Cardiovascular morbidity and mortality in psoriasis and psoriatic arthritis: A systematic literature review

Aix-Marseille University, UMR 911, INSERM CRO2 and Dermatology Department, Timone Hospital, Marseille, France.
Journal of the European Academy of Dermatology and Venereology (Impact Factor: 2.83). 08/2013; 27 Suppl 3(s3):12-29. DOI: 10.1111/jdv.12163
Source: PubMed


Previous epidemiological studies have demonstrated a high prevalence of cardiovascular (CV) risk factors in psoriasis patients, including metabolic syndrome, cigarette smoking, obesity, hypertension, diabetes mellitus, insulin resistance and dyslipidaemia. An increase in CV morbidity and mortality attributable to psoriasis is still under question.

Primary objective:
to assess CV morbidity and mortality in psoriasis and psoriatic arthritis (PsA) including stroke, coronary artery disease, myocardial infarction (MI) and peripheral artery disease.

Secondary objectives:
to assess if psoriasis per se is an independent CV risk factor and if psoriasis severity is a predictor of CV risk. We also evaluated the effect of conventional systemic treatments for psoriasis on CV mortality. A systematic literature search was carried out from 1980 to December 2011, in the Embase, Medline and Cochrane Library databases, in English and French using a combination of keywords including (Psoriasis) OR (Psoriatic arthritis) AND (Myocardial infarction) OR (Coronaropathy) OR (Stroke) OR (Cardiovascular) AND (Methotrexate) AND (Ciclosporin) AND (Retinoids). Of the 929 identified references, 33 observational studies evaluating the rates of cardiovascular events (CVE) in patients with psoriasis and PsA compared with controls were selected. Meta-analysis of both cohort and cross-sectional studies showed an increased risk of MI with Odds Ratio (OR) of 1.25 (95% CI 1.03-1.52) and 1.57 (95% CI 1.08-2.27) in psoriasis and PsA, respectively, compared with the general population. The risk of MI was more pronounced for patients having severe psoriasis and for patients with psoriasis of early onset. It remained significantly elevated after controlling for major CV risk factors. The meta-analysis identified a small, but significant association between psoriasis, PsA and coronary artery disease with an OR between 1.19 (95% CI 1.14-1.24) for cross-sectional studies, 1.20 (95% CI 1.13-1.27) for cohort studies and 1.84 (95% CI 1.09-3.09) for case-control studies. The risk of coronary artery disease seemed to be more pronounced in patients with severe psoriasis and in patients with psoriasis of early onset. The meta-analysis assessing the risk of stroke gave inconclusive results: analysis of cross-sectional studies suggested that psoriasis patients had a slightly higher risk of stroke with an OR of 1.14 (95% CI 1.08-1.99), whereas the meta-analysis of cohort studies failed to show an association. There was also an increased risk of peripheral artery disease in psoriasis. No significant increased risk of CV mortality could be shown for both psoriasis and PsA patients. The use of methotrexate was associated with a reduced incidence of cardiovascular disease in two studies. The use of etretinate was associated with a reduction of CV mortality in one study. Potential selection bias such as the 'healthy user effect' prevents from drawing definite conclusions. There may be a small, but significant increased risk of CVE, but not of CV mortality in psoriasis and PsA patients. The psoriasis attributable risk remains difficult to assess due to confounding factors. The moderate quality of CV risk factors reporting in studies should be acknowledged. In addition, heterogeneity in study design, outcome definition and assessment represent major limitations. Nevertheless, screening and management of CV risk factors are important in psoriasis.

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Available from: Thomas Barnetche, Sep 03, 2014
    • "Research has shown that chronic and systemic inflammation plays a major role in the development of these diseases, and there are striking similarities between the molecular and inflammatory pathways in psoriasis and atherosclerosis (Coumbe et al., 2014). Indeed, many studies have confirmed that patients with psoriasis have a significantly higher risk of being afflicted with obesity and diabetes mellitus (Horreau et al., 2013). "
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    ABSTRACT: Psoriasis is increasingly recognised as a skin disease with far-reaching systemic effects, associated with a high prevalence of comorbid disease such as cardiometabolic dysfunction, shifting the focus from a single organ disease confined to the skin to a systemic inflammatory condition. Chronic and systemic inflammation plays a major role in the development of these diseases, and there are striking similarities between the molecular and inflammatory pathways in psoriasis and atherosclerosis. In a single-centre, cumulative, prospective registry study of 347 hypogonadal men (total testosterone ≤12.1 nmol l(-1) ), fifteen men with psoriasis could be studied. Upon testosterone administration, the skin disease improved considerably. Scores on the Psoriasis Area and Severity Index and Physician Global Assessment for Psoriasis showed significant improvement for the first 24 months. Thereafter, these improvements were sustained. Upon testosterone treatment, C-reactive protein declined significantly. There were significant improvements of obesity and of lipid profiles. Adipose tissue is now regarded as a source of inflammatory factors. These preliminary results deserve to be studied in a specifically designed study to investigate the effects of testosterone on psoriasis and its associated immunopathology. © 2015 Blackwell Verlag GmbH.
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    • "Consistent with data described in RA, patients with spondyloarthropathies also have a higher risk of CVD than the general population [14] [15]. CVD and CV mortality are more common in patients with PsA compared to the general population [16] [17] [18]. "
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    ABSTRACT: To establish the cardiovascular (CV) morbidity and associated risk factors for CV disease (CVD) in Spanish patients with chronic inflammatory rheumatic diseases (CIRD) and unexposed individuals attending rheumatology clinics. Analysis of data from the baseline visit of a 10-year prospective study [CARdiovascular in rheuMAtology (CARMA) project] that includes a cohort of patients with CIRD [rheumatoid arthritis (RA), ankylosing spondylitis (AS), and psoriatic arthritis (PsA)] and another cohort of matched individuals without CIRD attending outpatient rheumatology clinics from 67 hospitals in Spain. Prevalence of CV morbidity, CV risk factors, and systematic coronary risk evaluation (SCORE) assessment were analyzed. A total of 2234 patients (775 RA, 738 AS, and 721 PsA) and 677 unexposed subjects were included. Patients had low disease activity at the time of recruitment. PsA patients had more commonly classic CV risk factors and metabolic syndrome features than did the remaining individuals. The prevalence of CVD was higher in RA (10.5%) than in AS (7.6%), PsA (7.2%), and unexposed individuals (6.4%). A multivariate analysis adjusted for the presence of classic CV risk factors and disease duration revealed a positive trend for CVD in RA (OR = 1.58; 95% CI: 0.90-2.76; p = 0.10) and AS (OR = 1.77; 95% CI: 0.96-3.27; p = 0.07). Disease duration in all CIRD groups and functional capacity (HAQ) in RA were associated with an increased risk of CVD (OR = 2.15; 95% CI: 1.29-3.56; p = 0.003). Most patients had a moderate CV risk according to the SCORE charts. Despite recent advances in the management of CIRD, incidence of CVD remains increased in Spanish subjects with CIRD attending outpatient rheumatology clinics. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.
    Full-text · Article · Dec 2014 · Seminars in Arthritis and Rheumatism
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    • "TNF-a inhibitors significantly decreased MI risk and incident rate in psoriatic patients compared with topical treatment [192] independently of therapy duration [193]; a non-significant reduction was also observed when TNF-a inhibitors were compared with oral agents/phototherapy. Methotrexate was previously shown to reduce CVD incidence (including CHD and MI) in psoriatic patients [194]. "
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    ABSTRACT: Psoriasis is a chronic systemic inflammatory disease characterized by topical skin lesions as well as an increased risk for cardiovascular disease (CVD). There is also increasing evidence that patients with psoriasis are more prone to several CVD risk factors (hypertension, obesity, dyslipidemia and smoking), non-cardiac vascular diseases (carotid, peripheral artery and chronic kidney disease) and metabolic co-morbidities (type 2 diabetes mellitus, metabolic syndrome, non-alcoholic fatty liver disease and obstructive sleep apnea) compared with the general population. The associations are even greater in patients with severe psoriasis and those with psoriatic arthritis. Insulin resistance, endothelial dysfunction and obesity induced by several adipokines and inflammatory cytokines are proposed as the common mechanisms linking psoriasis with CVD, vascular risk factors and metabolic diseases. The present narrative review considers the associations between psoriasis (and psoriatic arthritis) with CVD, vascular risk factors and metabolic diseases. Drugs that reduce CVD risk and improve metabolic parameters may also beneficially affect psoriasis severity and prognosis. Furthermore, anti-psoriatic drugs can exert different effects on CVD risk and metabolic co-morbidities. Therefore, physicians should be aware of these associations in order to adequately monitor and treat psoriatic patients.
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