The Heart of the Matter

The growing body of evidence linking psoriasis to cardiometabolic diseases suggests that dermatologists may need to be more proactive about assessing heart risks among psoriasis patients.

“Psoriasis does go beyond the skin,” says Nehal N. Mehta, MD, MSCE, FAHA, Chief, Section of Inflammation and Cardiometabolic Diseases at the National Heart, Lung and Blood Institute, in Bethesda, MD. “We know that plaques are biologically active and that even one plaque that has been there for years should be treated.”

Research has also shown that the longer a patient has psoriasis, the greater their risk for developing cardiovascular disease and that disease severity also increases this risk. The more severe the psoriasis, the greater the odds of developing comorbidities including heart disease, he says.

Systemic inflammation may be the common denominator between psoriasis and cardiovascular diseases, but shared risk factors (obesity, sedentary behavior, and smoking) may up the ante. “Shared risk factors may magnify the risk, but there is something about psoriasis that is a specific risk factor for heart disease,” Dr Mehta says.

Mehta et al published a study in the Oct. 8, 2015 issue of the journal Arteriosclerosis, Thrombosis, and Vascular Biology highlighting the effect that psoriasis can have on blood vessels. The team used PET/CT scans to show blood vessel inflammation in individuals with psoriasis.1 “The more skin disease, the more blood vessel inflammation, but just one plaque is too much.”

Another study backs up this point. Even when well-established CV risk factors such as age, gender, ethnic group, smoking, alcohol consumption, metabolic syndrome, and hyperuricemia are controlled for, psoriasis increased the risk for heart attack, according to the study which appears in the August 2015 issue of the Journal of Cutaneous Medicine and Surgery.2

In this study, psoriatic patients were at significantly higher risks of developing MI (odds ratio [OR] 2.24; 95% CI: 1.27-3.95; P = .005) and ischemic heart disease (OR 1.90; 95% CI: 1.18-3.05; P = .008), but not stroke (OR 1.01; 95% CI: 0.48-2.16; P = .744), after adjustment was made for major cardiovascular risk factors.

The million-dollar question is, of course, will treating psoriasis reduce cardiometabolic disease risk? Mehta is now conducting a study that is set to answer this very question, with results expected sometime in 2017.

“There is anecdotal evidence that treatment does matter because we are decreasing inflammation,” he says.

QUELL Inflammation, Manage CV Risks

The key is to treat the underlying psoriasis and control the controllables when it comes to heart disease, adds Steven Feldman, MD, PhD, professor of Dermatology at Wake Forest Baptist Medical Center in Winston-Salem, NC. “In getting rid of inflammation, we may be treating CV disease too,” Dr. Feldman says. “There are certain cardiovascular screening tests that should be done in the general public and psoriasis patients with severe disease certainly need these tests.”

In particular, many younger male psoriasis patients may not be seeing an internist regularly. In these cases, the onus can fall on the treating dermatologist to screen for hypertension, cholesterol and diabetes and/or counsel the patient on appropriate actions regarding weight, diet, exercise, and smoking cessation, Dr. Feldman points out.

“It’s simple to screen for cardiometabolic diseases,” Dr. Mehta adds. “Screen for the three B’s: blood pressure, body mass index (BMI), and blood (for fasting glucose and fasting cholesterol).”

Amy Kassouf, MD, dermatologist at Cleveland Clinic in Ohio, sometimes adds these measures to her routine blood test requisition forms. “A lot of the drugs we use to treat psoriasis require blood tests anyway so I will sometimes add a lipid panel, and if it is elevated, I will suggest they see a primary care physician or cardiologist for further evaluation,” she says.

Relative Versus Absolute risk of CV Disease in Psoriasis

Dr. Feldman urges caution as well as vigilance. “We shouldn’t scare ourselves and the general public by just talking about relative risk without keeping the absolute risk in mind,” he says.

For example, “a 20 percent increased risk of heart disease in a 60-year-old is far greater than a three-fold elevation in 20-year-old,” he says. The baseline risk for heart disease in a 20-year-old is much lower than that of a 60-year-old. “If you don’t have severe psoriasis, and your heart disease risk factors are mild, your chances of having a heart attack are pretty low.” n

1. Mehta NN, et al. Severity of psoriasis associates with aortic vascular inflammation detected by FDG PET/CT and neutrophil activation in a prospective observational study. Arterioscler Thromb Vasc Biol. 2015. [Epub ahead of print]

2. Lai YCYew YW. Psoriasis as an independent risk factor for cardiovascular disease: An epidemiologic analysis using a national database. J Cutan Med Surg. 2015 Aug 27. pii: 1203475415602842. [Epub ahead of print]