP feels he needs two tests to see if things have changed as it may all be nothing, but originally the cardiologist did the test to check for inflammation in the heart, but the cardio didn't follow this result up because he felt it wasn't to do with my heart but I have other things (in a situation like Slipkid with seeing mutliple doctors), I'm not just a heart problem LOL

 

[Paleowoman]

Hi Ski Girl - yes I know my level isn't very high, but normally CRP is supposed to be practically undetectable, so having a level, even just a bit high above lab reference range shows some inflammation is going on. When it is very high like yours was that shows that infection is going on - I had no symptoms of infection. I have an inflammatory airways disease so it may be something to do with that, maybe the steroid I take is not fully effective ? I certainly am coughing more recently. Or it may be related to the pain I am getting from time to time in my sternum, particularly when I breathe in. My GP feels he needs two tests to see if things have changed as it may all be nothing, but originally the cardiologist did the test to check for inflammation in the heart, but the cardio didn't follow this result up because he felt it wasn't to do with my heart but I have other things (in a situation like Slipkid with seeing mutliple doctors), I'm not just a heart problem LOL

 

[pellicle]

Well actually, no its normally meant to be detectable and it is normally below 10

 

[Paleowoman]

There seems to be some confusion about CRP then !

Here from a few websites:

From MedlinePlus: http://www.nlm.nih.gov/medlineplus/e...cle/003356.htm : Normal CRP values vary from lab to lab. Generally, there is no CRP detectable in the blood.

A couple more:

If amounts are significantly elevated (greater than 10), the cause can be trauma, infection, autoimmune illnesses or infections of the prostate, gums or stomach. Levels this elevated should be discussed with your doctor.

and

With this assay, the tertiles of cardiovascular risk factors are CRP <1 mg/L for low risk, 1 to 3 mg/L for moderate risk, and 3 to 10 mg/L for high risk. CRP levels >10 mg/L generally are considered to indicate bacterial infection and the test is repeated 2 weeks later.

And this one from the Mayo:

If you're having a CRP test to evaluate your risk of heart disease, these are the current risk levels used:
&#149; Low risk. You have a CRP level of less than 1.0 milligrams per liter (mg/L).
&#149; Average risk. You have a CRP level between 1.0 and 3.0 mg/L.
&#149; High risk. You have a CRP level greater than 3.0 mg/L.
Keep in mind that these risk levels aren't a definitive measure of your risk because there's disagreement on whether a high CRP level is a true risk factor for heart disease.

A test result showing a CRP level greater than 8 mg/L is a sign of serious inflammation or infection, and you should talk to your doctor about your test result to check for other medical problems.

 

[pellicle]

mean while on the subject of using CRP for infection determination (rather than as a risk indicator for heart disease):

http://www.australianprescriber.com/magazine/30/3/74/6

Normal ranges

The median normal concentration of C-reactive protein is 0.8 mg/L, with 90% of apparently healthy individuals having a value less than 3 mg/L and 99% less than 12 mg/L. Elevated values are
abnormal and suggest the presence of organic disease, although minimal C-reactive protein rises can be seen with obesity.

http://en.wikipedia.org/wiki/C-reactive_protein

A high-sensitivity CRP (hs-CRP) test measures low levels of CRP using laser nephelometry. The test gives results in 25 minutes with a sensitivity down to 0.04 mg/L.

Normal concentration in healthy human serum is usually lower than 10 mg/L, slightly increasing with aging.

When I was in Finland it was measured with a pinprick sample similar to how INR is measured. So clearly hospitals and pathologists seem to know more about it than heart specialists.


PS: - its important to recognise that these sorts of tests (such as CRP) are not like taking a micrometer scale to a piece of steel and measuring it, there is variation. So if from one sample two labs came up with different results by a small margin I would not be surprised. Indeed I'd be surprised if they were the same. For instance 5 vs 8 or 15 vs 20

Such is the nature of tests

Secondly you are not young, its established that CRP creeps up with age due to the myriad of small dammages that you have all around your body (such as perhaps your joints). Its not unexpectable that at your age CRP will be nearer 10 than 2.

Even such things as what you eat and your gut micro flora can influence it.

I took the time to call my friend in the pathology lab (he's a pathologist, not just a worker). He went off as soon as I mentioned that heart journals were sprouting that a CRP of 3 could be used as an indicator of Heart Disease.

It may be such, but it is such a noisy system to base a metric on one could only ever use it as a gross indicator in a plethora of other indicators.

More significan would be that you had chronic CRP

Now, I'm not saying that you do not have any infection (because ... well we all have infections at some level), but rather am saying that the discomfort in your chest may not be a smouldering Golden Staph infection, but just discomfort due to having so many tissues pulled, streched and perhaps even torn and cut during your OHS that it may take years before you feel no discomfort.

Having said that an old SriLankan friend of mine said once: "when you're over 50 and you wake up feeling no discomfort its because you're dead"

 

[pellicle]

http://diabetes.diabetesjournals.org/content/58/4/798.full

Why should CRP not better predict risk in individuals, given its consistent association with CVD and mortality? Several issues contribute. The association of CRP with incident events is linear when both CRP values and risk are plotted on a log scale, with no threshold value of CRP above which risk is substantial and below which it is negligible. This means that individuals in a population with intermediate values of CRP are at moderate risk of events. Moreover, the distribution of CRP in a population is log (normal), such that most individuals have intermediate values of CRP. Thus, a large proportion of events would be expected among people with nearly average CRP values, which explains the wide overlap in the distribution of CRP values among those who remain disease free and those who later suffer events (whether fatal or nonfatal) (respectively 2.5 mg/l [95% CI 1.2–5.3] and 3.7 mg/l [1.6–9.1] in the study by Bruno et al. [4]). With the broad overlap, it is difficult to set CRP cut point values that adequately discriminate later cases from those remaining disease free, accounting for the modest C-statistic.

which makes it clear how murky an indicator this is for predicting the type of disease involved. As they go on to say:

In a recent systematic review of 31 prospective cohorts (1), CRP did not perform better than the established Framingham risk equation for discrimination. Moreover, improvement in risk stratification or reclassification from the addition of CRP was small and inconsistent (1).

Then there is this writing

http://circ.ahajournals.org/content/114/15/1591

High Serum C-Reactive Protein Level Is Not an Independent Predictor for Stroke
The Rotterdam Study

Background— Current guidelines recommend the assessment of C-reactive protein (CRP) levels with a high-sensitivity assay in cardiovascular risk prediction. Recent studies have put forward that although elevated CRP is a risk factor for cardiovascular disease, it is not helpful in the prediction of cardiovascular disease risk. We studied the importance of CRP as a risk factor and as a risk predictor of future stroke.

which further suggests that the usefulness of CRP as a magic indicator is limited with respect to a specific problem

then


http://www.ncbi.nlm.nih.gov/pubmed/17015791

BACKGROUND:

Current guidelines recommend the assessment of C-reactive protein (CRP) levels with a high-sensitivity assay in cardiovascular risk prediction. Recent studies have put forward that although elevated CRP is a risk factor for cardiovascular disease, it is not helpful in the prediction of cardiovascular disease risk. We studied the importance of CRP as a risk factor and as a risk predictor of future stroke.

CONCLUSIONS:

Although CRP levels are associated with stroke risk, their use in the assessment of individual stroke risk seems limited.

and yet another suggesting that its not a panacea indicator at all.

I would like to re-iterate that we (especially we here) are not by and large medical experts, even among the expertos confusion applies to almost everything. Despite having a great resorce (google scholar for instance) available to us, access to information does not make us experts.

What is beneficial is a well rounded approach of consultation followed by a triangulation of those points. The truth is frequently found in the middle.

Can you describe if youre experiencing pain or discomfort? I've taught some people (older people) to stretch properly when exersizing and they initially report "pain" which they later learn to be actually a good indicator. I would like to know more about what your feeling so as to perhaps offer some assistance (if I can).

 

[Paleowoman]

Can you describe if youre experiencing pain or discomfort? I've taught some people (older people) to stretch properly when exersizing and they initially report "pain" which they later learn to be actually a good indicator. I would like to know more about what your feeling so as to perhaps offer some assistance (if I can).

Thanks Pell. The pain I get, which the cardiologist did the blood tests for, is around the sternum, hurts when I take a breath in - it is intermtitant - happens every few weeks and lasts several days, hurts more when I lie down, also breathless when I have never been breathless before ! Doing exercise when I get this pain does not make the pain worse. I don't think the cardiologist was looking for infection - he was looking for inflammation.

More significan would be that you had chronic CRP

Yes, that's why the GP is repeating the test.

I could have raised CRP for any quite logical reason - I have chronic small airways disease which is inflammation of the small airways and I use a steroid preventer inhaler for that and have been cutting down the amount (due to steroids not being too good for the rest of the body when you are on them long, long term) - could be the inflammation in my lungs is showing with the raised CRP ? Also getting a lot of tendon pains - seeing rheumatologist about that next month. That could be inflammatory too. I don't think the CRP is anything to do with my heart…but it could be residual inflammation along the sternum like the GP said - there's a couple of small bumps in the area when the wires are which are a bit sore.

 

[pellicle]

Hi

pardon the out of order reply

raised CRP for any quite logical reason
... chronic small airways disease which is inflammation
... a lot of tendon pains - seeing rheumatologist

yep, from what I understand, all of those things can cause slightly elevated CRP (like around 10). My mate actually mentioned arthritus as a cause today in our conversation.

not that I'm suggesting you do not see your doctor about it, what I'm trying to suggest is that it may not be an indicator of infection in the sternum.

With respect to that I'm going to say that its perhaps a waiting game and perhaps (like staking out a moose), and much like that game the moose may not even turn up. For you (and the moose) that's a good thing. It does however require you to adjust your attitude to be "no news is good news" rather than feeling that the game is afoot.

If you have an infection eventually it will reveal itself. While it has not revealed itself with clarity (and may not in fact exist) it is like trying to chase down any intermittent fault - fraught.

When things break its easy to see and do something, when they rattle occasionally (and never before the mechanic) its just an exersize in frustration.

The pain I get.. is around the sternum

around the outside edge? Say, between the ribs? Perhaps in the costal cartilage that connects the ribs to the sternum?

I'm going to say that mine equally feels discomfort (I use that word discomfort because for me pain is something which I've come to recognise as distinctly different). If you consider that there has been an amount of unnatural streching go on during the surgery that's likely to cause soft tissue damage, say like spraining an ankle rather than breaking it.

I have also had someone else say to me that the disturbances to the soft tissues can take quite some time to settle down. I have memories from my first OHS (distant ones) where I was really easily disturbed by pressure to that area (don't ask why I took up fencing ok) and to me it took from my early teens to my late teens before that settled.

When I had my second OHS it took about a year before I could do the sort of deep breathing that comes with sustained cycling at HR between 140 and 160 bpm. At first it just felt like my chest was tight.

Actually I have always found the descriptions of this to be ambiguous, for "tight ness in the chest" seems so unclear.

A couple of years after my 2nd surgery I had a fall and broke 2 ribs (wasn't that fun) and well after the 8 weeks time I was feeling difficulty in breathing in with exactly the same sort of "tightness" as I had after the OHS.

So I guess that what I'm saying is that when I read this:

, hurts when I take a breath in - it is intermittent - happens every few weeks and lasts several days, hurts more when I lie down

it somehow makes me think of back than ... but its of course difficult to say.

, also breathless when I have never been breathless before ! Doing exercise when I get this pain does not make the pain worse.

what do you mean "breathless"

I've fallen an landed and been "winded" (when I broke my ribs) and "had the wind knocked out of me ... I literally couldn't breath in.

like that?

I've pushed myself up hills skiing to the point where I was about to puke on the snow and was just unable to satisfy my need for oxygen at the top of the hill (despite heaving breaths), and somehow felt that breathing was doing nothing. People call that breathless too ...

When I was riding my bike out to a place in Finland (just after I got there) I was feeling that there was some restriction in my breathing, that I couldn't get enough in, almost as if something was reaching a limit of expansion. Then (because I'm a mad bastard I pushed through that) something felt like it "tore" but without pain, like when I'm pulling things out of an fish that I'm gutting (ok, I fish too ... and I hunt, ya got me there). Soon after that the blood blister popped up (I posted about that in my thread on "post surgical feelings".

I'm of the view that there was some "adhesion" (you know, the layers of tissue {pellicle membranes} that surround and seperate muscles from the areas they lay in, and the bones they move across) which being damaged during surgery grow together (as they are not supposed to) in a scar tissue.

Since these scar tissues lack the levels of elastin (normally found in skin and such membranes) they are inflexible and need to be stretched. I'm sure that (them containing nerves) this also feels painful.

So, how does that fit with your feelings of what you're feeling?

 

[Paleowoman]

↵Hi,

"raised CRP for any quite logical reason
... chronic small airways disease which is inflammation
... a lot of tendon pains - seeing rheumatologist"

yep, from what I understand, all of those things can cause slightly elevated CRP (like around 10). My mate actually mentioned arthritus as a cause today in our conversation.

And the 10 is not much lower than the 15.9 I got, so definitely those causes are likely to be (some of) the culprits.

not that I'm suggesting you do not see your doctor about it, what I'm trying to suggest is that it may not be an indicator of infection in the sternum.

I don't think it's an infection either, just inflammation. I tend to equate infections with having a raised temperature. But also my white cell count was normal which shows no infection AFAIK.

"The pain I get.. is around the sternum"

around the outside edge? Say, between the ribs? Perhaps in the costal cartilage that connects the ribs to the sternum?

Yes could well be that.

I have also had someone else say to me that the disturbances to the soft tissues can take quite some time to settle down. I have memories from my first OHS (distant ones) where I was really easily disturbed by pressure to that area (don't ask why I took up fencing ok) and to me it took from my early teens to my late teens before that settled.

When I had my second OHS it took about a year before I could do the sort of deep breathing that comes with sustained cycling at HR between 140 and 160 bpm. At first it just felt like my chest was tight.

You know, sometimes when I read something like that I do wonder why we are led to believe everything will be so hunky-dory within a few months. If we were just told "it can take a year, 18 months, whatever" maybe we (I) wouldn't have such high expectations and would just accept that healing takes time.

So I guess that what I'm saying is that when I read this:

," hurts when I take a breath in - it is intermittent - happens every few weeks and lasts several days, hurts more when I lie down"

it somehow makes me think of back than ... but its of course difficult to say.
"also breathless when I have never been breathless before ! Doing exercise when I get this pain does not make the pain worse."

what do you mean "breathless"

I mean that when I climb just the ordinary stairs in our house I get out of puff, out of breath...same with even a very slight hill when walking. The other day my husband asked me why I was breathing so heavily - it was because I'd got out of breath just going upstairs. I never experienced getting out of breath pre-surgery so I find this a surprise and definitely doesn't feel like it's "normal". Mind you, if this is all part of the healing process I'm satisfied with that

I've pushed myself up hills skiing to the point where I was about to puke on the snow and was just unable to satisfy my need for oxygen at the top of the hill (despite heaving breaths), and somehow felt that breathing was doing nothing. People call that breathless too ...

When I was riding my bike out to a place in Finland (just after I got there) I was feeling that there was some restriction in my breathing, that I couldn't get enough in, almost as if something was reaching a limit of expansion.

Yes like that, I feel like I can't breathe fast or hard enough or deep enough to get in the air I need.

Then (because I'm a mad bastard I pushed through that)

I do push through things, I try to pretend they're not there. Also I don't like to worry my family so I don't tell them or let them know, but my husband can hear when I'm out of breath (we're going on holiday next week and will be doing lots of hill walking and he said he doesn't want to do some of the hills I love climbing because he thinks I'll get ill becasue I get so out of breath - I told him I can manage - I will, but will get out of breath and keep stopping to catch it).

I'm of the view that there was some "adhesion" (you know, the layers of tissue {pellicle membranes) that surround and seperate muscles from the areas they lay in, and the bones they move across) which being damaged during surgery grow together (as they are not supposed to) in a scar tissue.

Since these scar tissues lack the levels of elastin (normally found in skin and such membranes) they are inflexible and need to be stretched. I'm sure that (them containing nerves) this also feels painful.

And I always wonder if having a slightly depressed sternum makes a bit of a difficulty or difference for the surgeon ? means a bit more pulling ? There's nothing about the incision in my operation notes so I can't find out.

So, how does that fit with your feelings of what you're feeling?

A lot of it does, thank you pell Btw, is your username pellicle because of the "pellicle membranes" ?

 

[pellicle]

Hi

I mean that when I climb just the ordinary stairs in our house I get out of puff, out of breath...same with even a very slight hill when walking.

sounds to me like just lack of aerobic fitness. You've mentioned the small air ways and so probably its just the result of the degredation in your health prior to the surgery (caused by the combination of valve degredation and existing other conditions you've mentioned). So now post surgery without the valve issue you still have all the other components of the system which need to be pushed up.

Then there is the fact that as you age you will not be as fit as your potential for fitness at 20 ...

My own fitness was quite good before the aneurysm was found, in 2010 (surgery was Nov 2011) I was skiing the local tracks in Kouvola (with more hills than you would care to believe in a place that is supplsed to be flat like Finland) every day. I had noticed that my HR and responce to hills was going down and "changing" and I'd attributed that to my valve (which was also a culprit).

My recovery took about a year of hard and contentious effort after being "clear" of hospitals / PIC lines and VAC bandages

I do push through things, I try to pretend they're not there.

My approach is similar, I listen to what its "saying" and determine is this "complaint" or "signs of impending damage". There is a difference, it can only be learned it can't be taught.

Btw, is your username pellicle because of the "pellicle membranes" ?

yes, but its actually a double word score (think scrabble) with the Canon Pellix and EOS RT which have pellicle mirrors (semi transparent and fixed, instead of the usual SLR fully transparent moving mirror).

 

[Paleowoman]

Thanks Pellicle Everything makes much more sense from what you are saying !