Cardiovascular Risks Associated With IMIDs

Joel Gelfand, MD, MSCE, presented the session “Cardiovascular Risk and Immune-Mediated Inflammatory Disorders” on the 3rd day of the Interdisciplinary Autoimmune Summit. Because immune-mediated inflammatory diseases (IMIDs) are associated with increased mortality due to cardiovascular disease (CVD), it is important to understand the impact of immune-targeted treatment on cardiovascular events.

Dr Gelfand noted that moderate to severe psoriasis is associated with an increased risk of major cardiovascular events, and chronic inflammation and metabolic abnormalities are common to both psoriasis and cardiovascular disease. There are 27 studies confirming the relationship between CVD and psoriasis, with similar but less robust data on the relationship between CVD and psoriatic arthritis, rheumatoid arthritis (RA), and inflammatory bowel disease, respectively. Many patients with psoriasis have more than one nontraditional cardiovascular risk factor. For example, metabolic syndrome and chronic kidney disease are increased in people with psoriasis.

Discussing the Incident Health Outcomes and Psoriasis Events, or iHOPE, study, Dr Gelfand stated, “For patients who had a 10% or more body surface area affected by psoriasis, they had about an 80% higher likelihood of dying in the ensuing 4 to 5 years of follow up, independent of all the risk factors for mortality in the medical record database.”

Can targeting inflammation prevent CVD? “The problem is that the immune system can be very unpredictable,” Dr Gelfand remarked. In the case of IL-17 and CVD, “Models and evidence suggest that IL-17 can be both pro- and anti-atherogenic,” he said.

Recent research showed that subcutaneous and visceral fat were reduced by 5% to 6% through week 16 and maintained at week 52 in patients taking apremilast. However, apremilast seemed to lower the benefit of high-density lipoprotein, or “good,” cholesterol. Randomized controlled trials are needed to confirm these results.

Biologic treatment of psoriasis is associated with reduced coronary inflammation assessed as perivascular fat attenuation index. And TNF inhibitors are cardioprotective in psoriasis and RA, according to meta-analyses of observational studies. Methotrexate is also cardioprotective in RA, according to a meta-analysis of observational studies. However, Dr Gelfand indicated that “there are really big limitations in these studies, the biggest one being the healthy user effect.”

About a 50% higher risk of death in patients taking tofacitinib twice a day compared with a TNF inhibitor has been seen. “JAK inhibitors should be second-line agents to the other biologics we have available to us,” Dr Gelfand suggested.

Dr Gelfand concluded that because cardiovascular risk factors are underscreened and undermanaged in patients with psoriasis, it is a model opportunity for prevention, “The overwhelming majority of dermatologists think it's completely doable to screen for traditional risk factors, meaning screening for diabetes and good cholesterol levels and check[ing] blood pressure, and patients really welcome this type of screening,” he said.

Reference

Gelfand JM. Cardiovascular risk and immune-mediated inflammatory disorders. Presented at: Interdisciplinary Autoimmune Summit; April 21-24, 2022; Virtual.