The signature signs of heart disease in psoriasis

Signs of aortic vascular inflammation in psoriasis patients may indicate early signs of coronary artery disease, report researchers writing in the Sept. 12 issue of JAMA Cardiology.

Signs of aortic vascular inflammation in psoriasis patients may indicate early signs of coronary artery disease, report researchers writing in the Sept. 12 issue of JAMA Cardiology.

"The major finding was that vascular inflammation―in this case measured in the aorta by PET/CT scan―positively correlates with the likelihood of having coronary disease. In particular, coronary disease that is likely to be more severe or of the type that's going to progress to a cardiac event," said co-author Joel M. Gelfand, M.D., M.S.C.E., of the University of Pennsylvania Department of Dermatology.

Investigators were attempting to understand the relationship between chronic inflammation and coronary artery disease variants that can lead to cardiovascular events.

"There is a wide range of literature linking chronic inflammation to atherosclerotic disease and cardiovascular events," Dr. Gelfand said. “We’re trying to determine if treating psoriasis successfully lowers risk of cardiovascular events and mortality. It's a critical issue for our patients."
Patients with psoriasis of increasing severity are at higher risk for hypertension, hyperlipidemia and coronary artery disease. "These are things their dermatologist may want to counsel the patient about or refer them to a primary care physician to undergo risk factor reduction screenings and treatments,” he said.

While previous studies suggest that psoriasis patients on TNF inhibitors may have better cardiovascular disease outcomes than patients receiving methotrexate or phototherapy, but a study by Dr. Gelfand published in the July issue of Circulation: Cardiovascular Imaging showed that adalimumab had no influence on the development of aortic vascular inflammation. “But we did show that it had fairly substantial impacts on inflammatory biomarker pathways known to be related causally to cardiovascular events," he said.  Adalimumab reduced the activity of TNF alpha and certain interleukins in the blood, as well as glycoprotein acetylation, which has recently been shown to be an important inflammatory biomarker of cardiovascular events.

This study included 215 psoriasis patients (mean age 50.4 years, 59% were men). Between 2013 and 2017, the patients underwent F-FDG positron emission tomography (PED) computed tomography (CT) testing for aortic vascular inflammation analysis. Of these, 190 patients  underwent coronary computed tomography (CT) angiography to assess for coronary artery disease.

Investigators, led by Nehal Mehta, M.D., of the National Heart, Lung and Blood Institute, found that patients with increased aortic vascular inflammation had higher levels of total plaque burden and a higher level of luminal stenosis and high-risk plaques.

“The aortic vascular inflammation and total plaque burden association was primarily driven by noncalcified coronary plaque burden, whereas the aortic vascular inflammation high-risk plaques association was driven by low-attenuation plaque. All associations of aortic vascular inflammation remained significant after adjustment for cardiovascular risk factors: aortic vascular inflammation and total plaque burden, noncalcified coronary plaque burden, luminal stenosis and high-risk plaques . No association was found between aortic vascular inflammation and dense-calcified coronary plaque burden,” the authors wrote.

Regarding study limitations, Dr. Gelfand added, “one cannot exclude the possibility that factors outside of inflammation may explain the relationship researchers uncovered. That said, we adjusted for a number of major cardiovascular risk factors, and the association persisted."
This persistence indicates that the relationship exists not because patients had dyslipidemia or obesity driving the association. "The relationship is pretty direct between inflammation and atherosclerosis. But it's possible that something we didn't measure, such as how much they exercise, could be mediating some of what we're seeing," he said.

“The research we're doing eventually may generalize to the broader field of cardiovascular medicine, where people would look at the impact of, say, adalimumab, an interleukin (IL)-17 inhibitor or an IL-23 inhibitor on cardiovascular events in patients not with psoriasis, but with high risk of cardiovascular disease."


Aditya A Joshi MD, Joseph B Lerman MD, Amit K Dey MD, et al. "Association Between Aortic Vascular Inflammation and Coronary Artery Plaque Characteristics in Psoriasis," JAMA Cardiology. Sept. 12, 2018. DOI:10.1001/jamacardio.2018.2769