By Joan Stephenson
NEW YORK (Reuters Health) - Psoriasis patients have higher levels of risky lipid-rich non-calcified coronary-artery plaque compared with both hyperlipidemic patients a decade older and age- and gender-matched healthy volunteers, a new study shows.
The prospective observational study also found that prevalence of “high-risk plaque” (plaque with features indicating a high risk for rupture) was higher in psoriasis patients than in healthy volunteers and equivalent to prevalence of high-risk plaque in the older hyperlipidemic patients.
In addition, among psoriasis patients followed for one year, a decrease in skin disease severity after treatment was associated with a reduction in non-calcified coronary-artery plaque and improvement in markers of inflammation.
“Taken together, these findings suggest that patients with psoriasis are at high risk for having coronary-artery disease and that treatment of their skin disease may improve heart disease,” corresponding author Dr. Nehal N. Mehta, chief of the section of inflammation and cardiometabolic diseases at the National Heart, Lung, and Blood Institute, told Reuters Health in an email.
Both psoriasis and atherosclerosis are inflammatory disorders, and patients with psoriasis experience myocardial infarction at younger ages than people without the skin disease. This accelerated risk is “likely attributable” to a higher burden of subclinical coronary artery disease that is not flagged by traditional risk assessment, the researchers note.
Medical conditions such as HIV disease that feature inflammation have been associated with increased non-calcified coronary artery plaque and high-risk plaque features. But efforts to directly measure subclinical coronary artery disease in people with psoriasis before they have a cardiovascular event have been inadequate.
“Therefore, we asked the question whether psoriasis is associated with the presence of lipid-rich plaque and high-risk plaque features, to understand whether these features may in part contribute to the early heart attack risk in psoriasis,” Dr. Mehta said.
The researchers recruited three cohorts of participants, including 105 psoriasis patients (mean age, 50.2), 100 hyperlipidemic patients eligible for statin therapy under NCEP-ATP III guidelines (mean age, 61.2), and 25 healthy volunteers without psoriasis or other inflammatory conditions (mean age, 47.7).
Cardiovascular risk by both Framingham risk score and Atherosclerotic Cardiovascular Disease (ASCVD) 10-year risk was similar for the psoriasis patients and healthy volunteers and significantly higher for the hyperlipidemic group.
Coronary computed-tomography angiography (CCTA) revealed that psoriasis patients, despite being about 10 years younger and at lower traditional risk than hyperlipidemic patients, had a higher non-calcified plaque burden (1.18 (x 100) mm2 vs. 1.11 (x 100) mm2, p=0.02) and a similar prevalence of high-risk plaque (34% vs. 38%, p=0.58), the researchers report in Circulation, online May 8.
Compared with healthy volunteers, psoriasis patients also had higher total plaque burden (1.22 vs. 1.04, p=0.001) and non-calcified plaque burden (1.18 vs. 1.03, p=0.004). Their high-risk plaque prevalence was about six times higher after adjustment for various factors (odds ratio, 6.0, p=0.03).
“Psoriasis patients have similar coronary artery disease risk as hyperlipidemic patients one decade older,” the researchers write. “As such, this young, vulnerable population should be screened earlier for cardiovascular disease, and should be educated about their elevated risk.”
A consecutive sample of 50 psoriasis patients were followed for one year and underwent repeat blood tests, assessment for skin disease severity, and CCTA scans at the end of that period.
Improvement in skin disease (as reflected in the psoriasis severity score) was significantly associated with a decrease in total coronary artery plaque burden and non-calcified plaque burden. Patients with a clinical response to treatment also showed improvement in inflammatory markers compared with non-responders, even when risk-adjusted in a multivariate analysis.
Longer-term follow-up is needed beyond one year to see if this effect is durable, Dr. Mehta cautioned.
“Previous studies have demonstrated that systemic anti-inflammatory treatment for psoriasis is associated with lower (cardiovascular) event rates and reduced coronary artery disease progression using CCTA,” Dr. Eugene Yang, of the University of Washington School of Medicine in Seattle, told Reuters Health by email.
The current study provides some mechanistic insights about how anti-inflammatory therapy might prevent cardiovascular events, noted Dr. Yang, a member of the American College of Cardiology Prevention of Cardiovascular Disease Committee, who was not involved in the new research.
It’s plausible that anti-inflammatory therapy reduces an early, non-calcified plaque burden and prevents progression to high-risk lesions that confer an increased risk of myocardial infarction, he said.
“These results suggest that early, aggressive treatment of CV risk factors for psoriasis patients should be considered, as they may not be captured as a high-risk group using traditional risk-assessment tools,” Dr. Yang said.
Randomized, prospective clinical trials of psoriasis patients treated with anti-inflammatory therapy are needed to confirm the association between systemic inflammation and cardiovascular events, he said.
SOURCE: https://bit.ly/2qeqErE
Circulation 2017.
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