Greater EAT-V May Predict Adverse Cardiovascular Risk in Men with Severe Psoriasis

A recent study showed that men with psoriasis have larger EAT-V than those without the skin disease.

Male patients with psoriasis with no known diabetes or heart disease have larger epicardial adipose tissue (EAT) volumes (EAT-Vs) than patients without psoriasis, suggesting that EAT-V could identify men with psoriasis who may be at increased risk of adverse cardiovascular (CV) outcomes, according to findings from a cross-sectional study.

Psoriasis has been consistently linked to an increased risk of coronary artery disease (CAD), even when classic coronary risk factors are taken into consideration, according to study researchers. “The pathogenesis is thought [to be] related primarily to systemic inflammation in patients with psoriasis,” the authors wrote in their Journal of the American Academy of Dermatology paper, which first appeared online October 2021.

The authors noted that EAT, which was once believed to provide only cushion to and support for the myocardium within the thorax, is actually a biologically active tissue. Improved understanding of EAT indicates that the tissue generates numerous proinflammatory cytokines, suggesting that elevated EAT-V may be associated with coronary events that are independent of traditional CV risk factors and coronary calcium score.

Given the systemic inflammation associated with psoriasis and the increased cytokine production with elevated EAT-V, the researchers suggested there is a need to identify whether EAT-V, when measured on standard imaging, can provide early prediction of adverse CV risk in this patient population.

In a cross-sectional study, a team of researchers from the University of Michigan recruited 25 patients with severe, chronic plaque psoriasis from a convenience sample of patients who attended University of Michigan dermatology clinics. Additionally, the study enrolled 16 controls without psoriasis or any rheumatologic condition among themselves or in a first-degree relative.

Participants in the study were between 34 to 55 years of age and had no known CAD or diabetes mellitus. All participants underwent computed tomography (CT). The investigators obtained contrast-enhanced electrocardiogram-gated coronary CT angiography (CCTA) scans as well as non-contrast coronary calcium scoring with prospectively triggered electrocardiogram-gated CT.

The analysis of EAT-V relied on the non-contrast CT scans that were used for calcium scoring. The researchers tested the differences in EAT-Vs between patients with psoriasis vs controls, overall, as well as by sex.

No differences were found between the psoriasis group and the control group in regard to several demographic and clinical characteristics, including sex, age, body mass index, and standard CV risk factors. There was also no difference between the groups in terms of family history of premature CV disease.

At baseline, however, study participants with psoriasis had greater amounts of EAT-V compared with controls (91 ± 31 vs 70 ± 33 cm3, respectively; P =.04). In male participants, those with psoriasis also had a significantly greater high-sensitivity C-reactive protein (hs-CRP) level compared with controls (2.5 ± 1.8 vs 1.0 ± 0.8, respectively; P =.03).

The greater EAT-V was maintained for men with psoriasis in an analysis adjusted for hs-CRP as a covariate (P = .05), but hs-CRP was not significantly correlated with EAT-V in these patients (P = .29). According to the investigators, only 7% of the variance in EAT-V in the male population can be explained by hs-CRP.

“As EAT-V measurements become more integrated into clinical practice, the degree to which EAT-V provides prognostic utility beyond that of hs-CRP should become clearer,” they wrote.

No difference was found between the psoriasis group and control in terms of the mean total coronary artery calcium score. Additionally, the researchers found no significant difference between male patients with psoriasis and controls, according to the distribution of CAD Reporting and Data System score by CCTA scan.

The investigators found excellent interobserver agreement (intraclass correlation coefficient, 0.96) in EAT-V measurements that were obtained from the cardiothoracic radiologist and a medical student. This high level of agreement in determining EAT-V, the investigators explained, seems to suggest that accurate EAT measurement can be accomplished across clinicians with various levels of expertise. As such, this could “increase the likelihood of obtaining EAT-V in routine clinical practice for patients undergoing CAD evaluation with CT,” according to the study.

According to lead study author Charles Ellis, MD, professor Emeritus in the Department of Dermatology at the University of Michigan Medical School, in Ann Arbor, the elevated EAT-V in the study population is consistent with the increased overall risk of coronary events in patients with psoriasis.

“The increased CV risk in patients with psoriasis is thought to be due to an increased systemic inflammatory load or may be to the elevated EAT-V, or possibly both,” Ellis told Dermatology Times®. “Whether the elevated EAT-V itself is a sign of increased general inflammation or an independent finding will need to be determined by more investigations in this interesting research field.”

Given that the findings indicate EAT-V can be a useful calculation for patients with severe psoriasis, there is a need to ensure clinicians are considering this calculation in this patient population. Ellis noted that EAT-Vs can be calculated from routine cardiac radiologic exams that are ordered by many patients’ primary care physicians. “EAT-Vs can be determined with no additional radiation and no additional time for the cardiac test to be performed on the patient,” he added.

“As EAT-V becomes a more commonly reported result and possibly even automated, the results will more often become available to the patient’s primary care doctor,” Ellis said. “In patients in [which] EAT-V is elevated, they will be identified as patients who need closer attention and perhaps more interventions to prevent subsequent heart disease.”

Limitations of the study included its single-center convenience sample, which consisted of only a small number of patients with psoriasis. The findings may also not be applicable to patients with mild or moderate forms of the disease.

Additionally, the lack of statistical significance regarding the relationship between EAT-V and psoriasis among women likely limits the generalizability of the study’s findings, he said. Despite this limitation, Ellis suggested the findings may eventually be confirmed in women with psoriasis and may also be further confirmed in male patients.

“Women with psoriasis had higher EAT-Vs than their controls but not statistically significantly so,” he said. “Studying a larger group of women might confirm that psoriasis is also associated with higher EAT volumes in women.”

References:

Ellis CN, Neville SJ, Sayyouh M, et al. Epicardial adipose tissue volume is greater in men with severe psoriasis, implying an increased cardiovascular disease risk: A cross-sectional studyJ Am Acad Dermatol. 2022;86(3):535-543. doi: 10.1016/j.jaad.2021.09.069