Addressing Cardiovascular Risk Factors in Psoriasis Patients

Recent advances in genetics, immunology, and epidemiology have uncovered a connection between psoriasis and cardiovascular (CV) disease, becoming a leading cause of excess mortality in affected individuals. Dermatology clinicians play a pivotal role in recognizing and managing this heightened CV risk, necessitating a paradigm shift in patient care. Joel Gelfand, MD, MSCE, FAAD, professor of dermatology and epidemiology at the University of Pennsylvania Perelman School of Medicine in Philadelphia, Pennsylvania, shared a new article of CV considerations for dermatology clinicians with Dermatology Times.¹

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The Burden of Cardiovascular Risk in Psoriasis

Psoriasis is no longer confined to its dermatological implications; it is now acknowledged as a systemic inflammatory disease with a significant burden of major cardiovascular events. Patients with psoriasis exhibit an increased prevalence of major modifiable CV risk factors, such as hypertension, obesity, diabetes, dyslipidemia, and smoking. This heightened risk translates into an elevated susceptibility to myocardial infarction, stroke, and CV mortality, independent of conventional risk factors.²

Patients with moderate to severe psoriasis face a reduced life expectancy, with approximately 42% of excess mortality attributed to CV disease. Meta-analyses indicate that these individuals have over a 40% increased risk of CV death compared to those without psoriasis. The severity of psoriasis, measured by the body surface area affected, correlates directly with the risk of developing diabetes. Genetic studies suggest a bidirectional relationship between psoriasis and cardiovascular diseases, further underscoring the need for comprehensive management.³

Impact of Psoriasis Treatment on Cardiovascular Risk

Controlling psoriasis becomes imperative in mitigating cardiovascular risk. Observational studies suggest that systemic therapies like tumor necrosis factor (TNF) inhibitors and methotrexate may reduce major CV events and mortality. However, caution is warranted in interpreting these findings, as the healthy user effect may confound results.

Mechanistic studies reveal potential benefits of psoriasis treatments on vascular and inflammatory markers. Biologic therapies, such as ustekinumab (Stelara) and adalimumab (Humira), demonstrate promise in reducing coronary inflammation, plaque burden, and biomarkers of cardiometabolic risk. However, evidence from randomized controlled trials (RCTs) assessing the direct impact on CV eventsremains sparse and inconclusive.⁴

Managing Modifiable Cardiovascular Risk Factors

The importance of managing modifiable CV risk factors cannot be overstated, according to Gelfand and his fellow investigators. Smoking cessation, effective blood pressure control, and lipid-lowering therapies, especially statins, significantly reduce CV morbidity and mortality. Statins, with pleiotropic anti-inflammatory effects, emerge as potential agents not only for CV risk reduction but also for improving psoriasis symptoms.

Current guidelines underscore the need for heightened efforts in identifying and managing CV risk factors in psoriasis patients. Dermatologists are urged to perform baseline CV risk factor screenings, incorporating hypertension, diabetes, and dyslipidemia assessments. Guidelines recommend earlier and more frequent screening for moderate to severe psoriasis cases, emphasizing the importance of a multidisciplinary approach involving primary care providers and preventive cardiologists.

Challenges in Current Practice

Despite the evidence linking psoriasis to CV risk, a glaring gap exists in the identification and management of these risk factors in routine clinical practice. Dermatology clinicians are urged to take a proactive role in screening and managing CV risk factors. Current statistics reveal suboptimal screening rates for blood pressure and cholesterol among patients with psoriasis.

Addressing this gap requires a collaborative effort between dermatologists, primary care providers, and preventive cardiologists. Establishing robust relationships with these healthcare professionals can facilitateefficient multidisciplinary care, ensuring comprehensive identification and management of CV risk factors.

Screening Guidelines and Strategies

Guidelines recommend dermatologists to educate psoriasis patients about their increased CV risk and perform baseline, age-appropriate CV risk factor screenings. Dermatologists are encouraged to incorporate screenings for hypertension, dyslipidemia, diabetes, obesity, and smoking during routine psoriasis care. The emphasis is on early detection and prompt management to prevent the onset of asymptomatic atherosclerotic CV disease.

Strategies to Improve CV Screening

The dermatologist's role extends beyond treating skin manifestations; it encompasses holistic patient care. Patients with psoriasis often lack regular access to primary care providers, making dermatologists their primary healthcare contact. Recent studies indicate that patients are receptive to CV risk factor screenings by dermatologists, reinforcing the potential for a more active role in primary care.

Building on these findings, dermatologists can enhance CV risk factor screening during routine psoriasis care. Leveraging existing relationships with patients, dermatologists can incorporate basic screenings, educate patients about CV risks, and establish connections with primary care providers or preventive cardiologists when necessary. A step-wise guide for baseline CV risk screening is provided, ensuring a comprehensive approach tailored to individual patient needs.

Conclusion

Dermatology clinicians are at the frontline of psoriasis care and play an important role in addressing the associated cardiovascular risks. Through proactive education, baseline screenings, and collaboration with primary care providers, dermatologists can bridge the evidence-to-practice gap, significantly improving the health and lifespan ofpatients with psoriasis.

References

1. Song W, Soffer D, Gelfand JM, Using guidelines of care to lower cardiovascular risk in patients with psoriasis. Dermatol Clinics. 2024 Mar. doi: 10.1016/j.det.2024.02.008.
2. Kampe T, Dorko E, Rimárová K, et al. Prevalence of cardiovascular risk factors in patients with psoriasis. Cent Eur J Public Health. 2022 Jun;30(Supplement):S05-S10. doi: 10.21101/cejph.a6806. PMID: 35841218.
3. Gelfand JM, Troxel AB, Lewis JD, et al. The risk of mortality in patients with psoriasis: results from a population-based study. Arch Dermatol. 2007 Dec;143(12):1493-9. doi: 10.1001/archderm.143.12.1493. PMID: 18086997.
4. González-Cantero A, Ortega-Quijano D, Álvarez-Díaz N, et al. Impact of Biological Agents on Imaging and Biomarkers of Cardiovascular Disease in Patients with Psoriasis: A Systematic Review and Meta-Analysis of Randomized Placebo-Controlled Trials. J Invest Dermatol. 2021 Oct;141(10):2402-2411. doi: 10.1016/j.jid.2021.03.024. Epub 2021 Apr 21. PMID: 33891953.