Cardiovascular Screening Practices and Statin Prescription Habits in Patients with Psoriasis among Dermatologists, Rheumatologists and Primary Care Physicians

Abstract

Patients with psoriasis have a higher prevalence of cardiovascular risk factors. This study evaluated cardiovascular screening practices and statin prescribing habits among dermatologists, rheumatologists and primary care physicians (PCPs) through an online questionnaire, which was distributed through the Spanish scientific societies of the above-mentioned specialties. A total of 299 physicians (103 dermatologists, 94 rheumatologists and 102 PCPs) responded to the questionnaire. Of these, 74.6% reported screening for smoking, 37.8% for hypertension, 80.3% for dyslipidaemia, and 79.6% for diabetes mellitus. Notably, only 28.4% performed global screening, defined as screening for smoking, hypertension, dyslipidaemia, and diabetes mellitus by the same physician, and 24.4% reported calculating 10-year cardiovascular disease (CVD) risk, probably reflecting a lack of comprehensive cardiovascular risk assessment in these patients. This study also identified unmet needs for awareness of cardiovascular comorbidities in psoriasis and corresponding screening and treatment recommendations among PCPs. Of PCPs, 61.2% reported not being aware of the association between psoriasis and CVD and/or not being aware of its screening recommendations, and 67.6% did not consider psoriasis as a risk-enhancing factor when deciding on statin prescription. Thirteen dermatologists (12.6%) and 35 rheumatologists (37.2%) reported prescribing statins. Among those who do not prescribe, 49.7% would be willing to start their prescription.

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ORIGINAL ARTICLE
SIGNIFICANCE
Patients with psoriasis have an increased risk of cardio-
vascular events. This is partly due to a higher prevalence
of smoking, hypertension, diabetes mellitus and dyslipi-
daemia. This study found that less than 30% of the phy-
sicians evaluated (dermatologists, rheumatologists and
primary care physicians) performed global screening, de-
ned as screening for hypertension, dyslipidaemia, smoking
and diabetes mellitus by the same physician. In addition,
more than 60% of the primary care physicians stated that
they were unaware of the association between psoriasis
and cardiovascular disease. Regarding treatment, 50% of
dermatologists and rheumatologists who do not prescribe
statins would be willing to start prescribing them.
Cardiovascular Screening Practices and Statin Prescription Habits
in Patients with Psoriasis among Dermatologists, Rheumatologists
and Primary Care Physicians
Emilio BERNA-RICO
1#
, Carlota ABBAD-JAIME DE ARAGON
1#
, Ángel GARCIA-APARICIO
2
, David PALACIOS-MARTINEZ
3
,
Asunción BALLESTER-MARTÍNEZ
1
, Jose-M CARRASCOSA
4
, Pablo DE LA CUEVA
5
, Cristina ANTON
6
, Carlos AZCARRAGA-
LLOBET
1
, Emilio GARCIA-MOURONTE
1
, Belén DE NICOLAS-RUANES
1
, Lluis PUIG
7
, Pedro JAEN
1
, Nehal N. MEHTA
8
, Joel M.
GELFAND
9
and Álvaro GONZALEZ-CANTERO
1,6
1
Department of Dermatology, Hospital Universitario Ramon y Cajal, IRYCIS, Madrid,
2
Department of Rheumatology, Hospital Universitario
de Toledo, Toledo,
3
Centro de Salud Universitario Isabel II, Parla, Madrid,
4
Department of Dermatology, Hospital Universitari Germans Trias
i Pujol. Universitat Autònoma de Barcelona, IGTP, Badalona,
5
Department of Dermatology, Infanta Leonor Hospital, Madrid,
6
Faculty of
Medicine, Universidad Francisco de Vitoria, Madrid,
7
Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma
de Barcelona, Barcelona, Spain,
8
Laboratory of Inammation & Cardiometabolic diseases, Cardiovascular Branch, National Heart, Lung, and
Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD and
9
Department of Dermatology and Department of Biostatistics,
Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
#
These authors contributed equally.
Patients with psoriasis have a higher prevalence of car-
diovascular risk factors. This study evaluated cardio-
vascular screening practices and statin prescribing
habits among dermatologists, rheumatologists and pri-
mary care physicians (PCPs) through an online ques-
tionnaire, which was distributed through the Spanish
scientic societies of the above-mentioned specialties.
A total of 299 physicians (103 dermatologists, 94 rheu-
matologists and 102 PCPs) responded to the questionn-
aire. Of these, 74.6% reported screening for smoking,
37.8% for hypertension, 80.3% for dyslipidaemia,
and 79.6% for diabetes mellitus. Notably, only 28.4%
performed global screening, dened as screening for
smoking, hypertension, dyslipidaemia, and diabetes
mellitus by the same physician, and 24.4% reported
calculating 10-year cardiovascular disease (CVD) risk,
probably reecting a lack of comprehensive cardiovas-
cular risk assessment in these patients. This study also
identied unmet needs for awareness of cardiovascular
comorbidities in psoriasis and corresponding screening
and treatment recommendations among PCPs. Of PCPs,
61.2% reported not being aware of the association bet-
ween psoriasis and CVD and/or not being aware of its
screening recommendations, and 67.6% did not con-
sider psoriasis as a risk-enhancing factor when deci-
ding on statin prescription. Thirteen dermatologists
(12.6%) and 35 rheumatologists (37.2%) reported
prescribing statins. Among those who do not prescribe,
49.7% would be willing to start their prescription.
Key words: cardiovascular disease; diagnosis; hearth disease
risk factor; psoriasis.
Accepted Jan 31, 2023; Published Mar 28, 2023
Acta Derm Venereol 2023; 103: adv5087.
DOI: 10.2340/actadv.v103.5087
Corr: Alvaro Gonzalez-Cantero, Dermatology Department, Ramon y Cajal
University Hospital, IRYCIS, Colmenar Viejo km 9.100, ES-28034 Madrid,
Spain. E-mail: alvarogc261893@hotmail.com
Psoriasis is a chronic immune-mediated skin disease,
which is associated with accelerated atherosclero-
sis (1, 2) and an increased risk of major cardiovascular
events (3–6). Myocardial infarction occurs, on average, 5
years earlier in people with psoriasis than in the general
population (7).
This elevated cardiovascular risk could be
driven by both systemic inammation in moderate-to-se-
vere forms of the disease (8–10) and a higher prevalence
of modiable cardiovascular risk factors (CVRF), such
as obesity, smoking, hypertension, diabetes mellitus,
dyslipidaemia, metabolic syndrome or sedentary lifestyle
(11–14). Interestingly, disease severity is associated with
an increased likelihood of having CVRFs (15, 16), and with
poorer control of hypertension in a dose-dependent manner
(17). Primary care-based and dermatologist-based scree-
ning studies have shown that CVRFs are underdiagnosed
in these patients, with 27.5–48% of patients with psoriasis
having at least 1 undetected CVRF (18, 19). Moreover,
an international cross-sectional study that included 2,254
patients with psoriasis and/or psoriatic arthritis found that
65.6% of those with dyslipidaemia were not adequately
treated with statins (20).
On this basis, a European working group and the
National Psoriasis Foundation (NPF)/American Academy
of Dermatology (AAD) have independently developed

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position statements for the diagnosis and treatment of
psoriasis comorbidities, including CVRFs screening
recommendations (21, 22).
Both documents recommend
following national guidelines, considering earlier and more
frequent assessment in those patients with moderate-to-se-
vere forms of the disease. The most followed guidelines
for primary cardiovascular disease (CVD) prevention are
those from the European Society of Cardiology (ESC)
and the American Heart Association/American College
of Cardiology (AHA/ACC) (23, 24),
which recommend a
global approach based on the estimation of 10-year CVD
risk with different scores, rather than an approximation
based on individual CVRFs. These scores are easily
calculated through free online or mobile applications in
which demographic information, smoking status, blood
pressure, cholesterol values and diabetes mellitus status
must be entered. Statins are usually indicated when blood
cholesterol levels are above treatment goals, which are
dened according to 10-year risk of CVD. Psoriasis is not
quantitatively included in these tools, but it is considered
as a risk-enhancing factor that can tip the balance towards
more proactive treatment in borderline cases (23).
D
espite the screening recommendations for comorbi-
dities in patients with psoriasis, the extent to which these
guidelines are implemented in clinical practice is unclear,
and which specialist should assume the burden of this CVD
prevention remains controversial. Although a primary
care-based management of CVRFs is recommended, scree-
ning measures are usually shared by both specialists and
primary care physicians (PCP), and NPF/AAD guidelines
open the door to hypertension and dyslipidaemia treatment
by the dermatologists (21).
The principal aim of this study was to evaluate scree-
ning practices among dermatologists, rheumatologists and
PCPs regarding CVRFs, especially focusing on a global
approach through calculation of 10-year risk of CVD. This
study also examined statin prescribing habits among the
above-mentioned specialties, exploring whether derma-
tologists and rheumatologists viewed statin prescription
feasible.
MATERIALS AND METHODS
Study setting and instrument
From September 2021 to February 2022, an online questionnaire
was distributed via e-mail to dermatologists from the Spanish
Academy of Dermatology and Venereology (AEDV) and from
the Spanish Group of Psoriasis (GPS), to rheumatologists from
the Spanish Society of Rheumatology (SER) and to PCPs from
the Spanish Society of Primary Care Physicians (SEMERGEN).
Each of the above-mentioned societies sent the survey to all their
members via their institutional e-mail list. The Institutional Review
Board of the Hospital Universitario Ramon y Cajal considered
that the study protocol was exempt from review given its design.
Survey questions were developed and reviewed by an expert
panel of clinicians (EBR, AGC, ABM, IGD, JMG) and a survey
methodology expert (CAR). Questions included: demographic
data, degree of training and specialization, CVRF screening habits
and factors that could affect the screening ratio. Questions related
to statin prescription habits were included in the dermatologists’
and rheumatologists’ questionnaires. For PCPs, a nal question
was included, assessing whether they consider psoriasis as a risk-
enhancing factor when prescribing statins.
Questions were designed according to recommendations from
the most relevant CVD primary prevention guidelines (23, 24),
guidelines for the diagnosis and management of individual CVRFs
(25–30) and position statements for the management of comorbi-
dities in psoriasis (21, 22). Table SI summarizes baseline screening
recommendations and their periodicity for each CVRF.
The questionnaire is provided in Appendix S1.
The study followed the relevant portions of the Strengthening the
Reporting of Observational Studies in Epidemiology (STROBE)
reporting guideline (31) and the American Association for Public
Opinion Research (AAPOR) reporting guideline (32).
Outcomes and study covariates
The primary outcome of this study was to evaluate the screening
rates of smoking, obesity, hypertension, dyslipidaemia and dia-
betes mellitus among dermatologists, rheumatologists and PCPs
in patients with psoriasis. Global screening (GS) was dened as
screening for smoking, hypertension, dyslipidaemia and diabetes
mellitus by the same physician, since these are the 4 CVRFs needed
to estimate 10-year CVD risk. This study also assessed if the
10-
year CVD risk estimation via the
SCORE Risk Charts or the Pooled
Cohort ASCVD Risk Equation
was calculated in these patients.
Secondary outcomes were: (
i
) to compare screening rates among
the above-mentioned specialties; (
ii
) to identify factors associated
with a higher or lower frequency of screening; and (
iii
) to explore
statin prescribing habits among dermatologists and rheumatologists
and factors that could help their implementation.
Statistical analysis
In the descriptive analysis, categorical variables were described
using absolute frequencies and percentages. Exact 95% condence
intervals (95% CI) were provided for selected parameters.
Univariable logistic regression was used to evaluate differences
in screening rates between dermatologists, rheumatologists and
PCPs. A multivariable logistic regression model was built to
identify predictors (independent variables) of GS, 10-year CVD
risk calculation and statin prescription. Medical specialty, sex,
practice setting (public, private or both), years since completing
residency training, number of patients with psoriasis treated per
month, participation in a specialized psoriasis outpatient clinic,
participation in research projects related to psoriasis and univer-
sity teaching were evaluated. As a rst step, a univariable logistic
regression was performed between each of the aforementioned
variables and the dependent variables GS, 10-year CVD risk
calculation and statin prescription. Variables with p < 0.20 were
included in the multivariable model (33). Variables with p > 0.20,
but which were identied as potential confounders, were also
included. A p-value of < 0.05 was considered signicant for all
analyses. Statistical analyses were completed using SPSS v.25.0
(SPSS, Chicago, IL, USA).
RESULTS
A total of 103 out of 1,930 dermatologists (response rate
5.3%), 94 out of 1,879 rheumatologists (response rate
5.0%) and 102 out of 412 PCPs surveyed (response rate
24.8%) responded to the questionnaire. Table I shows
the baseline characteristics of the participants. Baseline

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characteristics of dermatologists and rheumatologists
were similar in terms of sex, percentage of fellows and
private practice to those of the AEDV and SER members,
respectively (Tables SII and SIII).
Screening practices for cardiovascular risk factors
Overall, 223 physicians (74.6%, 95% CI 69.9–79.8)
reported screening for smoking, 136 (45.5%, 95% CI
39.8–51.2) for obesity, 113 (37.8%, 95% CI 32.3–43.3)
for hypertension, 240 (80.3%, 95% CI 75.7–84.8) for
dyslipidaemia and 238 (79.6%, 95% CI 75.0–84.2) for
diabetes mellitus. Eighty-ve physicians (28.4%, 95%
CI 23.3–33.6) performed GS and 73 physicians (24.4%,
95% CI 19.5–29.3) reported calculating 10-year CVD risk.
Table II summarizes the screening rates for each cardio-
vascular risk factor among dermatologists, rheumatolo-
gists and PCPs and the univariable comparative analysis.
On multivariable analysis (Table III), dermatologists
were less likely to perform GS compared with rheumato-
logists (OR 0.33, 95% CI 0.15–0.74, p = 0.007) and PCPs
(OR 0.14, 95% CI 0.05–0.38, p < 0.001); they were also
less likely than PCPs to calculate 10-year CVD risk (OR
0.05, 95% CI 0.02–0.20, p < 0.001).
Among those who do not perform GS, 42 dermatolo-
gists (51.2%) and 32 rheumatologists (49.2%) reported
referring the patient to a PCP and/or cardiologist (OR
1.08, 95% CI 0.57–2.08, p = 0.811).
Predictors and factors reported as stimuli or obstacles
for cardiovascular risk factors screening
Among physician characteristics, the participation in a
specialized psoriasis outpatient clinic was independently
associated with an increased likelihood of performing GS
(OR 2.59, 95% CI 1.01–6.69, p = 0.049). Participation in
research projects related to psoriasis was independently
associated with an increased likelihood of both GS (OR
2.32, 95% CI 1.03–5.24, p = 0.044) and 10-year CVD risk
(OR 3.30, 95% CI 1.17–9.34, p = 0.024). Male physicians
were less likely to perform GS than females (OR 0.53,
95% CI 0.28–0.97, p = 0.040). The adjusted values for
each predictor of GS and 10-year CVD risk calculation
in multivariable analysis are detailed in Table III.
Table I. Baseline characteristics of the respondents
Dermatologists (n=103) Rheumatologists (n=94) PCPs (n=102) Total (n=299) p-value*
Female, n (%) 65 (63.1) 63 (67.0) 61 (59.8) 189 (63.2) 0.467
Practice setting, n (%) < 0.001
Public hospital/clinic 43 (41.7) 72 (76.6) 96 (94.1) 212 (70.9)
Private hospital/clinic 18 (17.5) 9 (9.6) 4 (3.9) 30 (10.0)
Both 42 (40.8) 12 (12.8) 2 (2.0) 56 (18.8)
Years since completing residency training, n (%) 0.621
Fellow 9 (8.7) 3 (3.2) 10 (9.8) 22 (7.4)
1–10 25 (24.3) 29 (30.9) 21 (20.6) 75 (25.3)
11–20 24 (23.3) 22 (23.4) 20 (19.6) 66 (22.2)
21–30 27 (26.2) 22 (23.4) 29 (28.4) 78 (26.3)
> 30 17 (16.5) 17 (18.1) 22 (21.6) 56 (18.9)
Psoriasis patients treated per month, n (%) < 0.001
< 5 7 (6.8) 4 (4.3) 62 (60.8) 73 (24.4)
5–20 32 (31.1) 46 (48.9) 40 (39.2) 118 (39.5)
> 20 64 (62.1) 44 (46.8) 0 (0) 108 (36.1)
Specialization, n (%)
Specialized psoriasis outpatient clinic 41 (39.8) 8 (8.5) 2 (2.0) 41 (17.3) < 0.001
Research projects 47 (45.6) 30 (30.5) 0 (0) 77 (26.1) < 0.001
University teaching 25 (24.3) 17 (18.1) 1 (1) 43 (14.6) < 0.001
PCPs: primary care physician.
*χ2 test.
Table II. Screening practices among the specialists evaluated with univariable logistic regression results
Dermatologists (n=103) Rheumatologists (n=94) PCPs (n=102) Total (n=299) ORγ (95% CI)
*D vs R; **D vs PCPs
Smoking, n (%) 81 (78.6 86 (91.5) 56 (54.9) 223 (74.6) *OR 0.34 (0.14–0.81)
**OR 3.02 (1.64–5.58)
Obesity, n (%) 56 (54.4) 47 (50.0) 33 (32.4) 136 (45.5) *OR 1.19 (0.68–2.09)
**OR 2.49 (1.41–4.40)
HTN, n (%) 22 (21.4) 34 (36.2) 57 (55.9 113 (37.8) *OR 0.48 (0.26–0.902)
**OR 0.21 (0.12–0.40)
Dyslipidaemia, n (%) 80 (77.7) 92 (97.9) 68 (66.7) 240 (80.3) *OR 0.08 (0.02–0.33)
**OR 1.74 (0.94–3.23)
DM, n (%) 77 (74.8) 87 (92.6) 74 (72.6) 238 (79.6) *OR 0.24 (0.01–0.58)
**OR 1.12 (0.60–2.09)
Global screening, n (%) 21 (20.6) 29 (30.9) 35 (34.3) 85 (28.4) *OR 0.57 (0.3–1.1)
**OR 0.49 (0.26–0.92)
10-year cardiovascular risk
calculation, n (%) 12 (11.7) 12 (12.8) 49 (48.0) 73 (24.4) *OR 0.90 (0.38–2.12)
**OR 0.14 (0.07–0.29)
D: dermatologists; 95% CI: 95% condence interval; DM: diabetes mellitus; HTN: hypertension; OR: odds ratio; PCP: primary care physician; R: rheumatologists; γ:
univariable logistic regression.

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When asked about factors that prompt physicians to
screen for CVRFs in psoriasis (more than 1 answer was
possible), 33 dermatologists (32.0%), 9 rheumatologists
(9.6%) and 16 PCPs (15.5%) answered the severity of
the disease, whereas 40 dermatologists (40.8%), 27
rheumatologists (28.7%) and 22 PCPs (21.4%) answe-
red a personal or family history suggestive of increased
cardiovascular risk.
Regarding the reasons for not screening for CVRFs
(more than 1 answer was possible), the most frequent
response among those who did not perform GS was lack
of time, reported by 105 physicians (65.9% of derma-
tologists, 63.1% of rheumatologist and 14.9% of PCPs,
p < 0.001). Interestingly, unawareness of the association
between psoriasis and increased CVR and unawareness
of screening recommendations in psoriasis patients were
answered essentially by PCPs (0.0% of dermatologists,
0.0% of rheumatologists and 32.8% of PCPs, p < 0.001,
and 3.7% of dermatologists, 4.6% of rheu-
matologists and 38.8% of PCPs, p < 0,001,
respectively). Figs 1 and 2 summarize the
reasons reported.
Statin prescription
When PCPs were asked whether they con-
sidered psoriasis as a risk-enhancing factor
when prescribing statins, 69 physicians
(67.6%) answered that they did not.
Thirteen dermatologists (12.6%, 95% CI
6.1–19.1) and 35 rheumatologists (37.2%,
95% CI 27.3–47.2) reported statin prescrip-
tion according to ESC/AHA guidelines. The
difference was signicant (OR 0.04, 95%
CI 0.01–0.16, p < 0.001) after adjustment for
years since completing residence, number
of psoriasis patients seen per month, parti-
cipation in a specialized psoriasis outpatient
clinic, participation in research projects
related to psoriasis and university teaching
including psoriasis lectures (Table SIV).
Those who do not routinely prescribe
statins were asked if they would be willing
to start prescribing them. Forty-seven out of 90 derma-
tologists (52.2%) and 27/59 rheumatologists (45.8%)
would start prescribing statins.
Table IV summarizes the statin prescription habits and
the reasons for initiating or not initiating their prescrip-
tion among dermatologists and rheumatologists.
DISCUSSION
The most relevant ndings of this survey study are: (
i
) a
comprehensive approach to cardiovascular risk in patients
with psoriasis is apparently lacking. Overall, only 28.4%
of the specialists surveyed performed GS, and 24.4%
reported calculating 10-year CVD risk. (
ii
) PCPs were
insufciently aware of the increased cardiovascular risk
experienced by patients with psoriasis and the implica-
tions that this entity has on CVRFs screening and mana-
gement. The fact that almost 70% of them
did not consider
Table III. Multivariable regression models for global screening and 10-year
CVD risk calculation
Global screening* 10-year CVD risk calculation
ORa95% CIap-value ORa95% CIap-value
Specialty 0.001 0.001
Dermatologists vs rheumatologists 0.33 0.15–0.74 0.007 0.53 0.18–1.54 0.241
Dermatologists vs PCPs 0.14 0.05–0.38 < 0.001 0.05 0.02–0.20 < 0.001
Sex
Men vs women 0.53 0.28–0.97 0.040 — — —
Practice setting 0.533
Private vs public — — — 2.01 0.59–6.91 0.266
Private + public vs only public — — — 1.22 0.43–3.45 0.704
Years of experience 0.027 0.047
1–10 years vs resident 0.52 0.15–1.80 0.304 0.68 0.20–2.29 0.534
10–20 years vs resident 0.46 0.13–1.66 0.235 0.28 0.08–1.03 0.056
20–30 years vs resident 1.44 0.43–4.78 0.552 0.92 0.27–3.14 0.898
> 20 years vs resident 1.24 0.37–4.14 0.732 0.35 0.10–1.27 0.111
Patients with psoriasis treated per month 0.426 0.662
5–20 vs < 5 1.71 0.76–3.83 0.193 0.72 0.33–1.57 0.406
> 20 vs < 5 1.75 0.57–5.42 0.33 0.60 1.61–2.22 0.442
Specialized psoriasis outpatient clinic
Yes vs no 2.59 1.01–6.69 0.049 1.95 0.61–6.25 0.264
Research projects related to psoriasis
Yes vs no 2.32 1.03–5.24 0.044 3.30 1.17–9.34 0.024
University teaching including psoriasis
Yes vs no 1.50 0.65–3.48 0.344 1.47 0.51–4.23 0.475
aVariables with no value in any of the columns are those with a p-value > 0.20 in a rst univariable
logistic regression and which were not identied as potential confounders, as detailed in methods.
95% CI: 95% condence interval; CVD: cardiovascular disease; OR: odds ratio; PCP: primary
care physician.
*Dened as screening for smoking, hypertension, dyslipidaemia and diabetes mellitus by the
same physician.
Fig. 1. Factors that prompt cardiovascular risk factor (CVRF) screening. Bars indicate percentage of physicians within each specialty that marked
every option. PCP: primary care physician.

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psoriasis as a risk-enhancing factor when deciding on
statin prescription is noteworthy. (
iii
) Dermatologists
and rheumatologists reported a high predisposition to
start prescribing statins.
Parsi et al. (34)
studied the cardiovascular screening
practices in patients with psoriasis among PCPs and
cardiologists launching a questionnaire based on 2008
NPF and American Journal of Cardiology recommen-
dations. Manalo et al. (35) explored the same topic
among dermatologists. Both studies showed less than
half of the above-mentioned specialists screened for
hypertension, dyslipidaemia and diabetes mellitus ac-
cording to guidelines. In this regard, 2 studies
analyse
data from the National Ambulatory Medical Care Survey
(NAMCS), a cross-sectional ongoing survey of non-
federally employed, ofce-based physician practices
in the USA. Blood pressure values were included in
32.2–36.4% of psoriasis outpatient visits, glucose levels
in 4.9–5.9%, cholesterol levels in 9–9.2% and body mass
index (BMI) values in 26–29.9% (36, 37).
In the current
study, although hypertension was screened by only 21.4%
of dermatologists, 36.2% of rheumatologists and 55.9%
of PCPs, screening rates for dyslipidaemia (80.3%) and
diabetes mellitus (79.6%) were higher compared with
those previously reported, especially among dermatolo-
gists and rheumatologists. Screening rates for smoking
were also acceptable (74.6%).
The gap between elevated screening rates for most
CVRFs included in 10-year CVD risk scores and low
frequency of GS could indicate a fractional approach to
cardiovascular risk assessment in these patients and the
absence of a strategy that integrates all aspects of their
cardiometabolic map. It is essential to identify the barriers
behind these gaps, since the absence of a comprehensive
cardiovascular approach could preclude not only the co-
rrect assessment of these patients, but also their adequate
management. Serum lipid prole and blood glucose deter-
minations are easily ordered and integrated in blood tests
that dermatologists and rheumatologists usually request
before starting systemic medication or in their controls.
However, blood pressure measurement is time-consuming
and requires specic (albeit cheap and accessible) equip-
ment. In this regard, lack of time and lack of facilities were
the reasons for not screening most commonly reported
among dermatologists and rheumatologists. Interestingly,
the GS rate among these specialists is twice the rate of
10-year CVD risk calculation. Therefore, there appear to
be dermatologists and rheumatologists who are collecting
all the required information, but who are not calculating
the scores, even though this can be done through free, fast
and easy-to-use apps (ESC CVD Risk Calculation App
®
or ASCVD Risk Estimator Plus
®
) or web pages (38, 39).
A lack of condence in these prediction systems could
be behind this discrepancy. Several studies have pointed
Table IV. Statin prescription habits and predisposition to start prescribing them
Dermatologists
(n = 103) Rheumatologists
(n = 94) OR (95% CI)
Current prescription of statins, n (%) 13 (12.6) 35 (37.2) *OR 0.24 (0.12–0.50)
**OR 0.04 (0.01–0.16)
Would you be willing to start prescribing statins?a
Yes (%) 47 (52.2) 27 (45.8)
I would start prescribing after attending specic training courses for dermatologists or
rheumatologists 43 (91.5) 27 (100)
Others motivesb 4 (8.5) 0 (0.0)
No (%) 43 (47.8) 32 (54.2)
This exceeds the role of a dermatologists 15 (35.0) 9 (28.1)
I do not have enough time to determine the need for statins 23 (53.5) 19 (59.4)
I do not have the necessary material means to determine the need for statins 14 (32.6) 4 (12.5)
aMore than 1 answer was possible. bRespondents could provide free text: “I would prescribe if the prescription of statins was included in protocols developed for dermatologists”
was answered by 1 dermatologist and “Clearer criteria for prescribing statins” by another. Two respondents marked the free-text option, but did not provide any text.
95% CI: 95% condence interval; OR: odds ratio. *Univariable logistic regression; **multivariable logistic regression, adjusted for years since completing residence,
number of psoriasis patients seen per month, participation in a specialized psoriasis outpatient clinic, participation in research project related with psoriasis and university
teaching including psoriasis lessons.
Fig. 2. Reasons for not screening for cardiovascular risk factors (CVRFs). Bars indicate percentage of physicians within each specialty that marked
every option. PCP: primary care physician.

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out that they may underestimate the actual CVD risk in
patients with chronic inammatory states such as psoriasis,
especially in moderate-to-severe forms of the disease (40,
41).
However, clinical practice guidelines still consider the
calculation of 10-year CVD risk as the basis for preventive
measures, considering psoriasis as a risk-enhancing factor
that may guide primary preventive measures in interme-
diate risk patient (23, 24). Lack of familiarity with CVD
prediction systems, usually outside the scope of practice of
dermatologists and rheumatologists, could also contribute
to this gap.
Conversely, blood pressure measurement and calcula-
tion of 10-year CVD risk scores are integrated in routine
workup performed by PCPs. This may explain a higher
rate of that variable, despite the fact that screening for
most individual CVRFs was less frequent among PCPs
than among dermatologists and rheumatologists. However,
the reported rate of 10-year CVD risk calculation was still
less than 50%.
In this regard, 61.2% of PCPs reported
not being aware of the association between psoriasis and
increased cardiovascular risk and/or not being aware of
its screening recommendations, and 67.7% of them did
not consider the presence of psoriasis when deciding
on statin prescription, despite ESC and AHA guideline
recommendation (23, 24). This is especially relevant
considering that patients with psoriasis are nowadays
referred to their PCPs for screening and management
of CVRFs.
The severity of the disease may inuence the screening
rates among different specialists. Patients with moderate-
to-severe psoriasis have a higher risk of cardiovascular
events, and may also be more involved with dermatolo-
gists and rheumatologists. However, the questionnaire
asked about factors that prompt screening, and less than
30% of the specialists surveyed answered the severity
of the disease. This could reect the lack of clear recom-
mendations from clinical practice guidelines. The AAD/
NPF guidelines recommends earlier and more frequent
screening for CVRFs in patients with moderate-to-severe
forms of the disease, but without providing concrete ages
of onset or intervals (21). In the coming years, more
studies and clearer positions may be needed to dene
the best screening strategy in this particularly high-risk
subgroup of patients.
T
he strategy chosen to try to improve cardiovascular
outcomes of patients with psoriasis should be adapted
according to available resources and the structure of each
healthcare system. In the US, 16.9% of women and 21.6%
of men with psoriasis had no encounters with a PCP in
the year following their rst visit to a dermatologist (42),
whereas in Spain psoriatic patients seem to be more en-
gaged with their PCPs, with a mean of 8.7 visits per year
(43).
Barbieri et al.
(44) explore dermatologists’ perspecti-
ves on a specialist-led model of cardiovascular screening
and management. More than two-thirds of dermatologists
(69.3%) agreed that screening for CVRFs was doable,
and 36.1% considered that prescribing statins was feasi-
ble. To facilitate the lipid management in specialty care
clinics, they propose the use of a care coordinator. The
specialists measure or identify individual CVRFs and the
care coordinators review test results and other sociodemo-
graphic information to calculate 10-year CVD risk score.
Finally, a protocolized clinician decision support system
would help them to determine whether statin therapy or
blood pressure management are indicated. The current
study also shows that, although current prescription rates
of statins by dermatologists and rheumatologists were
low, nearly 50% of those who did not prescribe statins
would be willing to start prescribing them after attending
specic training courses. However
,
PCPs have greater
expertise in the management of statins and antihyper-
tensives and can offer a more comprehensive view of
the patient. Allocating more resources to training PCPs
in the cardiovascular comorbidities of psoriasis could
be a more reasonable and efcient measure in settings
where patients with psoriasis are properly engaged with
them, always ensuring good communication with hospital
specialists.
Study limitations
Limitations of the study should be considered in the
context of its design. Response and sampling bias are
both inherent to questionnaire-based studies. To mitigate
the sampling bias, the online survey was distributed th-
rough national email lists; hence we could assume a wide
geographical distribution of the questionnaire. Although
the response rate among PCPs was acceptable, the low
response rate among dermatologists and rheumatologists
severely limits our ability to generalize the results. The
response rate among dermatologists in the study by Bar-
bieri et al. was, surprisingly, very similar (5.2%) to that
of the current study, with considerably fewer responses
from rheumatologists (42). Both survey respondents
and members of the AEDV and SER showed relatively
similar demographic characteristics in terms of sex, pri-
vate practice and percentage of fellows, which would
support that the respondents might adequately represent
the population from which they were sampled. Parsi et
al. (34)
reported a response rate of 21% among PCPs and
cardiologists, similar to that observed among PCPs in the
current study. Cardiologists were not asked, as they are
more involved in the treatment of established cardiovas-
cular diseases than in screening practices in our setting.
Finally, a considerable proportion of dermatologists and
rheumatologists who responded to the questionnaire came
from an academic setting. They may be more likely to be
aware of new scientic publications and to consider the
patient’s comorbidities compared with their colleagues,
which may bias these results. Actual screening rates could
therefore be lower than reported.

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Acta Derm Venereol 2023
Conclusion
The decit of a comprehensive approach to cardiovas-
cular risk in patients with psoriasis highlighted by the
current study could hinder the adequate treatment of
their modiable CVRFs, which is of utmost importance
given their increased risk of CVD. Obstacles behind the
screening difculties for each specialist need to be iden-
tied. PCPs showed considerable rates of unawareness
of the link between psoriasis and CVD and the cor-
responding screening and treatment recommendations.
Allocating more resources to training PCPs in psoriasis
comorbidities seems a reasonable measure if we want
to increase their involvement in the management of
the cardiovascular comorbidities of these patients. In
scenarios where PCP-based CVRFs management stra-
tegies are ineffective, specialist-based models could
be considered in light of their high predisposition to
prescribe statins.
ACKNOWLEDGEMENTS
The authors thank Dr Ignacio Garcia Doval for his invaluable help
in preparing the survey; the Spanish Academy of Dermatology and
Venereology (AEDV) and its Psoriasis Working Group (GPS), the
Spanish Society of Rheumatology (SER) and the Spanish Society
of Primary Care Physicians (SEMERGEN) for enabling us to
distribute the survey among their members; and to all colleagues
who answered the questionnaire.
IRB approval status. This study was deemed exempt from re-
view by the Institutional Review Board of Hospital Universitario
Ramon y Cajal.
Conicts of interest. PdlC received consultancy/speaker’s honora-
ria from and/or participated in clinical trials sponsored by Abbvie,
Almirall, Astellas, Biogen, Boehringer, Celgene, Janssen., LEO
Pharma, Lilly, MSD, Novartis, Pzer, Roche, Sano and UCB,
not related with the submitted work. LP received consultancy/
speaker’s honoraria from and/or participated in clinical trials spon-
sored by Abbvie, Almirall, Amgen, Biogen, Boehringer Ingelheim,
Bristol Myers Squibb, Janssen, Leo-Pharma, Lilly, Novartis, P-
zer, Sandoz, Sano, and UCB. NNM is a full-time US government
employee and has served as a consultant for Amgen, Eli Lilly,
and Leo Pharma, receiving grants/other payments; as a principal
investigator and/or investigator for AbbVie, Celgene, AstraZeneca,
Janssen Pharmaceuticals, Inc, Novartis, and Abcentra, receiving
grants and/or research funding; and as a principal investigator for
the NIH, receiving grants and/or research funding. JMG served
as a consultant for Abbvie, BMS, Boehringer Ingelheim, Celldex
(DSMB), FIDE (which is sponsored by multiple pharmaceutical
companies) GSK, Happify, Lilly (DMC), Leo, Janssen Biologics,
Neumentum, Novartis Corp, Pzer, UCB (DSMB), Neuroderm
(DSMB), Regeneron, Trevi, and Mindera Dx., receiving honoraria;
and receives research grants (to the Trustees of the University of
Pennsylvania) from Amgen, Boehringer Ingelheim, and Pzer
Inc.; and received payment for continuing medical education work
related to psoriasis that was supported indirectly by pharmaceuti-
cal sponsors. Dr Gelfand is a co-patent holder of resiquimod for
treatment of cutaneous T cell lymphoma. Dr Gelfand is a Deputy
Editor for the Journal of Investigative Dermatology receiving
honoraria from the Society for Investigative Dermatology, is Chief
Medical Editor for Healio Psoriatic Disease (receiving honoraria)
and is a member of the Board of Directors for the International
Psoriasis Council, receiving no honoraria. AG-C has served as a
consultant for Abbie, Janssen, Novartis, Lilly, Almirall, Celgene,
and Leo Pharma, receiving grants/other payments.
REFERENCES
1. Lerman JB, Joshi AA, Chaturvedi A, Aberra TM, Dey AK, Ro-
dante JA, et al. Coronary plaque characterization in psoriasis
reveals high-risk features that improve after treatment in
a prospective observational study. Circulation 2017; 136:
263–276.
2. Gonzalez-Cantero A, Gonzalez-Cantero J, Sanchez-Moya
AI, Perez-Hortet C, Arias-Santiago S, Schoendorff-Ortega
C, et al. Subclinical atherosclerosis in psoriasis. Usefulness
of femoral artery ultrasound for the diagnosis, and analysis
of its relationship with insulin resistance. PloS One 2019;
14: e0211808.
3. Gelfand JM, Neimann AL, Shin DB, Wang X, Margolis DJ,
Troxel AB. Risk of myocardial infarction in patients with
psoriasis. JAMA 2006; 296: 1735.
4. Gelfand JM, Dommasch ED, Shin DB, Azfar RS, Kurd SK,
Wang X, et al. The risk of stroke in patients with psoriasis.
J Invest Dermatol 2009; 129: 2411–2418.
5. Dhana A, Yen H, Yen H, Cho E. All-cause and cause-specic
mortality in psoriasis: a systematic review and meta-ana-
lysis. J Am Acad Dermatol 2019; 80: 1332–1343.
6. Samarasekera EJ, Neilson JM, Warren RB, Parnham J, Smith
CH. Incidence of cardiovascular disease in individuals with
psoriasis: a systematic review and meta-analysis. J Invest
Dermatol 2013; 133: 2340–2346.
7. Karbach S, Hobohm L, Wild J, Münzel T, Gori T, Wegner J,
et al. Impact of psoriasis on mortality rate and outcome in
myocardial infarction. J Am Heart Assoc 2020; 9.
8. Garshick MS, Barrett TJ, Wechter T, Azarchi S, Scher JU,
Neimann A, et al. Inammasome signaling and impaired
vascular health in psoriasis. Arterioscler Thromb Vasc Biol
2019; 39: 787–798.
9. Karbach S, Croxford AL, Oelze M, Schüler R, Minwegen D,
Wegner J, et al. Interleukin 17 drives vascular inamma-
tion, endothelial dysfunction, and arterial hypertension in
psoriasis-like skin disease. Arterioscler Thromb Vasc Biol
2014; 34: 2658–2668.
10. Mehta NN, Teague HL, Swindell WR, Baumer Y, Ward NL,
Xing X, et al. IFN-γ and TNF-α synergism may provide a
link between psoriasis and inammatory atherogenesis. Sci
Rep 2017; 7: 13831.
11. Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB, Gel-
fand JM. Prevalence of cardiovascular risk factors in patients
with psoriasis. J Am Acad Dermatol 2006; 55: 829–835.
12. Armstrong AW, Harskamp CT, Armstrong EJ. Psoriasis and
metabolic syndrome: a systematic review and meta-analysis
of observational studies. J Am Acad Dermatol 2013; 68:
654–662.
13. Armstrong AW, Harskamp CT, Dhillon JS, Armstrong EJ. Pso-
riasis and smoking: a systematic review and meta-analysis.
Br J Dermatol 2014; 170: 304–314.
14. Zheng Q, Sun XY, Miao X, Xu R, Ma T, Zhang YN, et al. As-
sociation between physical activity and risk of prevalent
psoriasis: a MOOSE-compliant meta-analysis. Medicine
(Baltimore) 2018; 97: e11394.
15. Langan SM, Seminara NM, Shin DB, Troxel AB, Kimmel SE,
Mehta NN, et al. Prevalence of metabolic syndrome in pa-
tients with psoriasis: a population-based study in the United
Kingdom. J Invest Dermatol 2012; 132: 556–562.
16. Wan MT, Shin DB, Hubbard RA, Noe MH, Mehta NN, Gel-
fand JM. Psoriasis and the risk of diabetes: a prospective
population-based cohort study. J Am Acad Dermatol 2018;
78: 315–322.e311.
17. Takeshita J, Wang S, Shin DB, Mehta NN, Kimmel SE, Margolis
DJ, et al. Effect of psoriasis severity on hypertension control.
JAMA Dermatol 2015; 151: 161.
18. Rutter MK, Kane K, Lunt M, Cordingley L, Littlewood A, Young
HS, et al. Primary care-based screening for cardiovascular
risk factors in patients with psoriasis. Br J Dermatol 2016;

ActaDV ActaDV
Advances in dermatology and venereology Acta Dermato-Venereologica
E. Berna-Rico et al. “Cardiovascular screening and statin prescription in patients with psoriasis”8/8
Acta Derm Venereol 2023
175: 348–356.
19. Cea-Calvo L, Vanaclocha F, Belinchón I, Rincón Ó, Juliá B, Puig
L. Underdiagnosis of cardiovascular risk factors in outpatients
with psoriasis followed at hospital dermatology ofces: the
PSO-RISK study. Acta Derm Venereol 2016; 96: 972–973.
20. Eder L, Harvey P, Chandran V, Rosen CF, Dutz J, Elder JT, et
al. Gaps in diagnosis and treatment of cardiovascular risk
factors in patients with psoriatic disease: an international
multicenter study. J Rheumatol 2018; 45: 378–384.
21. Elmets CA, Leonardi CL, Davis DMR, Gelfand JM, Lichten J,
Mehta NN, et al. Joint AAD-NPF guidelines of care for the
management and treatment of psoriasis with awareness
and attention to comorbidities. J Am Acad Dermatol 2019;
80: 1073–1113.
22. Dauden E, Blasco AJ, Bonanad C, Botella R, Carrascosa JM,
González-Parra E, et al. Position statement for the mana-
gement of comorbidities in psoriasis. J Eur Acad Dermatol
Venereol 2018; 32: 2058–2073.
23. Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger
ZD, Hahn EJ, et al. 2019 ACC/AHA Guideline on the primary
prevention of cardiovascular disease: a report of the Ame-
rican College of Cardiology/American Heart Association Task
Force on Clinical Practice Guidelines. Circulation 2019; 140.
24. Visseren FL J, Mach F, Smulders YM, Carballo D, Koskinas
KC, Bäck M, et al. 2021 ESC Guidelines on cardiovascular
disease prevention in clinical practice. Eur Heart J 2021;
42: 3227–3337.
25. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi
M, Burnier M, et al. 2018 ESC/ESH Guidelines for the ma-
nagement of arterial hypertension. Eur Heart J 2018; 39:
3021–3104.
26. Siu AL; U.S. Preventive Services Task Force. Screening for
high blood pressure in adults: U.S. Preventive Services Task
Force recommendation statement. Ann Intern Med 2015;
163: 778–786.
27. Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Ba-
dimon L, et al. 2019 ESC/EAS guidelines for the management
of dyslipidaemias: lipid modication to reduce cardiovascular
risk. Atherosclerosis 2019; 290: 140–205.
28. Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blu-
menthal RS, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/
ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the manage-
ment of blood cholesterol: a report of the American College of
Cardiology/American Heart Association Task Force on Clinical
Practice Guidelines. Circulation 2019; 139: e1082–e1143.
29. Jellinger PS, Handelsman Y, Rosenblit PD, Bloomgarden ZT,
Fonseca VA, Garber AJ, et al. American Association of Clini-
cal Endocrinologists and American College of Endocrinology
Guidelines for Management of Dyslipidemia and Prevention
of Cardiovascular Disease. Endocr Pract 2017; 23: 1–87.
30. American Diabetes Association. 2.Classication and diagnosis
of diabetes: standards of medical care in diabetes – 2019.
Diabetes Care 2019; 42: S13–s28.
31. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC,
Vandenbroucke JP. The Strengthening the Reporting of Ob-
servational Studies in Epidemiology (STROBE) statement:
guidelines for reporting observational studies. Lancet 2007;
370: 1453–1457.
32. American Association for Public Opinion Research. Survey
disclosure checklist. May 13, 2019. [Accessed 2022, Feb 3].
Available from: https://www.aapor.org/Standards-Ethics/
AAPOR-Code-of-Ethics/Survey-Disclosure-Checklist.aspx.
33. Zhang Z. Model building strategy for logistic regression:
purposeful selection. Ann Transl Med 2016; 4: 111.
34. Parsi KK, Brezinski EA, Lin TC, Li CS, Armstrong AW. Are
patients with psoriasis being screened for cardiovascular
risk factors? A study of screening practices and awareness
among primary care physicians and cardiologists. J Am Acad
Dermatol 2012; 67: 357–362.
35. Manalo IF, Gilbert KE, Wu JJ. Survey of trends and gaps in
dermatologists’ cardiovascular screening practices in psoria-
sis patients: areas still in need of improvement. J Am Acad
Dermatol 2015; 73: 872–874.e874.
36. Alamdari HS, Gustafson CJ, Davis SA, Huang W, Feldman SR.
Psoriasis and cardiovascular screening rates in the United
States. J Drugs Dermatol 2013; 12: e14–19.
37. Singh P, Silverberg JI. Screening for cardiovascular comor-
bidity in United States outpatients with psoriasis, hidrade-
nitis, and atopic dermatitis. Arch Dermatol Res 2021; 313:
163–171.
38. European Association of Preventive Cardiology. HeartScore.
[Accessed 2022, April 1]. Available from: https://www.
heartscore.org/en_GB/
39. American Heart Association. 2018 Prevention guidelines
tool CV risk calculator. [Accessed 2022, April 1] Available
from: https://static.heart.org/riskcalc/app/index.html#!/
baseline-risk.
40. Mehta NN, Yu Y, Pinnelas R, Krishnamoorthy P, Shin DB,
Troxel AB, et al. Attributable risk estimate of severe psoriasis
on major cardiovascular events. Am J Med 2011; 124: 775.
e1–775.e7756.
41. Gonzalez-Cantero A, Reddy AS, Dey AK, Gonzalez-Cantero
J, Munger E, Rodante J, et al. Underperformance of clinical
risk scores in identifying imaging-based high cardiovascular
risk in psoriasis: results from two observational cohorts. Eur
J Prev Cardiol 2022; 29: 591–598.
42. 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 2021; 2: 31–36.
43. Puig L, Ferrándiz C, Pujol RM, Vela E, Albertí-Casas C, Comel-
las M, et al. Burden of psoriasis in Catalonia: epidemiology,
associated comorbidities, health care utilization, and sick
leave. Actas Dermosiliogr (Engl Ed) 2021; 112: 425–433.
44. Barbieri JS, Beidas RS, Gondo GC, Fishman J, Williams NJ,
Armstrong AW, et al. Analysis of specialist and patient per-
spectives on strategies to improve cardiovascular disease
prevention among persons with psoriatic disease. JAMA
Dermatol 2022; 158: 252–259.