Cardiovascular Risk in PsA Greater Than It Seems

January 14, 2015

The classic Framingham risk factors underestimate the threat of cardiovascular disease in psoriatic arthritis. But effective treatment appears to ameliorate the risk.

Ernste FC, Sánchez-Menéndez M, Wilton KM, et al., Cardiovascular Risk Profile at the Onset of Psoriatic Arthritis: A Population-based, Cohort Study.Arthritis Care & Research. 2015. Accepted MS. Online Jan 7, 2015. doi: 10.1002/acr.22536.

Roubille C, Richer V, Starnino T, et al., The effects of tumour necrosis factor inhibitors, methotrexate, non-steroidal anti-inflammatory drugs and corticosteroids on cardiovascular events in rheumatoid arthritis, psoriasis and psoriatic arthritis: a systematic review and meta-analysis. Ann Rheum Dis doi:10.1136/annrheumdis-2014-206624. [online first Dec 30]

People with psoriatic arthritis (PsA) are at increased risk for cardiovascular disease (CVD) -- even early on -- and the commonly used tool for assessing risk, the Framingham risk score (FRS) may vastly underestimate the risk in newly-diagnosed patients, according to a new study.

The retrospective cohort study by the Mayo Clinic of 158 PsA patients (61% men, mean age 43, 94% with inflammatory joint disease) finds the 10-year risk of CVD to be twice as high as that predicted by the FRS, especially after age 40.

Among the study group, 32 patients had at least one cardiovascular event over the 12 year follow-up. This is a 17% 10-year cumulative incidence, twice the incidence predicted using the FRS.

Of the 126 PsA patients with no cardiovascular history under age 30, 18 developed CVD, for a cumulative incidence of 17% - again, twice that predicted by the FRS.

There were no significant differences between the two groups with regard to CVD risk factors (smoking, obesity, blood pressure, and cholesterol). Nor were there associations between the FRS and disease activity, as measured by erythrocyte sedimentation rate (ESR) and other markers.

In RA, traditional risk factors, disease activity, corticosteroid use, and inflammation are believed to play a role in accelerated atherosclerosis and elevated CVD risk. [See The Riddle of Cardiovascular Disease in RA]

While these links are less well-understood in PsA, “[s]ubclinical atherosclerosis has been detected in PsA patients without traditional cardiovascular risk factors,” the study authors note.

“The presence of psoriasis alone may be enough to account for the increased CVD risk in our cohort,” and could justify using aggressive therapy early in the disease course to lessen long-term cardiac risk, they conclude.  

Limitations noted by the authors: Lack of a comparator group and perhaps a too-short followup period. 

Do Antiinflammatory Therapies Reduce Risk?

Authors of the second article above echo a number of recent studies hinting that tumor necrosis factor-alpha (TNF-α) drugs and other systemic therapies may reduce the risks of CVD that accompany rheumatic diseases like PsA.

Their meta-analysis of biologics and other systemic therapies finds that the drugs’ anti-inflammatory properties may decrease the relative risk of heart attacks, strokes, and other cardiovascular events in PsA by 70%, compared to non-use.

The meta-analysis looked at 34 studies of anti-rheumatic drugs - methotrexate (MTX), TNF-α inhibitors, corticosteroids, and non-steroidal anti-inflammatory drugs (NSAIDs) - in both PsA and rheumatoid arthritis (RA).

Because the researchers could find only six studies specifically about PsA, they judged the evidence less conclusive than for RA, for which the data show TNF drugs and MTX may cut the relative risk of cardiac events by more than 30% and 28% respectively.

NSAIDs and corticosteroids increased the risk of cardiac events in RA by 18% and 47%, respectively, due largely in the case of NSAIDs to studies that included rofecoxib (Vioxx), withdrawn from the market in 2004 because of this risk. A separate analysis found that celecoxib (Celebrex) did not appear to increase the risk of heart attacks and stroke.

The results of the meta-analysis are consistent with recent reviews in PsA, but the researchers say studies with higher power and better controls are needed.