Psoriasis: Disease Duration and CV Risk

Psoriasis Disease Duration and Cardiovascular Risk

Psoriasis vulgaris is associated with systemic comorbid conditions, including diabetes, metabolic syndrome, coronary artery disease, and myocardial infarction (MI).^[1] This has led to the concept of the "psoriatic march,"—psoriasis as a chronic inflammatory condition driving cardiovascular disease (CVD).^[2,3] Furthermore, patients with moderate-to-severe psoriasis treated with tumor necrosis factor (TNF)-alpha inhibitors showed reductions in the proinflammatory marker C-reactive protein level and arterial intima-media thickness^[4,5]—both surrogate markers for CVD.

Because vascular inflammation in patients with psoriasis correlates with disease severity,^[6] it stands to reason that it might also correlate with disease duration. In this context, Egeberg and colleagues^[7] hypothesized a relationship between psoriasis vulgaris duration, vascular inflammation, and major adverse cardiovascular events (MACE) such as MI, ischemic stroke, or death due to CVD. They investigated this link with two approaches:

• A National Institutes of Health (NIH) human imaging study (18-fluorodeoxyglucose PET/CT scan; n=190 patients with mild-to-moderate psoriasis) to assess vascular inflammation; and

• A Danish population-based study of CVD events in patients with moderate-to-severe psoriasis(n = 87,161) vs a control group (n = 4,321,964). The primary outcome measure in this cohort was the first occurrence of a MACE.

Both the imaging study and population-based cohort analysis showed that patients with psoriasis had an increased prevalence of CVD risk and that this risk worsened with disease duration. Specifically:

• The NIH cohort of 190 patients (57% men) with mild-to-moderate psoriasis showed evidence of vascular inflammation that increased with disease duration.

• In the population cohort, the risk for MACE increased by 1% per year of psoriasis duration.

• Multivariable hazard ratios for specific MACE were 1.006 (MI), 1.011 (ischemic stroke), and 1.011 (cardiovascular [CV] death).

Viewpoint

This intelligently designed two-part study by Egeberg and colleagues further strengthens the link between psoriasis and CVD, adding one more important concept: that this risk is time dependent. Simply put, the longer an individual has moderate-to-severe psoriasis, the higher the risk for MACEs.

Why is this such an important finding? Because we now have a myriad of targeted therapies that control psoriasis by suppressing the chronic and systemic inflammation that is the hallmark of this disease. We already have evidence that blockade of proinflammatory cytokines such as TNF-alpha reduces serum markers of inflammation and may even slow the progression of CVD.^[4,5] If disease duration is a critical determinant of CV risk, it stands to reason that patients with moderate-to-severe psoriasis will benefit most if they start effective treatment early.

As Egeberg and colleagues concluded, clinicians should consider both the severity and the duration of psoriasis when assessing a patient's CV risk. Future studies need to compare CV morbidity and mortality in patients who have controlled versus poorly controlled psoriasis (and psoriatic arthritis). Only then will we know whether starting early biologic therapy for psoriasis can potentially save lives.