Coronary Artery Disease in Patients With Psoriasis Referred for Coronary Angiography

doi:10.1016/j.amjcard.2011.11.025

The American Journal of Cardiology

Volume 109, Issue 7, 1 April 2012, Pages 976-980

https://doi.org/10.1016/j.amjcard.2011.11.025 Get rights and content

Patients with psoriasis may have an increased risk of cardiovascular disease and myocardial infarction. The aim of this study was to investigate whether psoriasis is associated with an increased prevalence of coronary artery disease (CAD) independent of established cardiovascular risk factors in patients undergoing coronary angiography. A retrospective cohort analysis was performed by linking records of all patients undergoing coronary angiography from 2004 through 2009 with dermatology medical records. From an overall cohort of 9,473 patients, we identified 204 patients (2.2%) with psoriasis before coronary angiography. Patients with psoriasis had higher body mass index (31.3 ± 8.1 vs 29.3 ± 7.1 kg/m², p <0.001) but the prevalence of other risk factors was similar. Median duration of psoriasis before cardiac catheterization was 8 years (interquartile range 2 to 24). Patients with psoriasis were more likely to have CAD (84.3% vs 75.7%, p = 0.005) at coronary angiography. After adjusting for established cardiovascular risk factors, psoriasis was independently associated with presence of angiographically confirmed CAD (adjusted odds ratio 1.8, 95% confidence interval 1.2 to 2.8, p = 0.006). In patients with psoriasis, duration of psoriasis >8 years was also independently associated with angiographically confirmed CAD after adjusting for established cardiovascular risk factors (adjusted odds ratio 3.5, 95% confidence interval 1.3 to 9.6, p = 0.02). In conclusion, patients with psoriasis and especially those with psoriasis for >8 years have a higher prevalence of CAD than patients without psoriasis undergoing coronary angiography.

Section snippets

Methods

We identified all patients who underwent cardiac catheterization at the University of California, Davis from 2004 through 2009. This database contains prospective data entered at the time of cardiac catheterization including patient risk factors, medical history, and quantitative results of coronary angiography. Patients were included if they were ≥18 years of age and had undergone coronary angiography from 2004 through 2009. This study was approved by the University of California, Davis,

Results

From a total population of 9,473 patients who underwent coronary angiography, we identified 204 patients (2.2% of overall population) who had psoriasis before coronary angiography (Table 1). Compared to the overall population, patients with psoriasis had a higher body mass index (31.3 ± 8.1 vs 29.3 ± 7.1 kg/m², p <0.001) and were more likely to have a history of hypercholesterolemia (72% vs 66%, p = 0.06). Eighteen percent of patients with psoriasis had previous myocardial infarction and 45% of

Discussion

This analysis represents the first systematic study of the prevalence of angiographically confirmed CAD in psoriasis patients referred for coronary angiography. Three important findings emerge from this study. First, patients with psoriasis have an increased prevalence of cardiovascular risk factors even compared to an otherwise high-risk cohort. Second, patients with psoriasis are more likely to have CAD as visualized on coronary angiogram even after adjusting for established cardiovascular

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Association between psoriasis and atrial fibrillation: A Systematic review and meta-analysis
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Psoriasis is a prevalent inflammatory skin condition characterized by erythematous plaques with scaling. Recent research has demonstrated an increased risk of cardiovascular diseases in patients with psoriasis; however, current evidence on atrial fibrillation (AF) risk in psoriasis is limited.
A systematic literature search was performed on major bibliographic databases to retrieve studies that evaluated AF risk in patients with psoriasis. The DerSimonian and Laird random effects model was used to pool the hazard ratios (HR) with 95 % confidence intervals (CI). Subgroup analysis was conducted by dividing the patients into mild and severe psoriasis groups. Publication bias was assessed by visual inspection and Egger's regression test. Statistical significance was set at p < 0.05.
Seven studies were included, with 10,974,668 participants (1,94,230 in the psoriasis group and 10,780,439 in the control group). Patients with psoriasis had a significantly higher risk of AF [Pooled HR: 1.28; 95 % CI: 1.20, 1.36; p < 0.00001]. In subgroup analysis, patients with severe psoriasis [HR: 1.32; 95 % CI: 1.23, 1.42; p < 0.00001] demonstrated a slightly higher risk of AF, although statistically insignificant (p = 0.17), than the mild psoriasis group [HR: 1.21; 95 % CI: 1.10, 1.33; p < 0.0001]. Egger's regression test showed no statistically significant publication bias (p = 0.24).
Our analysis demonstrated that patients with psoriasis are at a significantly higher risk of AF and hence should be closely monitored for AF. Further large-scale and multicenter randomized trials are warranted to validate the robustness of our findings.
2022 Taiwanese Dermatological Association (TDA), Taiwanese Association for Psoriasis and Skin Immunology (TAPSI), and Taiwan Society of cardiology (TSOC) joint consensus recommendations for the management of psoriatic disease with attention to cardiovascular comorbidities
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Psoriatic disease is a chronic inflammatory disorder with skin and joint manifestations. Due to the persistent inflammatory state exhibited by patients with psoriasis, multiple systemic comorbidities occur more frequently in patients with psoriasis than in the general population, and the risk of cardiovascular (CV) diseases is significantly increased. As the pathophysiology of psoriatic disease is becoming better understood, the sharing of underlying pathogenic mechanisms between psoriatic and CV diseases is becoming increasingly apparent. Consequently, careful attention to CV comorbidities that already exist or may potentially develop is needed in the management of patients with psoriasis, particularly in the screening and primary prevention of CV disease and in treatment selection due to potential drug–drug and drug-disease interactions. Furthermore, as the use of effective biologic therapy and more aggressive oral systemic treatment for psoriatic disease is increasing, consideration of the potential positive and negative effects of oral and biologic treatment on CV disease is warranted. To improve outcomes and quality of care for patients with psoriasis, the Taiwanese Dermatological Association, the Taiwanese Association for Psoriasis and Skin Immunology, and the Taiwan Society of Cardiology established a Task Force of 20 clinicians from the fields of dermatology, cardiology, and rheumatology to jointly develop consensus expert recommendations for the management of patients with psoriatic disease with attention to CV comorbidities.
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Studies have shown a higher risk of cardiovascular diseases in psoriasis patients in comparison with controls (Samarasekera et al., 2013). Some of the cardiovascular comorbidities of psoriasis include metabolic syndrome, venous thromboembolism, hypertension, dyslipidemia, coronary artery disease, metabolic infarction, and stroke (Armstrong et al., 2013; Ahlehoff et al., 2011; Armstrong et al., 2013; Gelfand et al., 2006; Armstrong et al., 2012; Gelfand et al., 2009). Also, the systemic inflammatory state in patients with psoriasis can cause insulin resistance leading to endothelial dysfunction and atherosclerosis (Golden et al., 2013).
Cardiovascular diseases, including atherosclerosis, are the number one cause of death worldwide. These diseases have taken the place of pneumonia and other infectious diseases in the epidemiological charts. Thus, their importance should not be underestimated. Atherosclerosis is an inflammatory disease. Therefore, immunological signaling molecules and immune cells carry out a central role in its etiology. One of these signaling molecules is interleukin (IL)-17. This relatively newly discovered signaling molecule might have a dual role as acting both pro-atherogenic and anti-atherogenic depending on the situation. The majority of articles have discussed IL-17 and its action in atherosclerosis, and it may be a new target for the treatment of patients with this disease. In this review, the immunological basis of atherosclerosis with an emphasis on the role of IL-17 and a brief explanation of the role of IL-17 on atherosclerogenic disorders will be discussed.
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Tapinarof, a novel, first-in-class, small-molecule topical therapeutic aryl hydrocarbon receptor (AhR)–modulating agent, is in clinical development for the treatment of psoriasis and atopic dermatitis. The efficacy of tapinarof in psoriasis is attributed to its specific binding and activation of AhR, a ligand-dependent transcription factor, leading to the downregulation of proinflammatory cytokines, including interleukin 17, and regulation of skin barrier protein expression to promote skin barrier normalization. AhR signaling regulates gene expression in immune cells and skin cells and has critical roles in the regulation of skin homeostasis. Tapinarof-mediated AhR signaling underlies the mechanistic basis for the significant efficacy and acceptable tolerability observed in early-phase clinical trials of tapinarof cream in the treatment of psoriasis.
Epicardial Adipose Tissue Inflammation Can Cause the Distinctive Pattern of Cardiovascular Disorders Seen in Psoriasis
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This risk is particularly marked in younger patients with early-onset disease as well as those with clinically severe or prolonged psoriasis15-17; when these factors are combined, the risk is increased 3- to 9-fold.9,18 Typically, the accelerated coronary atherosclerosis cannot be readily explained by changes in body weight, blood pressure, lipids, or glucose.19 Interestingly, the coronary plaques generally exhibit high-risk features for plaque rupture,20,21 but they regress following the use of anticytokine agents for their psoriasis; these agents also reduce the risk of myocardial infarction.20-22
Psoriasis is a systemic inflammatory disorder that can target adipose tissue; the resulting adipocyte dysfunction is manifest clinically as the metabolic syndrome, which is present in ≈20%-40% of patients. Epicardial adipose tissue inflammation is likely responsible for a distinctive pattern of cardiovascular disorders consisting of 1) accelerated coronary atherosclerosis leading to myocardial infarction, 2) atrial myopathy leading to atrial fibrillation and thromboembolic stroke, and 3) ventricular myopathy leading to heart failure with a preserved ejection fraction. If cardiovascular inflammation drives these risks, then treatments that focus on blood pressure, lipids, and glucose will not ameliorate the burden of cardiovascular disease in patients with psoriasis, especially in those who are young and have severe inflammation. Instead, interventions that alleviate systemic and adipose tissue inflammation may not only minimize the risks of atrial fibrillation and heart failure but may also have favorable effects on the severity of psoriasis. Viewed from this perspective, the known link between psoriasis and cardiovascular disease is not related to the influence of the individual diagnostic components of the metabolic syndrome.
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Sex hormones are involved in pathways of metabolic syndrome (MetS), an observation supported by animal studies. The relationships of sex hormones with components of MetS, such as insulin resistance and dyslipidemia, have been studied in pre- and postmenopausal women. High testosterone, low sex hormone-binding globulin, and low estrogen levels increase the risks of MetS and type 2 diabetes in women. Cutaneous diseases that are sex hormone mediated, such as polycystic ovary syndrome, acanthosis nigricans, acne vulgaris, and pattern alopecia, have been associated with insulin resistance and increased risk for MetS. Furthermore, inflammatory skin conditions, such as hidradenitis suppurativa and psoriasis, increase the risk for MetS. Patients with such skin conditions should be followed for metabolic complications, and early lifestyle interventions toward these populations may be warranted.

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: This work was supported by the Dermatology Foundation, Evanston, Illinois. Dr. Rogers is a consultant for Volcano, Medtronic, Cordis and Boston Scientific. Dr. A.W. Armstrong is an investigator and consultant for Abbott and Centocor.

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Coronary artery diseaseCoronary Artery Disease in Patients With Psoriasis Referred for Coronary Angiography

Section snippets

Methods

Results

Discussion

J Am Acad Dermatol

Am J Med

J Dermatol Sci

J Dermatol Sci

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Am Acad Dermatol

J Am Coll Cardiol

Methods of covariate selection: directed acyclic graphs and the change-in-estimate procedure

Am J Epidemiol

Risk of myocardial infarction in patients with psoriasis

JAMA

Coronary artery disease
Coronary Artery Disease in Patients With Psoriasis Referred for Coronary Angiography