This biomarker is a better predictor of heart disease than cholesterol: What to know about C-reactive protein.
Heart disease stands as the primary cause of death in the United States.
Since the 1950s, when researchers identified the connection between diet, cholesterol, and heart disease, cholesterol levels have been used—alongside routine blood tests—to gauge heart disease risk.
However, recent evidence shows that a biomarker known as C-reactive protein, which indicates low-grade inflammation, may actually provide a more accurate risk assessment for heart disease than cholesterol levels do.
This led to new recommendations from the American College of Cardiology in September 2025, advocating for universal screening of C-reactive protein in conjunction with cholesterol testing.
What is C-reactive protein?
C-reactive protein is produced by the liver in response to various factors, such as infections, tissue damage, autoimmune conditions, and metabolic disorders like obesity and diabetes. It’s essentially a marker of inflammation, reflecting immune system activity in the body.
A simple blood test can measure C-reactive protein levels. Low levels (under 1 milligram per deciliter) indicate minimal inflammation, which offers some protection against heart disease. Conversely, higher levels (over 3 milligrams per deciliter) signify heightened inflammation and increased heart disease risk. Notably, about 52% of Americans have elevated C-reactive protein levels.
Research indicates that C-reactive protein is a stronger predictor of heart attacks and strokes than “bad” LDL cholesterol or another genetically linked marker called lipoprotein(a). In fact, one study found it can predict heart disease risk as effectively as blood pressure.
Why does inflammation matter in heart disease?
Inflammation is key in the development of fatty plaque in arteries, leading to a condition known as atherosclerosis, which can result in heart attacks and strokes.
When a blood vessel is damaged—due to factors like high blood sugar or cigarette smoke—immune cells rush to the site. They then engulf cholesterol particles, forming fatty plaques within the vessel wall.
This process can persist for years, until immune mediators eventually rupture the plaque cap, creating a blood clot that blocks blood flow and may cause a heart attack or stroke. So, while cholesterol is a factor, the immune system plays a significant role in the progression of heart disease.
Can diet influence C-reactive protein levels?
Lifestyle choices heavily impact the level of C-reactive protein that the liver produces.
Certain foods, particularly those high in dietary fiber—like beans, vegetables, and nuts—as well as berries, olive oil, green tea, chia seeds, and flaxseeds, can help lower C-reactive protein levels. Additionally, weight loss and regular exercise can also be beneficial.
Does cholesterol still matter for heart disease risk?
Although cholesterol isn’t the most critical risk factor for heart disease, it remains relevant.
It’s essential to understand that it’s not just the amount of cholesterol that’s significant—the specific particles that carry bad (LDL) cholesterol matter as well. Two individuals with identical cholesterol levels can have differing heart disease risks based on how many particles are present. More particles typically mean higher risk.
This is why a blood test measuring apolipoprotein B, which reflects the number of cholesterol particles, is often a better indicator of cardiovascular risk compared to traditional cholesterol measurements.
Like cholesterol and C-reactive protein, apolipoprotein B levels are also influenced by lifestyle. Consuming fiber, nuts, and omega-3 fatty acids can decrease the number of cholesterol particles, whereas increased sugar intake can lead to more particles.
Furthermore, lipoprotein(a)—a protein that encases cholesterol particles—can predict heart disease risk more accurately than cholesterol levels alone. However, lipoprotein(a) levels remain genetic and should only be measured once in a lifetime.
What’s the best way to prevent heart disease?
Ultimately, heart disease arises from multiple interacting risk factors over a lifetime.
This means preventing heart disease is far more complex than just aiming for a cholesterol-free diet.
Understanding your LDL cholesterol, C-reactive protein, apolipoprotein B, and lipoprotein(a) levels can provide a more complete risk profile, encouraging a long-term commitment to heart disease prevention. This involves maintaining a nutritious diet, regular exercise, sufficient sleep, effective stress management, healthy weight maintenance, and quitting smoking if necessary.
