To understand how biologic therapies might translate into a reduction in cardiovascular events in psoriasis, large, placebo-controlled, prospective studies with long-term follow-up would be needed. However, structural changes (eg, atherosclerotic progression) can take several months or even years to observe, and patients with psoriasis should not be assigned to a placebo for such extended durations. We have been analyzing blood-based cardiometabolic biomarkers, and we have also measured aortic vascular inflammation (AVI) in several of our trials because this approach has been shown to be predictive of future cardiovascular events and these changes occur rapidly with therapies that are known to lower cardiovascular risk, such as statins. 

In our 2018 study comparing the effects of adalimumab, phototherapy, or placebo on vascular inflammation and cardiovascular biomarkers, we reported a reduction in inflammatory markers in the adalimumab group for C-reactive protein, tumor necrosis factor, IL-6, and glycoprotein acetylation, whereas C-reactive protein and IL-6 were reduced in the phototherapy arm. We did not observe a reduction in AVI with either adalimumab or phototherapy. In other studies, we have seen that secukinumab appears to be somewhat neutral in its effects on these markers and on AVI. In some ways, this was unexpected because the hypothesis had been that marked skin clearance with secukinumab would be paralleled by a marked reduction in these markers. In contrast, in our recent study on the effects of ustekinumab on vascular inflammation in psoriasis, ustekinumab did appear to reduce AVI vs placebo at week 12; however, that effect was transient and it did not persist when patients stayed on the drug for 1 year. Thus, our findings demonstrated that blockade of IL-12 and/or IL-23 may transiently reduce AVI, with a more durable reduction in inflammatory cytokines associated with cardiovascular disease; however, the clinical significance of these findings is uncertain. 

In clinical practice, patients with psoriasis benefit from education about the increased cardiovascular risk that is associated with this disease. We know that our patients with psoriatic disease tend to have higher rates of hypertension, diabetes, obesity, and hyperlipidemia. These factors are often underdiagnosed, and, when they are diagnosed, they tend to be undertreated. We also know that the prevalence of these risk factors increases with the severity of skin disease. During the first conversation that we have with our patients about psoriasis and cardiovascular risk, we must emphasize the importance of screening and management of traditional cardiovascular risk factors, and we should encourage the adoption of healthy lifestyle changes. For example, among patients with psoriasis, my experience has been that only about 25% of those in whom statins are recommended are taking them. If we could solve that problem alone, we would dramatically improve the life expectancies of our patients.