Dermatology

Plaque Psoriasis

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Plaque Psoriasis and Cardiovascular Disease

clinical topic updates by Steven R. Feldman, MD, PhD

Overview

As ongoing studies by the National Institutes of Health aim to elucidate the relationship between psoriasis and cardiometabolic diseases, our featured expert discusses practical approaches to understanding and managing cardiovascular (CV) risk in patients with plaque psoriasis.

Expert Commentary

Steven R. Feldman, MD, PhD

Professor of Dermatology, Pathology, and Social Sciences & Health Policy
Wake Forest University School of Medicine
Winston-Salem, NC

“The work by Gelfand et al using the large UK General Practice Research Database showed that patients with psoriasis are at independent increased risk for CVD, and this was enormously important.”

Steven R. Feldman, MD, PhD

CV risk in patients with psoriasis may be the most exciting research that has emerged in dermatology over the last few years. The work by Gelfand et al using the large UK General Practice Research Database showed that patients with psoriasis are at independent increased risk for CV disease (CVD), and this was enormously important. The follow-up work using advanced imaging was also exciting; aortic vascular inflammation may be a surrogate for early coronary artery disease in patients with psoriasis. There are ongoing studies by the National Institutes of Health that are designed to elucidate the relationship between psoriasis and cardiometabolic diseases, and the prospect of therapies to modify CV risk in patients with psoriasis is exciting, as well.

I think that dermatologists are intrigued by this research on multiple levels. The cost of the newer, highly effective psoriasis medications is often an issue, and if these therapies impact patients’ CV risk—and not just psoriasis—that could be hugely important. Further, if psoriasis is accepted as a causative factor for CVD, we believe that insurers may be more likely to accept the need to treat it systemically.

We need to keep these CV risks in perspective, however, and we should look at absolute risk, not just relative risk. Consider a 2- to 3-fold increased risk of myocardial infarction in 20- to 30-year-old patients with psoriasis. While that sounds high, the baseline risk of having a myocardial infarction in 20- to 30-year-old patients without psoriasis is nearly zero. Therefore, 3 times that very low risk in a patient with psoriasis is still quite a low risk. However, that risk equation does change in older patients, who have a considerably higher baseline CV risk. We do not yet know for sure whether systemic treatment for psoriasis will prevent CV events. Even if it does, even if the CV risk attributed to psoriasis were as great as that of cholesterol, the absolute improvements that we might get in CVD for treatment may be quite small.

To summarize, psoriasis does appear to be associated with CV risk. Individuals with or without psoriasis who have CV risk should be screened for their cholesterol and do their blood pressure checks, among other things. At this point, I do not know that we need to be doing anything beyond the standard recommendations for CV risk reduction in patients with psoriasis, but we should at least be following those standard recommendations.

References

Aksentijevich M, Lateef SS, Anzenberg P, Dey AK, Mehta NN. Chronic inflammation, cardiometabolic diseases and effects of treatment: psoriasis as a human model. Trends Cardiovasc Med. 2020;30(8):472-478. doi:10.1016/j.tcm.2019.11.001

Barbieri JS, Mostaghimi A, Noe MH, Margolis DJ, Gelfand JM. Use of primary care services among patients with chronic skin disease seen by dermatologists. JAAD Int. 2020;2:31-36. doi:10.1016/j.jdin.2020.10.010

ClinicalTrials.gov. The Psoriasis, Atherosclerosis, and Cardiometabolic Disease Initiative (PACI). Accessed October 21, 2022. https://clinicaltrials.gov/ct2/show/NCT01778569

Dey AK, Teague HL, Adamstein NH, et al. Association of neutrophil-to-lymphocyte ratio with non-calcified coronary artery burden in psoriasis: findings from an observational cohort study. J Cardiovasc Comput Tomogr. 2021;15(4):372-379. doi:10.1016/j.jcct.2020.12.006

Gelfand JM, Neimann AL, Shin DB, et al. Risk of myocardial infarction in patients with psoriasis. JAMA2006;296(14):1735-1741. doi:10.1001/jama.296.14.1735

Joshi AA, Lerman JB, Dey AK, et al. Association between aortic vascular inflammation and coronary artery plaque characteristics in psoriasis. JAMA Cardiol. 2018;3(10):949-956. doi:10.1001/jamacardio.2018.2769

Neimann AL, Shin DB, Wang X, et al. Prevalence of cardiovascular risk factors in patients with psoriasis. J Am Acad Dermatol. 2006;55(5):829-835. doi:10.1016/j.jaad.2006.08.040

Piros ÉA, Szilveszter B, Vattay B, et al. Novel anti-inflammatory therapies to reduce cardiovascular burden of psoriasis. Dermatol Ther. 2021;34(1):e14721. doi:10.1111/dth.14721

Zwain A, Aldiwani M, Taqi H. The association between psoriasis and cardiovascular diseases. Eur Cardiol. 2021;16:e19. doi:10.15420/ecr.2020.15.R2

Steven R. Feldman, MD, PhD

Professor of Dermatology, Pathology, and Social Sciences & Health Policy
Wake Forest University School of Medicine
Winston-Salem, NC

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