New researchoffers strong evidence that vascular inflammation and risk of having a major adverse cardiovascular event, such as heart attack or stroke, increase with psoriasis duration.
As a result, dermatologists and other providers should consider asking how long patients have had psoriasis when assessing cardiovascular risk stratification, according to the authors.
Studies have shown that psoriasis patients are more likely than those without the disease to have cardiovascular risk factors, cardiovascular disease and vascular inflammation. Researchers have also found that cumulative exposure to inflammation increases the risks for atherosclerosis and cardiovascular events. And psoriasis can result in chronic, low-grade systemic inflammation, according to the study.
The researchers used human imaging and population-based studies to understand psoriasis duration’s effect on vascular disease and cardiovascular events.
To study vascular inflammation and psoriasis, they used fludeoxyglucose F18 positron emission tomography/computed tomography imaging on 190 psoriasis patients, with mild to moderate disease, who were primarily middle-aged men.
They found the longer the duration of psoriasis, the more inflammation in subjects’ blood vessels. And that relationship was evident despite traditional cardiovascular risk factors. Male gender, smoking, Framingham 10-year risk and body mass index were strongly associated with vascular inflammation, as well.
The researchers also studied a population cohort of 4,321,954 adults, including 87,161 with psoriasis. The maximum duration of disease among those with psoriasis was 31.1 years. They found each year of psoriasis duration was associated with a 1 percent increased risk for future cardiovascular events-an effect similar to that from smoking.
In a separate analysis, they followed patients in the population cohort for 4.7 years and report that during the followup 152,122 adults without psoriasis had a major cardiovascular event, which is about 8 people in every 1,000. That’s compared to 4,472 people with psoriasis who had major cardiovascular events in the followup, which is about 11 people in every 1,000.
Each of the major adverse cardiovascular event components-heart attack, stroke and death-increased with longer disease duration. “…we have presented novel and convincing evidence to suggest a detrimental effect of psoriasis duration on [cardiovascular disease] beyond traditional [cardiovascular] risk factors, even in patients with low [cardiovascular] risk scores,” they write.
Based on the large study population, the absolute increase is roughly 10 percent for future adverse events.
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CARDIOVASCULAR RISK FACTORS
Classic cardiovascular risk factors don’t seem to be the only reason for a potentially heightened risk; rather, systemic inflammation might be a driver of cardiovascular disease risk in patients with psoriasis. The authors point out that inflammation is linked to cardiovascular disease markers that occur more often in psoriasis patients, including impaired insulin sensitivity, carotid intima-media thickening, endothelial dysfunction, aortic stiffness, vascular inflammation and coronary plaque burden.
“These insults could occur because of the consistent vascular damage consequent to immune activation in those with longer duration disease,” they write.
But questions remain. Most-not all-studies have linked psoriasis with increased cardiovascular disease risk. It’s still debated whether having psoriasis is independently associated with cardiovascular disease.
For example, a 2015 study published in the Journal of Investigative Dermatology looked at the association between psoriasis and risk of major cardiovascular events. In a cohort of 48,523 patients with psoriasis and 208,187 controls, and in an average 5.2 year follow up, researchers found nearly 2.6 percent of those with psoriasis had a major cardiovascular event, compared to 2.3 percent of controls. They found in a multivariable analysis that inflammatory arthritis, diabetes, chronic kidney disease, hypertension, valvular heart disease, thromboembolism, congestive heart failure, depression, smoking, age and male gender were statistically significantly factors for major cardiovascular disease risk.
However, neither psoriasis nor severe psoriasis were associated with the short-to-medium term-more than three to five years--risk of major cardiovascular events, after they adjusted for known cardiovascular disease risk factors.
Another thing that’s not clear still today is how systemic therapy might affect vascular inflammation and cardiovascular events, according to the authors.
A potential limitation of this new study is the population cohort data didn’t include information about body mass index or physical exercise. And among the 190 patients imaged for vascular inflammation, previous cardiovascular disease and diabetes did not relate to vascular inflammation, but those were two major predictors of major adverse cardiovascular events in the population cohort. The inconsistency could be due to the low numbers of patients with those characteristics in the 190-patient group, the authors write.
The authors have research, consulting and other ties to numerous companies, including Pfizer, Eli Lilly, Novartis, Galderma, Janssen Pharmaceuticals, LEO Pharma and others. One of the authors is employed by Eli Lilly.
Egeberg A, Skov L, Joshi AA, et al. “The relationship between duration of psoriasis, vascular inflammation, and cardiovascular events,”Journal of the American Academy of Dermatology. October 2017. DOI:10.1016/j.jaad.2017.06.028.
Parisi R, Rutter MK, Lunt M, et al. “Psoriasis and the Risk of Major Cardiovascular Events: Cohort Study Using the Clinical Practice Research Datalink,”Journal of Investigative Dermatology. Published online April 9, 2015 DOI:10.1038/jid.2015.87.