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Patients with severe psoriasis are at increased risk of cardiovascular mortality: A cohort study using the General Practice Research Database

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Psoriasis is a common chronic inflammatory T-helper cell-1/17 mediated skin disease. Recent studies suggest that psoriasis, particularly if severe, may be an independent risk factor for atherosclerosis, myocardial infarction (MI), and stroke. We conducted a cohort study using the General Practice Research Database to determine if severe psoriasis patients have an increased risk of cardiovascular (CV) mortality. Severe psoriasis was defined as patients who received a psoriasis diagnosis and systemic therapy consistent with severe psoriasis (n = 3603). Up to four unexposed patients without psoriasis were selected from the same practices and start dates for each psoriasis patient (n = 14 330). For every death, the cause was determined by review of the electronic medical record. Severe psoriasis was an independent risk factor for CV mortality (HR 1.57; 95% CI 1.26, 1.96) when adjusting for age, sex, smoking, diabetes, hypertension, and hyperlipidaemia. Overall, severe psoriasis patients experienced one extra CV death per 283 patients per year, even when adjusting for major CV risk factors. The relative risk of CV mortality was modified by age. For example, the RR of CV death for a 40-year-old and 60-year-old with severe psoriasis was 2.69 (1.45, 4.99) and 1.92 (1.41, 2.62), respectively. The findings were robust to multiple sensitivity analyses. Patients with severe psoriasis have an increased risk of CV mortality that is independent of traditional CV risk factors. Additional studies are needed to determine the mechanism of this association and the impact that control of psoriasis has on CV risk.
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CLINICAL RESEARCH
Prevention
Pa tients with sever e psoriasis are a t increased risk
of cardiovascular mortality: cohort study using
the General Pr actice Resear ch Database
Nehal N. Mehta
1,3
, Rahat S. Azfar
2,3
, Daniel B. Shin
2
, Andrea L. Neimann
5
,
Andrea B. Troxel
3,4
, and Joel M. Gelfand
2,3
*
1
Cardiovascular Institute, University of Pennsylvania School of Medicine, Philadelphia, PA, USA;
2
Department of Dermatology, University of Pennsylvania School of Medicine, One
Convention Avenue 1471 Penn Tower, Philadelphia, PA 19104, USA;
3
Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia,
PA, USA;
4
Department of Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA; and
5
Division of Dermatology, Department of
Medicine, Albert Einstein School of Medicine, New York, NY, USA
Received 25 October 2009; revised 14 November 2009; accepted 23 November 2009; online publish-ahead-of-print 27 December 2009
See page 902 for the editorial comment on this article (doi:10.1093/eurheartj/ehq042)
Aims Psoriasis is a common chronic inflammatory T-helper cell-1/17 mediated skin disease. Recent studies suggest that
psoriasis, particularly if severe, may be an independent risk factor for atherosclerosis, myocardial infarction (MI),
and stroke. We conducted a cohort study using the General Practice Research Database to determine if severe psor-
iasis patients have an increased risk of cardiovascular (CV) mortality.
Methods
and results
Severe psoriasis was defined as patients who received a psoriasis diagnosis and systemic therapy consistent with
severe psoriasis (n ¼ 3603). Up to four unexposed patients without psoriasis were selected from the same practices
and start dates for each psoriasis patient (n ¼ 14 330). For every death, the cause was determined by review of the
electronic medical record. Severe psoriasis was an independent risk factor for CV mortality (HR 1.57; 95% CI 1.26,
1.96) when adjusting for age, sex, smoking, diabetes, hypertension, and hyperlipidaemia. Overall, severe psoriasis
patients experienced one extra CV death per 283 patients per year, even when adjusting for major CV risk
factors. The relative risk of CV mortality was modified by age. For example, the RR of CV death for a
40-year-old and 60-year-old with severe psoriasis was 2.69 (1.45, 4.99) and 1.92 (1.41, 2.62), respectively. The
findings were robust to multiple sensitivity analyses.
Conclusion Patients with severe psoriasis have an increased risk of CV mortality that is independent of traditional CV risk factors.
Additional studies are needed to determine the mechanism of this association and the impact that control of psoriasis
has on CV risk.
-----------------------------------------------------------------------------------------------------------------------------------------------------------
Keywords Cardiovascular mortality Atherosclerosis Risk factors Psoriasis
Introduction
Psoriasis is a common, chronic inflammatory disease of the skin
and joints that affects 2 4% of the general adult population.
1,2
Psoriasis is associated with impairments in health-related quality
of life, even in mild cases, and is associated with excess all-cause
mortality in patients with severe disease.
3,4
The cause of psoriasis
remains unknown; however, its pathogenesis involves a complex
interaction between genetics, the immune system, and environ-
mental exposures.
Recent evidence suggests that chronic psoriasis may be associated
with other conditions that are caused, in part, by chronic inflam-
mation.
5
For example, helper T-cells type 1 (Th-1) chronic inflam-
mation characteristic of psoriasis is also central to the
pathophysiology of other conditions such as insulin resistance, ather-
osclerosis, and plaque rupture leading to thrombotic events.
6,7
Patients with psoriasis have increased prevalence of traditional cardi-
ovascular (CV) risk factors such as diabetes,
8
hypertension,
9
meta-
bolic dyslipidaemia,
10
tobacco use,
11
and obesity. Furthermore,
even after adjusting for these risk factors, recent epidemiological
* Correspondi ng author. Tel: þ1 215 662 6161, Fax: þ1 215 615 4966, Email: joel.gelfand@uphs.upenn.edu
Published by Oxford University Press on behalf of the European Society of Cardiology 2009.
European Heart Journal (2010) 31, 10001006
doi:10.1093/eurheartj/ehp567
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studies support an independent association between psoriasis and
myocardial infarction (MI), coronary artery disease, stroke, diabetes,
endothelial cell dysfunction, and atherosclerosis.
1215
Despite evidence of increased all-cause mortality
4
in patients
with severe psoriasis and accumulating evidence of increased
prevalence of CV risk factors, there is a paucity of data examining
whether psoriasis is associated with increased mortality due to CV
disease (CVD) after adjusting for CV risk factors. The purpose of
the present study was to determine if patients with severe psoriasis
have an increased risk of CV mortality.
Methods
Study population and data source
The study was conducted and is reported based on recommendations
of the STROBE statement.
16
The study population was derived from
the General Practice Research Database (GPRD), a medical records
database in the UK that was established for epidemiological research
in 1987.
17
The GPRD is representative of the UK population in
terms of age and sex, as well as geographic distribution. Approximately
5% of the UK is represented in this database, and it contains over 9
million patient records with 40 million person-years of follow-up.
Over 99% of patients through the National Health Service are regis-
tered through their general practitioner (GP) and the database cap-
tures both diagnoses and medications. The GPRD has been shown
to capture information on diagnoses and treatments from specialists
through the GP’s electronic medical record.
18
General practitioners
received specific training and incurred penalties in order to ensure
high quality data. The data are also audited for completeness and a
practice receives an up-to-standard (UTS) designation when at least
95% of relevant prescriptions and diagnoses are captured electroni-
cally. This database has also been studied in numerous validation
studies, including those of psoriasis and CVD, to demonstrate that it
captures these outcomes accurately.
1,12
Time period and age eligibility
Data were obtained between 1987 and 2002 for patients who were 18
or older at the date their person-time began.
Definition of exposure
We defined severe psoriasis patients as those with a diagnostic code of
psoriasis, and history of systemic therapy consistent with severe psor-
iasis. Systemic therapy included phototherapy, psoralen plus ultraviolet
A radiation, methotrexate, azathioprine, cyclosporine, oral retinoids
(etretinate, acitretin), hydroxyurea, and mycophenolate mofetil. Of
note, during the time period that this study was conducted, biologic
therapies were not approved for use for psoriasis in the UK. The
unexposed population (controls) was composed of patients with no
history of a psoriasis diagnostic code.
Sampling of exposed and unexposed cohorts
All patients with severe psoriasis (as defined above) who were age 18
or older at their index date and had at least 1 day of observation time
were included. For patients with severe psoriasis, their index date was
the first date on or after the first diagnosis of psoriasis in which the
patient received a code for treatment consistent with severe disease.
For patients without psoriasis, their index date was the date of a
medical record entry which was within 60 days of the psoriasis
index date. Up to four unexposed subjects who were age 18 or
older at their index date were randomly selected for each psoriasis
patient, matched on practice, date of registration in the practice, and
psoriasis index date (corresponding to a medical record date of the
unexposed patient). The matching on dates occurred as follows: regis-
tration: +90 days (if registration date 1980, otherwise +5 years),
index date: +60 days. The purpose of matching on practice, regis-
tration, and index dates was to ensure that patients with and
without psoriasis were evaluated by similar physicians during the
same time period to account for potential variations in medical prac-
tice and to allow for similar degrees of opportunity for GPs to identify
medical conditions in psoriasis and non-psoriasis patients.
Person-time calculation
For severe psoriasis patients, follow-up started at the latest of the date
of when the patient could first be defined as having severe psoriasis
(e.g. received a treatment code consistent with severe disease), was
registered with the practice, or the practice was deemed UTS. For
unexposed subjects, follow-up started at the latest date of when the
patient was registered in the practice, the index date (matched to
the psoriasis index date), and the practice was deemed UTS. For all
groups, follow-up ended at the date of death, transfer out of the prac-
tice, or end of UTS.
Outcome of interest
The outcome of interest was CV death defined as diagnoses consistent
with MI, stroke, peripheral vascular disease, arrhythmia, or left ventri-
cular thrombus entered on or very close to the entry of death. For
every death, the cause was determined by review of medical codes
on or very near date of death by two physician reviewers blinded to
exposure status (R.S.A. and A.L.N.). If there were discrepancies, a
third blinded physician reviewer was utilized (J.M.G.). Agreement on
cause of death was 96%.
Co-variables of interest
We identified traditional CV risk factors including age, sex, hyperten-
sion, diabetes, hyperlipidaemia, and smoking (current, former, never)
by the presence of diagnostic codes. Body mass index was directly cal-
culated from available data in the medical record.
Analysis
The sample size was determined by including the maximum eligible
number of patients with severe psoriasis based on age criteria. We ran-
domly selected up to four unexposed subjects per patient with psor-
iasis as additional matching yields minimal increases in statistical power.
Data were summarized descriptively. Dichotomous variables were
tested with Fisher’s exact test. Continuous variables were tested
with a t-test if they were normally distributed, or with the Wilcoxon
test if the data were not normally distributed. We fit age- and sex-
adjusted Cox models to determine the overall hazard ratio of CV
death in psoriasis patients.
19
When univariate Cox models indicated
an association of psoriasis with CV death, we fit additional models
with covariates included (described above) as well as models with
age and sex interaction terms, to determine if the relative risk of CV
death in psoriasis patients was different based on sex or age character-
istics. The primary model includes major CV risk factors. Body mass
index was recorded in about 69% of patients. Each dichotomous vari-
able in the model was checked for proportionality while adjusting for
the other covariates in the model by examining diagnostic log log
plots. We used the Greenland method of external adjustment to
determine the degree to which our findings could be explained by
an unknown or unmeasured confounder.
20
Multiple sensitivity analyses
were performed to test the underlying assumptions of our primary
analysis. All analyses were performed using STATA 10.0, and a
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P-value of ,0.05 was threshold for statistical significance, and P , 0.10
for interaction analysis.
Protection of human subjects
This study was approved by the University of Pennsylvania Institutional
Review Board and by the Independent Scientific Advisory Committee
of the Medicines and Healthcare Products Regulatory Agency of the
United Kingdom Department of Health. The study was conducted in
accordance with the Declaration of Helsinki.
Results
In this study, we identified 3603 patients with severe psoriasis, and
14 330 matched unexposed patients (Table 1). Patients with severe
psoriasis patients were slightly older and more likely to be male
and have established CV risk factors than patients without psoriasis
including hypertension, hyperlipidaemia, tobacco use, Type 2 dia-
betes (P , 0.05 for all). Furthermore, the majority of patients
with severe psoriasis were treated with methotrexate (Table 2).
The incidence of mortality due to CVD in unexposed subjects
and psoriasis subjects is shown in Table 3. The frequency of
deaths due to CVD was higher in patients with severe psoriasis.
The unadjusted overall risk of mortality due to CVD per 1000
person-years was significantly increased (P ¼ 0.002) in patients
with severe psoriasis patients (8.75, 95% CI 7.18 10.56) compared
with unexposed patients (6.19, 95% CI 5.51 6.93). After adjusting
for traditional CV risk factors (age, sex, hyperlipidaemia, hyperten-
sion, smoking, diabetes), severe psoriasis was an independent risk
factor for death due to CVD (HR 1.57; 95% CI 1.26, 1.96)
(Table 4). On the basis of these analyses, we estimate that each
year there is approximately one excess death from CVD per
283 severe psoriasis patients. There was no statistical interaction
(also known as effect modification) between psoriasis and sex
(P ¼ 0.99); however, there was an interaction between psoriasis
and age (P ¼ 0.07). For example, the adjusted relative risk of CV
mortality in a severe psoriasis patient who is 40 years old and
60 years old was 2.69 (1.45, 4.99) and 1.92 (1.41, 2.62), respect-
ively. The adjusted excess risk of CV mortality in a 40- and
60-year-old psoriasis patient was 6.05 deaths/10 000 person-years
and 41.30 deaths/10 000 person-years, respectively.
The results were robust to a variety of sensitivity analyses shown
in Table 5. Body mass index was not included in the primary model
................................................................................
Table 2 Systemic therapies received by patients with
severe psoriasis (n 53603)
Systemic therapy Number of patients with
severe psoriasis (%)
Methotrexate 2114 (58.7%)
Psoralen or phototherapy 607 (16.9%)
Azathioprine 582 (16.2%)
Cyclosporine 390 (10.8%)
Etretinate or acetretin 333 (9.2%)
Hydroxyurea 208 (5.8%)
Mycophenolate mofetil 9 (0.3%)
Percentages do not add up to 100 because patients could have received more than
one systemic therapy.
................................................................................
................................................................................
Table 3 Incidence of cardiovascular disease mortality
in patients with psoriasis compared with patients
without psoriasis (unexposed population)
Variable Unexposed
(n 5 14 330)
Psoriasis
(n 5 3603)
Follow-up time (year)
Mean + SD 3.4 + 2.8 3.4 + 2.7
Median (IQR) 2.6 (1.2 5.0) 2.7 (1.2 5.1)
Number of person-years 48 661.8 12 346.3
Number of CVD mortality
cases (%)
301 (2.1%)* 108 (3.0%)*
Incidence per 1000
person-years (95% CI)
6.19 (5.51, 6.92) 8.75 (7.18, 10.56)
CI, confidence interval; SD, standard deviation; IQR, interquartile range.
*P ¼ 0.002
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
Table 1 Characteristics of study group
Characteristics Unexposed
(n 5 14 330)
Psoriasis (n 5 3603)
Sex (male) 5783 (40.4%) 1750 (48.6%), P , 0.001
Age (year)
#
P , 0.001
Mean + SD 49.7 + 19.3 52.2 + 16.7
Median (IQR) 48 (33 65) 52 (39 66)
Diabetes mellitus 737 (5.1%) 270 (7.5%), P , 0.001
History of MI 375 (2.6%) 116 (3.2%), P ¼ 0.052
History of stroke 268 (1.9%) 89 (2.5%), P ¼ 0.023
History of TIA 243 (1.7%) 68 (1.9%), P ¼ 0.432
Hyperlipidaemia 842 (5.9%) 250 (6.9%), P ¼ 0.019
Hypertension 3049 (21.3%) 858 (23.8%), P ¼ 0.001
Smoking
Never 10 465 (73.0%) 2488 (69.1%)
Current 755 (5.3%) 241 (6.7%)
Former 3110 (21.7%) 874 (24.3%), P , 0.001
BMI
a
,25 5057 (51.2%) 1025 (42.1%)
25 and ,30 3291 (33.3%) 860 (35.4%)
30 1522 (15.4%) 548 (22.5%), P , 0.001
Reason for end of study
Death 790 (5.5%) 297 (8.2%)
End of UTS 11247 (78.5%) 2860 (79.4%)
Transfer out 2293 (16.0%) 446 (12.4%), P , 0.001
Unless notes otherwise, P-values are derived using Fisher exact test. MI,
myocardial infarction, TIA, transient ischaemic attack, BMI, body mass index
(calculated as weight in kilograms divided by height in meters squared); SD,
standard deviation; IQR, interquartile range.
a
Data for BMI were available for 69% of the patients.
#
Wilcoxon test.
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as its inclusion did not alter the association between psoriasis and
CV death and it was captured in only 69% of patients (Table 5).
Finally, analysing our data using an external adjustment approach
suggests that such an unknown or unmeasured confounder would
have to be common in the general population (prevalence of
20%), and have a strong association with psoriasis (OR 2.67 or
greater) and a very strong association (OR 6.5 or greater) with
CV death in order to render our findings null.
20
Discussion
The results of this study demonstrate that patients with severe
psoriasis have a clinically significant 57% increased risk of CV
death beyond the risk of death associated with traditional CV
risk factors. On the basis of our data, a patient with severe psor-
iasis has an excess risk of CV death attributable to psoriasis of 1
in 283 patients per year. The risk of CV mortality in patients
with severe psoriasis was not explained by major cardiac risk
factors identified in routine medical practice, suggesting that
severe psoriasis may be an independent risk factor for CV death.
Moreover, the relative risk of CV death associated with severe
psoriasis was highest in younger individuals suggesting a process
of accelerated CVD in younger severe psoriasis patients. There-
fore, it is of utmost importance that patients with severe psoriasis
and their providers are aware of this increased risk and that these
patients undergo appropriate risk assessment and implementation
of prevention strategies.
The strengths of the current study include the utilization of a
large population-based database that is well accepted for CV epi-
demiological studies and well-validated for psoriasis.
1,9,17,18
In
addition, the increased risk of CV death and point estimates
were robust to a variety of sensitivity analyses (Table 5). We
attempted to ensure that we were capturing patients who were
seen regularly, minimizing the risk that information bias could
explain the findings. In addition, even when patients with highest
risk for CV death (i.e. those with history of MI, stroke or transient
ischaemic attack, or atherosclerotic disease) were excluded, there
was still a 56% increase in CV death associated with severe psor-
iasis. The results also persisted when examining the risk based on
different treatments that theoretically could increase (e.g. cyclos-
porine, oral retinoids) or decrease (e.g. methotrexate) the risk
................................................................................
................................................................................
................................................................................
Table 4 Unadjusted and adjusted Cox proportional
hazard regression models of the risk of cardiovascular
disease mortality in severe psoriasis compared with
unexposed patients
Covariate Model hazard
ratio (95% CI)
Severe psoriasis
Unadjusted analysis
Psoriasis 1.42 (1.14, 1.76)
Adjusted for age and sex
Psoriasis 1.57 (1.26, 1.96)
Age per year 1.10 (1.09, 1.11)
Sex (male) 1.61 (1.32, 1.95)
Primary model (adjusted for major cardiovascular risk factors)
a
Psoriasis 1.57 (1.26, 1.96)
Age per year 1.10 (1.09, 1.11)
Sex (male) 1.54 (1.27, 1.88)
Hypertension 1.25 (1.01, 1.53)
Hyperlipidaemia 0.75 (0.42, 1.34)
Hx of diabetes 2.25 (1.68, 3.02)
Smoking (current vs. never) 1.33 (0.95, 1.86)
Smoking (former vs. never) 1.31 (0.98, 1.74)
Interaction term for sex was not statistically significant (P ¼ 0.99), but was for age
(P ¼ 0.07). CI, confidence interval.
a
Hypertension, hyperlipidaemia, diabetes, and smoking status.
...............................................................................................................................................................................
Table 5 Sensitivity analysis hazard ratio point estimates
Covariate n
Psoriasis
n
Controls
Model hazard
ratio (95% CI)
Primary analysis 3603 14 330 1.57 (1.26, 1.96)
Inclusion of patients with at least 1 GP visit per year on average 3563 13 643 1.54 (1.23, 1.93)
Primary model excluding patients with history of myocardial infarction, stroke, and/or TIA or
atherosclerotic disease
3310 13 335 1.56 (1.20, 2.04)
Primary model with exclusion of methotrexate 1489 14 330 2.04 (1.51, 2.74)
Primary model with exclusion of oral retinoids or cyclosporine 2914 14 330 1.51 (1.18, 1.94)
Primary model restricted to patients who received oral retinoids 333 14 663 1.59 (0.97, 2.60)
Primary model with exclusion of psoriatic arthritis 2375 14 330 1.52 (1.19, 1.94)
Primary model with BMI included
a
2433 9870 1.66 (1.19, 2.30)
Primary model without BMI included in those who had BMI measured
a
2433 9870 1.64 (1.18, 2.27)
Inclusion of patients with at least 6 months of person time 3246 12 766 1.66 (1.30, 2.11)
Primary model after matching cases to controls by age (+5 years) and sex
b
3603 7205 1.59 (1.23, 2.04)
CI, confidence interval; TIA, transient ischaemic attack; GP, general practitioner; BMI; body mass index.
a
BMI is included in n ¼ 12 303 or 69% of patients.
b
Two-to-one matching using original controls.
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of CVD.
21,22
Thus, these findings suggest that the increased CV
mortality is not due to treatment effect. The results also persisted
when restricting the severe group to patients treated with therapy
specific to severe psoriasis (e.g. oral retinoids), and when excluding
patients with psoriatic arthritis suggesting that the findings are
associated with severe skin psoriasis as opposed to misclassifi-
cation with other diseases in which our systemic therapies may
be indicated. Our data are consistent with recent studies that
demonstrate that psoriasis is an independent risk factor for coron-
ary artery disease,
12 15
stroke,
15,23
and MI.
12,15
Our study builds
upon previous findings that severe psoriasis patients have an
increased relative risk CV mortality that is highest in younger indi-
viduals by evaluating outpatients, as opposed to hospitalized
patients while also controlling for major CV risk factors.
24
Psoriasis is a prototypical Th-1, 17 inflammatory disease, and
Th-1 cellular secreted factors (e.g. intracellular adhesion
molecule-1, TNF-a) are indeed involved in the pathogenesis of
atherosclerosis and MI.
25
Furthermore, given the accumulating evi-
dence of inflammation playing a key role in development, pro-
gression, and complications of atherosclerosis,
26
our findings
have biological plausibility. Another Th-1 disease, rheumatoid
arthritis, has also been shown to be associated with increased
risk of MI
27
and multi-vessel coronary disease.
28
Recent studies
have shown coronary microvascular dysfunction in patients who
have chronic inflammation such as in rheumatoid arthritis or sys-
temic lupus erythematosus.
29
Patients with psoriasis have elevated
high-sensitivity C-reactive protein
30
which has been independently
associated as a marker for increased risk of CV events.
31,32
Finally,
a recent study showed increased CVD defined as coronary artery
disease, peripheral arterial disease, and stroke in patients with
psoriasis,
15
however this was not population-based and did not
evaluate for CV mortality.
In addition to the inflammatory burden driving CAD risk in these
disease states, there may be shared genetic risk which contributes
as well. Genetics have been shown to play a key role in suscepti-
bility to psoriasis
33
and metabolic disorders, such as diabetes
34
and dyslipidaemia,
35
as well as coronary artery disease.
36
Interest-
ingly, replicated genetic loci identified in psoriasis such as CDKALI
have been shown to be associated with Type 2 diabetes.
37
Dia-
betes has long been known to be a potent risk factor for MI,
38
and a shared genetic component between diabetes and psoriasis
may contribute to our findings. Recent studies have found that
psoriasis is an independent risk factor for developing diabetes
and therefore, it is possible that metabolic affects of psoriasis
may mediate the association of psoriasis and CVD.
9,39
Further-
more, a gene related to blood cholesterol levels, APOE4 (apolipo-
protein E-4),
40
was recently shown to be associated with psoriasis,
and this too may be a shared mechanism for increasing coronary
risk through lipid pathways. Interestingly, two key inflammatory sig-
nalling molecules, TNFAIP3 (tumour necrosis factor inducible
protein A20) and its interacting protein TNIP1
41
were discovered
using genome-wide association to be strongly associated with
psoriasis. Variation in the TNFAIP3 gene in mice
42
and in
humans
43
has been shown to increase coronary artery disease.
As with all studies, there are important limitations to consider.
In database studies, there remains the possibility for misclassifi-
cation of CV death. If misclassification of CV death is present,
such errors would be expected to be non-differential and there-
fore would bias our results toward the null. Another potential
limitation of our study is that we did not examine patients with
exclusively incident (new onset) psoriasis. Ideally, an inception
cohort study could be performed. However, in diseases such as
psoriasis which may not come to medical attention for many
years, it is difficult to validly identify truly incident (new onset)
cases in a medical records database setting. Finally, although our
study suggests that severe psoriasis is an independent risk factor
for CV death, it is possible that incomplete measurement of con-
founders or unknown confounding factors could explain some of
the observed association. For example, we did not control for
use of specific medications that may alter CV mortality risk, such
as angiotensin converting enzyme inhibitors, HMG-CoA reductase
inhibitors (statins), and non-steroidal anti-inflammatory drugs.
However, our external adjustment analysis reveals that such
unmeasured confounding is unlikely to be driving our results.
This study adds to the growing literature suggesting that patients
with severe psoriasis are at increased risk of CVD that is not
explained by traditional risk factors. This is the first paper to
report increased CV mortality in this group of patients while con-
trolling for major cardiovascular risk factors. In this study, severe
psoriasis was at least as potent a risk factor for CV death as
other major known risk factors such as smoking,
44
hyperlipidae-
mia,
45
and hypertension.
46
Our results did not show an increase
in CV mortality in the presence of hyperlipidaemia, although the
results were not statistically significant and therefore should be
interpreted cautiously. Although treatment of hyperlipidaemia
has been shown to decrease CVD events and subsequent mor-
tality at 1 year,
47
no study has shown that hyperlipidaemia is an
independent risk factor for CV death after controlling for age, dia-
betes, tobacco use, and hypertension. In further analyses (data not
shown), when we limited the outcome to only MI, consistent
with the literature, hyperlipidaemia was an independent risk
factor for MI.
This increase in CVD and mortality is important for clinicians to
recognize so that counselling and appropriate screening for CVD
and its risk factors in patients with severe psoriasis can be
implemented.
48,49
Future studies are necessary to determine
how psoriasis should influence cholesterol treatment targets as
outlined by guidelines such as Adult Treatment Panel III, in which
clinicians are advised to consider emerging CV risk factors in
their treatment decisions. Additionally, future studies are indicated
to determine what degree of psoriasis severity translates into clini-
cally significant CV risk, as well as to determine if controlling psor-
iasis results in reduction of CV risk.
Acknowledgements
We are indebted to Jean Liu and Xingmei Wang for their assistance
in creating the analytical dataset.
Funding
This work was supported by an unrestricted grant to the Trustees of
the University of Pennsylvania from Centocor (J.M.G.), the Psoriasis
Research Foundation in Honor of Herman Beerman (J.M.G.) and
grant K23AR051125 from the National Institute of Arthritis, Musculos-
keletal, and Skin Diseases and grant RO1HL089744 from the National
N.N. Mehta et al.1004
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Heart Lung Blood Institute (J.M.G.). The funding sources had no role in
the design and conduct of the study; collection, management, analysis,
and interpretation of the data; and preparation, review, or approval of
the manuscript. N.N.M. is a recipient of the American College of Car-
diology Young Investigator Award in the Metabolic Syndrome and
grant K23HL097151-01.
Conflict of interest. J.M.G. has grants from Amgen, Pfizer, and
Abbott, and is a consultant for Amgen, Abbott, Genentech, and Cen-
tocor. The other authors confirm that there are no other potential
conflicts of interest.
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CARDIOVASCULAR FLASHLIGHT
.............................................................................................................................................................................
doi:10.1093/eurheartj/ehp565
Online publish-ahead-of-print 17 December 2009
A sword-like foreign body lodged in the ventricular septum: a rare
complication of percutaneous vertebroplasty
Mi-Na Kim
1
, Jae-Seung Jung
2
, Sun-Won Kim
1
, Yong-Hyun Kim
1
, Seong-Mi Park
1
, and Wan-Joo Shim
1
*
1
Department of Cardiology, Korea University College of Medicine, Seoul, Republic of Korea and
2
Department of Thoracic & Cardiovascular Surgery, Korea University
College of Medicine, Seoul, Republic of Korea
* Correspondi ng author. Tel: þ82 2 920 5445, Fax: þ82 2 922 1478, Email: wjshimmd@unitel.co.kr
A 76-year-old woman was referred for NYHA
functional class III dyspnoea for 1 year. Her
medical histories were benign, except hyperten-
sion for 5 years. The physical examination
revealed irregular heart sounds, a soft holosystolic
murmur, and distended jugular veins. An electro-
cardiography showed atrial fibrillation and a
chest X-ray showed multiple, branching radiopaci-
ties in both lung fields (white arrows), and a curvi-
linear dense radiopacity overlying the cardiac
silhouette (black arrow; Panel A). An echocardio-
graphy confirmed a hyperechogenic linear struc-
ture (9 cm in length) in the right ventricle with
one end in the right atrium through the tricuspid
valve and the other end lodged in the ventricular
septum (Panel B). Colour Doppler echocardiogra-
phy disclosed severe tricuspid regurgitation (Panel
C). On further questioning, the patient disclosed a
history of percutaneous lumbar vertebroplasty for
a compression fracture 5 years ago and the cardi-
opulmonary embolization of bone cement was
diagnosed. The embolized bone cement was surgi-
cally removed. The intracardiac embolus was
10 cm in length, destroyed the septal tricuspid leaflet, and nearly perforated the ventricular septum (Panel D).
Polymethylmethacrylate (PMMA) is a transparent, thermoplastic substance with various medical applications. Percutaneous verteb-
roplasty using PMMA is regarded as a safe and effective procedure to treat compression fractures of vertebral bones. The paraver-
tebral venous leakage and pulmonary embolization of PMMA occurs frequently, but is clinically silent in most cases, while cardiac
embolization is rare, but may cause serious adverse events.
The abbreviations used are RA, right atrium; LA, left atrium; RV, right ventricle; LV, left ventricle; SVC, superior vena cava.
Published on behalf of the European Society of Cardi ology. All rights reserved. & The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org.
N.N. Mehta et al.1006
at University of Pennsylvania Library on August 2, 2011eurheartj.oxfordjournals.orgDownloaded from
... Moreover, the accumulation of neutrophils in psoriatic plaques and microabscesses is accompanied by an increase in these cells in the circulation [8,9], together with findings of subclinical inflammation in the liver, joints, and tendons, accompanied by a significant increase in vascular and subcutaneous inflammation [10,11]. In fact, approximately 73% of patients with psoriasis have a concomitant disease [12], presenting a higher prevalence of psoriatic arthritis, inflammatory bowel disease [13,14]both of them explained by their common pathogenesis with psoriasis [1,2]-diabetes mellitus, obesity, metabolic syndrome (abdominal obesity, high blood pressure, hyperglycemia, and atherogenic dyslipidemia), cardiovascular diseases [15][16][17][18], or non-alcoholic fatty liver [19], among others. ...
... The association between psoriasis and a higher incidence of cardiovascular disease (CVD) has been known for decades [15][16][17][18][20][21][22]. Although there is still some controversy about the milder forms of the disease [23][24][25], a higher prevalence of myocardial infarction [23,26], venous thromboembolism [27], stroke [27,28], ischemic heart disease, cerebrovascular accidents [29], and a substantial increase in cardiovascular mortality [26,30] has been observed in patients with moderate to severe psoriasis. ...
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Psoriasis is a chronic systemic inflammatory disease associated with a higher incidence of cardiovascular disease, especially in patients with moderate to severe psoriasis. It has been estimated that severe psoriasis confers a 25% increase in relative risk of cardiovascular disease, regardless of traditional risk factors. Although the underlying pathogenic mechanisms relating psoriasis to increased cardiovascular risk are not clear, atherosclerosis is emerging as a possible link between skin and vascular affection. The hypothesis that the inflammatory cascade activated in psoriasis contributes to the atherosclerotic process provides the underlying basis to suggest that an anti-inflammatory therapy that improved atherosclerosis would also reduce the risk of MACEs. In this sense, the introduction of biological drugs which specifically target cytokines implicated in the inflammatory cascade have increased the expectations of control over the cardiovascular comorbidity present in psoriasis patients, however, their role in vascular damage processes remains controversial. The aim of this paper is to review the mechanistic link between psoriasis and cardiovascular disease development, as well as analyzing which of the biological treatments could also reduce the cardiovascular risk in these patients, fueling a growing debate on the modification of the general algorithm of treatment.
... Psoriasis is a systemic inflammatory disease [30] and has implications beyond the skin. Studies have demonstrated the impact of psoriasis on the cardiovascular system, with the risk of death from cardiovascular causes estimated to be 57% higher in patients with severe psoriasis [31]. Other authors have indicated an increased risk of myocardial infarction (HR: 1.21) in patients with severe psoriasis [32]. ...
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COVID-19 causes thromboembolic complications that affect the patient’s prognosis. COVID-19 vaccines significantly improve the prognosis for the course of the infection. The aim of this study was to evaluate the impacts of patient characteristics, including COVID-19 vaccinations, on perioperative mortality in acute coronary syndrome in Poland during the pandemic. We analyzed the data of 243,515 patients from the National Registry of Invasive Cardiology Procedures (Ogólnopolski Rejestr Procedur Kardiologii Inwazyjnej [ORPKI]). In this group, 7407 patients (21.74%) had COVID-19. The statistical analysis was based on a neural network that was verified by the random forest method. In 2020, the most significant impact on prognosis came from a diagnosis of unstable angina, a short period (<2 h) from pain occurrence to first medical contact, and a history of stroke. In 2021, the most significant factors were pre-hospital cardiac arrest, female sex, and a short period (<2 h) from first medical contact to coronary angiography. After adjusting for a six-week lag, a diagnosis of unstable angina and psoriasis were found to be relevant in the data from 2020, while in 2021, it was the time from the pain occurrence to the first medical contact (2–12 h) in non-ST segment elevation myocardial infarction and the time from first contact to balloon inflation (2–12 h) in ST-segment elevation myocardial infarction. The number of vaccinations was one of the least significant factors. COVID-19 vaccination does not directly affect perioperative prognosis in patients with acute coronary syndrome.
... Patienten mit Pso-riasis sind oftvonnochweiterer Komorbidität betroffen, insbesondere dem metabolischen Syndrom [16], Depressionen [10], chronisch entzündlichen Darmerkrankungen [12] oder Uveitis [5]. Die Psoriasis per se gilt auch als ungünstiger kardiovaskulärer Risikofaktor [8,11,13,17], was zu einer Verkürzung der individuellen Lebenserwartung um 3 bis 4 Jahre führt [9]. Die Lebensqualität der Psoriasispatienten ist nicht zuletzt durch Juckreiz, Schmerzen und Stigmatisierung erheblich eingeschränkt [4]. ...
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Zusammenfassung Hintergrund Patienten mit systemischen Autoimmun- und/oder autoinflammatorischen Erkrankungen (AI/AInf) bedürfen in der Regel einer multidisziplinären Zusammenarbeit durch verschiedene Fachrichtungen. Ziel der Arbeit (Fragestellung) Wir evaluierten, ob die Etablierung eines multidisziplinären Boards (sog. Rheumaboard [RB]) zur Optimierung der Versorgung von Patienten mit Psoriasisarthritis (PsA) oder anderen AI/AInf führt. Material und Methoden Es wurden n = 272 Patienten mit AI/AInf eingeschlossen, die in 3 Gruppen eingeteilt wurden; Gruppe 1: 41 Patienten mit oder mit Verdacht auf (V. a.) PsA, von der Dermatologie in der Rheumatologie konsiliarisch avisiert; Gruppe 2: 166 Patienten mit oder mit V. a. PsA, vorstellig in der Dermatologie und im RB; Gruppe 3: 65 Patienten mit anderen AI/AInf, vorstellig in der Dermatologie und im RB. Evaluiert wurde die durchschnittliche Zeit von der initialen Vorstellung bis zur Therapieeinleitung nach erfolgter Beurteilung und Diagnostik durch beide Fachrichtungen. Darüber hinaus wurden die Diagnosesicherung/-bestätigung und die Therapieweiterführung/-optimierung bei allen 3 Gruppen analysiert. Ergebnisse Die durchschnittliche Zeitspanne von der initialen Vorstellung bis zur Therapieeinleitung betrug in Gruppe 1 85 ± 42,24 (5 bis 173) Tage, in Gruppe 2 15 ± 13,09 (0 bis 78) Tage und in Gruppe 3 20 ± 16,71 (1 bis 75) Tage. In Gruppe 2 und 3 konnte die Diagnose schneller gesichert oder bestätigt sowie die Wartezeit auf Diagnostik und Therapie deutlich reduziert werden. Diskussion Durch die Etablierung eines RB zeigt sich eine signifikante Verkürzung der Zeitspanne zwischen Erstvorstellung und Therapieeinleitung und damit eine deutliche Verbesserung des Versorgungsmanagements bei Patienten mit AI/AInf inklusive Diagnosesicherung und Therapieoptimierung. Graphic abstract
... Psoriasis patients are at high-risk of developing early-onset CAD, with an increased prevalence of non-calcified coronary plaques that are vulnerable to rupture, often leading to MI (3,51,53). In psoriasis, the prevalence of non-calcified coronary burden has a robust correlation with abnormal cholesterol trafficking, evident by impaired CEC, an elevation in circulating neutrophils that are activated, and increased activity in the bone marrow and spleen determined by heightened uptake of fluorodeoxyglucose (FDG) (2, 36, 54). ...
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Metabolic conditions such as obesity and associated comorbidities are increasing in prevalence worldwide. In chronically inflamed pathologies, metabolic conditions are linked to early onset cardiovascular disease, which remains the leading cause of death despite decades of research. In recent years, studies focused on the interdependent pathways connecting metabolism and the immune response have highlighted that dysregulated cholesterol trafficking instigates an overactive, systemic inflammatory response, thereby perpetuating early development of cardiovascular disease. In this review, we will discuss the overlapping pathways connecting cholesterol trafficking with innate immunity and present evidence that cholesterol accumulation in the bone marrow may drive systemic inflammation in chronically inflamed pathologies. Lastly, we will review the current therapeutic strategies that target both inflammation and cholesterol transport, and how biologic therapy restores lipoprotein function and mitigates the immune response.
... Environmental stimuli, such as trauma and infection, are believed to cause psoriasis in patients with genetic factors. Psoriasis can involve organs other than the skin, such as joints, and has recently been reported to be related to metabolic syndrome or cardiovascular diseases 1,2 . Therefore, it is now recognized as a whole-body disease rather than a simple skin disease. ...
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Background: Psoriasis is a multifactorial, chronic immunological disease, in which a specific allele HLA-Cw6 is associated with various clinical manifestations. However, information regarding this genetic factor in Korean patients with psoriasis remains limited. Objective: We aimed to explore the differences in clinical patterns and treatment responsiveness, depending on the expression of HLA-Cw6, in Korean patients with psoriasis. Methods: We divided patients into two groups, namely HLA-Cw6-positive and HLA-Cw6-negative, based on the HLA-Cw6 allelic analysis using the single specific primer-polymerase chain reaction method. All clinical information regarding these patients was collected in a retrospective manner. Next, we evaluated the levels of serum Th17-related cytokines in 34 patients diagnosed with psoriasis using a multiplex immunoassay. Finally, we performed immunohistochemical staining of interleukin (IL)-22 and IL-31, as these cytokines showed the maximum differential expression between the HLA-Cw6 positive and negative groups. Results: HLA-Cw6 positive and negative groups comprised of 13 and 21 patients, respectively. HLA-Cw6-positive group had more chance of having metabolic comorbidities (76.9% for HLA-Cw6-positive group; 28.6% for HLA-Cw6-negative group; p=0.002). Also, HLA-Cw6-positive group showed significantly higher treatment response (38.5% in positive group showed Psoriasis Area and Severity Index 90% improvement compared to 4.8% in the negative group; p=0.012). However, all Th17-related cytokines were not significantly different across the two groups. Furthermore, IL-22 and IL-31 immunohistochemical staining did not correlate with the serum cytokines levels. Conclusion: HLA-Cw6 types can be associated with disease severity, comorbidities, and treatment responsiveness in Korean patients with psoriasis.
... Despite a higher prevalence of severe comorbidities in our cohort of ESRD patients with concomitant psoriasis, multivariate regression models showed that the additional diagnosis of psoriasis in patients with ESRD was not associated with changes for in-hospital mortality and severe cardiovascular events such as myocardial infarction, pulmonary embolism, or stroke. This finding is not in line with previously published work [28,29]. We provide the following suggestions that might explain this result: The significantly younger age of ESRD patients with psoriasis may be one of the main causes for the lower number of cardiovascular events and case-fatality rate (in median 5 years younger). ...
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Full-text available
Background and objectives: During the last decades, growing evidence corroborates that chronic inflammatory disease impairs the body beyond the cutaneous barrier. Linkage between psoriasis and kidney disease, and in particular between psoriasis and end-stage renal disease (ESRD), have not yet been elucidated. We sought to analyze the impact of concomitant psoriasis on the in-hospital outcomes of patients hospitalized with ESRD. Patients and methods: We analyzed data on characteristics, comorbidities, and in-hospital outcomes of all hospitalized patients with ESRD stratified for concomitant psoriasis in the German nationwide in-patient sample between 2010 and 2020. Results: Overall, 360,980 hospitalizations of patients treated for ESRD in German hospitals were identified from 2010 to 2020 and among these 1063 patients (0.3%) additionally suffered from psoriasis. While the annual number of all ESRD patients increased within this time, the number of patients with ESRD and the additional psoriasis diagnosis decreased slightly. Patients with ESRD and psoriasis were five years younger (66 [IQR, 56-75] vs. 71 [59-79] years, p < 0.001), were more often obese (17.5% vs. 8.2%, p < 0.001) and more frequently had cancer (4.9% vs. 3.3%, p < 0.001), diabetes mellitus (42.7% vs. 38.5%, p = 0.005) and coronary artery disease (31.1% vs. 28.0%, p = 0.026). Multivariate regression models demonstrated that psoriasis was not associated with in-hospital case-fatality in patients with ESRD (OR 1.02 (95%CI 0.78-1.33), p = 0.915). Conclusions: ESRD patients with the concomitant psoriasis diagnosis were hospitalized on average 5 years earlier than patients without psoriasis. A higher prevalence of severe life-shortening comorbidities including coronary artery disease and cancer was detected in ESRD patients with psoriasis despite their younger age. Our findings support the understanding of psoriasis as an autoimmune skin disease crossing the boundary between dermatology and internal medicine.
Article
Background/objectives: Psoriasis, newly considered as a systemic inflammatory condition, has a high prevalence of cardiovascular diseases (CVD), including atherosclerosis and myocardial infarction. Measurement of carotid artery intima-media thickness (C-IMT) represents a non-invasive diagnostic tool for predicting cardiovascular disorders. We aimed to determine if psoriatic patients have an increased risk for the development of cardiovascular disorders by assessment of the presence of subclinical atherosclerosis in psoriasis patients. Methods: 40 adult psoriatic patients and 40 matched healthy controls were selected in this study. All participants were subjected to full history, examination, assessment of the severity of psoriasis using psoriasis area and severity index (PASI) score, measuring serum lipid profile (cholesterol, LDL and triglycerides) and C-IMT. Results: Psoriatic patients showed significantly higher serum lipid profile findings and C-IMT. There was a positive statistically significant correlation between C-IMT and each of age of the patients (r = 0.760, p < 0.001) and severity of psoriasis (PASI score). Conclusion: There is increased susceptibility to cardiovascular diseases in psoriatic patients represented by increased incidence of subclinical atherosclerosis and dyslipidemia in our patients.
Article
Objectives: The main goal of the study was to describe the demographic, epidemiological, clinical and laboratory characteristics of a monitored group of patients with psoriasis to assess the prevalence of cardiovascular comorbidities and to define the cardiovascular risk profile. Methods: One hundred and ninety outpatients aged over 18 were included in the prospective observational cross-sectional study. Demographic and clinical data were obtained from patients. The severity of psoriasis was evaluated using the Psoriasis Area and Severity Index (PASI) and the Dermatology Life Quality Index (DLQI). The results of laboratory testing were identified based on patient health records. Results: Based on an evaluation of psoriasis phenotypes, 150 patients (78.95%) suffered from plaque psoriasis, 18 (9.5%) from palmoplantar psoriasis, 11 (5.8%) from guttate psoriasis, 6 (3.2%) from generalized pustular psoriasis, and 5 (2.6%) from erythrodermic psoriasis. The personal medical history discovered the occurrence of arterial hypertension in 83 patients (43.7%), the occurrence of depression in 49 patients (25.8%), type 2 diabetes in 29 patients (15.3%), and dyslipidaemia in 48 patients (25.3%). Conclusion: It is noteworthy that psoriasis may be demonstrated as a multi-system disease which does not only affect the skin and its adnexa. The association of psoriasis with comorbidities may significantly increase morbidity and total mortality as well as the demands for health care provision.
Article
Background: There are no population-based epidemiological data on psoriasis in Southeast Asia including Malaysia OBJECTIVES: To determine the incidence and prevalence of psoriasis over 11 years in multi-ethnic Johor Bahru, Malaysia. Methods: A population-based cohort study using the Teleprimary Care database between January 2010 and December 2020. Psoriasis cases, identified by ICD-10 diagnostic codes, were validated by dermatologists. Annual prevalence and incidence were estimated and stratified by age, sex, and ethnicity. Results: We identified 3,932 people with dermatologist-confirmed psoriasis including 1,830 incident cases, among 1,164,724 Malaysians, yielding an 11-year prevalence of 0.34% (95% CI 0.33%-0.35%) and incidence of 34.2/100,000 person-years (95% CI 32.6-35.8). Rates were higher in Indian patients; prevalence was 0.54% (0.50%-0.58%) in Indians, 0.38% (0.36%-0.40%) in Chinese, 0.29% (0.28%-0.30%) in Malays and incidence/100,000 person-years was 52.5 (47.3-57.7) in Indians, 38.0 (34.1-41.8) in Chinese and 30.0 (28.2-31.8) in Malays. Rates were higher in males; prevalence was 0.39% (0.37%-0.41%) in males, 0.29% (0.27%-0.30%) in females, and incidence/100,000 person-years was 40.7 (38.2-43.2) in males and 28.3 (26.4-30.3) in females. Between 2010 and 2020, annual psoriasis prevalence and incidence increased steadily from 0.27% to 0.51% and 27.8 to 60.9/100,000 person-years, respectively. Annual rates were consistently higher in males than females and amongst Indians, followed by Chinese and Malays. Overall, psoriasis was significantly more common in males than females (OR 1.37, 95% CI 1.29-1.46) and in Indians and Chinese than in Malays [OR 1.85 (1.71-2.01) and OR 1.30 (1.20-1.41), respectively]. Prevalence increased with advancing age, with the highest rates in the 50-59 and 60-69 age groups at 0.67% and 0.66%, respectively. A modest bimodal trend in age of psoriasis onset was observed with first and second peaks at 20-29 and 50-59 years of age, respectively. Disease onset was significantly earlier in females than males (mean age ± SD: 36.8±17.3 vs 42.0±17.2 years, p<0.0001) and in Malays than Indians and Chinese [(mean age ± SD: Malay; 36.4±17.5, Indian; 40.8±15.2, Chinese; 47.4±16.9) years, p<0.0001]. Conclusions: We found that psoriasis incidence and prevalence are increasing and varied by age, sex and ethnicity. Our findings should help inform healthcare planning and management for psoriasis patients in Malaysia.
Article
Background: Patients with severe psoriasis have an increased cardiovascular (CV) risk and prevalence of subclinical coronary artery disease (CAD). Coronary artery calcium (CAC) testing can detect subclinical CAD and improve cardiovascular risk assessment beyond clinical scores. Objectives: Evaluate the presence and magnitude of subclinical CAD determined by CAC score among the different ESC/EAS CV risk categories, as well as the potential for risk reclassification, in patients with severe psoriasis from a low CV risk population. Methods: Unicentric cross-sectional study in 111 patients with severe chronic plaque psoriasis from a low CV risk population in the Mediterranean region. Patients were classified into four CV risk categories according to the ESC/EAS guideline recommendations and HeartScore/SCORE calibrated charts. Patients underwent coronary computed tomography to determine their CAC scores. Patients in the moderate-risk category with a CAC score of ≥100 were considered to be reclassified as recommended by the 2019 ESC/EAS guidelines. Reclassification was also considered for patients in the low-risk category with a CAC score >0. Results: Presence of subclinical CAD was detected in 46 (41.4%) patients. These accounted for 86.2% of patients in high/very-high-risk categories and 25.6% of patients in non-high-risk categories. Fourteen (17.1%) of the patients in non-high-risk categories were reclassifiable due to their CAC score. This percentage was higher (25%) when considering the moderate-risk category alone and lower (13.8%) in the low-risk category. Age was the only variable associated with presence of subclinical CAD and reclassification. Conclusions: Over 40% of patients with severe psoriasis from a low-risk region and up to 25% of those in non-high-risk categories have subclinical CAD. CAC appears to be useful for reclassification purposes in CV risk assessment of patients with severe psoriasis. Further research is required to elucidate how CAC could be implemented in everyday practice at outpatient dermatology clinics dedicated to severe psoriasis.
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Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalisability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control, and cross-sectional studies. We convened a 2-day workshop in September, 2004, with methodologists, researchers, and journal editors to draft a che-cklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. 18 items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed explanation and elaboration document is published separately and is freely available on the websites of PLoS Medicine, Annals of Internal Medicine, and Epidemiology. We hope that the STROBE statement will contribute to improving the quality of reporting of observational studies.
Article
Objective: To examine the cardiovascular risk factors in patients with psoriasis and the association between psoriasis and coronary artery, cerebrovascular, and peripheral vascular diseases. Design: Observational study. Setting: Large Department of Veterans Affairs hospital. Patients: The study included 3236 patients with psoriasis and 2500 patients without psoriasis (controls). Main Outcome Measures: Using International Classification of Diseases, Ninth Revision, Clinical Modification, codes, we compared the prevalence of traditional cardiovascular risk factors and other vascular diseases as well as mortality between patients with psoriasis and controls. Results: Similar to previous studies, we found a higher prevalence of diabetes mellitus, hypertension, dyslipidemia, and smoking in patients with psoriasis. After controlling for these variables, we found a higher prevalence not only of ischemic heart disease (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.51-2.11) but also of cerebrovascular (OR, 1.70; 95% CI, 1.33-2.17) and peripheral vascular (OR, 1.98; 95% CI, 1.32-2.82) diseases in patients with psoriasis compared with controls. Psoriasis was also found to be an independent risk factor for mortality (OR, 1.86; 95% CI, 1.56-2.21). Conclusions: Psoriasis is associated with atherosclerosis. This association applies to coronary artery, cerebrovascular, and peripheral vascular diseases and results in increased mortality.