Letter: Clinical Incremental Value of the hs-CRP/Albumin Ratio After PCI-Treated STEMI

Dear Editor,

We read with great interest the article by Li et al examining the prognostic value of the high-sensitivity C-reactive protein/albumin (hs-CRP/ALB) ratio among patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). By linking an inexpensive marker of inflammation and nutritional reserve with major adverse cardiovascular events and all-cause mortality during long-term follow-up, the study highlights a clinically relevant, readily obtainable signal after STEMI. This contribution is timely, given the established roles of inflammation, plaque instability, and serum albumin in cardiovascular risk.^{1 -3}

One issue, however, may warrant more explicit discussion: whether hs-CRP/ALB provides incremental information beyond established post-STEMI risk assessment. The area under the curve for all-cause mortality was 0.68, suggesting moderate discrimination, but this metric alone does not demonstrate added clinical utility. Contemporary acute coronary syndrome risk stratification remains anchored in presentation, electrocardiographic findings, hemodynamic status, renal function, cardiac biomarkers, and revascularization details; Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) scores integrate several of these variables.^{4 -6} Because age, left ventricular ejection fraction, creatinine, high-sensitivity troponin, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) already carry substantial prognostic weight, the manuscript would be strengthened by reporting optimism-corrected C-statistics, calibration, net reclassification improvement, integrated discrimination improvement, and decision-curve analysis for models with and without hs-CRP/ALB.^7,8

This point is particularly relevant if hs-CRP/ALB is to be proposed as a decision-support marker for closer follow-up or anti-inflammatory strategies. Residual inflammatory risk after myocardial infarction is biologically plausible and clinically important, as reflected by large biomarker studies and anti-inflammatory trials.^9,10 Nevertheless, routine use would require evidence that the ratio meaningfully changes risk classification after standard discharge planning, secondary prevention, and follow-up intensity have been considered. Analyses stratified by reperfusion delay, renal dysfunction, reduced ejection fraction, and achieved secondary-prevention therapy might help identify subgroups in which the ratio is most informative.

Overall, Li et al offer useful evidence that hs-CRP/ALB is associated with long-term outcomes after PCI-treated STEMI. Future analyses showing incremental discrimination, calibration, and net clinical benefit would further support its role as a practical decision-support tool, rather than solely as a prognostic correlate.