Ultrasound on Point as Predictor of Cardiovascular Risk in Psoriatic Disease

July 8, 2019

The presence of carotid atherosclerosis in psoriasis and psoriatic arthritis patients is associated with an increased risk of having a cardiovascular event, researchers report.

The presence of carotid atherosclerosis in psoriasis and psoriatic arthritis patients is associated with an increased risk of having a cardiovascular event, researchers report.

The findings, by Lihi Eder, M.D., of Women's College Hospital, Toronto, appear in the June 5 issue of Arthritis & Rheumatology.

“This study demonstrates that increased atherosclerotic plaque burden is associated with incident cardiovascular events in patients with psoriatic disease. This atherosclerotic burden, as estimated by carotid ultrasound, can improve prediction of cardiovascular events in psoriatic patients when combined with the Framingham Risk Score. Thus, it has a potential of improving cardiovascular risk estimation and stratification in this patient population,” the authors wrote.

It is known that psoriasis and psoriatic arthritis patients have an increased risk for cardiovascular events. This risk stems from a combination of traditional cardiovascular risk factors, such as diabetes and hypertension, and systemic inflammation associated with psoriatic disease.

An important part of managing psoriatic arthritis is to assess possible outcomes. Risk stratification allows the clinician to adjust treatment to mitigate disease progression, morbidity and possibility mortality.

A challenge in psoriatic disease is that traditional risk models, such as the Framingham Risk Score, do not take systemic inflammation into account and may underestimate the risk of cardiovascular events in people with psoriatic disease.

In this study, Dr. Eder and colleagues sought to determine if carotid ultrasound could be used to assess the state of subclinical atherosclerosis and predict incident cardiovascular events patients with psoriatic disease. If so, they theorized that the use of imaging could improve the prediction of cardiovascular risk as determined by the Framingham Risk Score.

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The study included 559 patients with psoriatic disease of whom 42 patients had a potential for a cardiovascular event during the follow up period and of this, 23 went on to develop a cardiovascular event (19 of which were major). Other events included:  10 myocardial infarctions (two fatal); five strokes (one fatal); 12 patients with revascularization; three patients with heart failure exacerbation; seven with angina and one with transient ischemic attack.

The majority of patients had atherosclerotic plaques at baseline: 27 percent had unilateral plaques and 31.5 percent had bilateral plaques. A Kaplan-Meier estimate showed that the risk of developing a cardiovascular event was significantly higher in patients with higher burden of atherosclerotic plaques at baseline.

The calculated rate of developing a first cardiovascular event and first major cardiovascular event during the study period was 1.11 and 0.91 events per 100 patient years, respectively.

The primary outcomes included major cardiovascular events, such as myocardial infarction, unstable angina, ischemic stroke, re-vascularization procedures or cardiovascular-related death and minor cardiovascular events such as stable angina, exacerbation of congestive heart failure and transient ischemic attack.

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TAKE-HOME POINTS

Increased plaque burden in the carotid arteries of patients with psoriatic disease is associated with more―and major―cardiovascular events.

When combined with the Framingham Risk Score, carotid ultrasound in psoriatic patients can improve prediction of cardiovascular events even more allowing clinicians to stratify patients with psoriatic disease in the hopes of providing more intensive risk reduction strategies.

While an increase in traditional cardiovascular risk factors in patients with psoriatic disease is partially to blame for the increase in cardiovascular events, clinicians must recognize the contribution of systemic inflammation. Goals of treatment should be reduction in disease activity for psoriasis and psoriatic arthritis as well as prevention and treatment of comorbid conditions that increase the risk for cardiovascular events.

Finally, clinicians should consider using carotid ultrasound as a complement to traditional cardiovascular risk prediction models. This non-invasive and readily available point of care test may allow us to treat earlier and improve outcomes in our patients with psoriatic disease at increased cardiovascular risk.

REFERENCE:

Sobchak, C. , Akhtari, S. , Harvey, P. , et al. “The value of carotid ultrasound in cardiovascular risk stratification in patients with psoriatic disease.”Arthritis and Rheumatology. June 5, 2019. DOI:10.1002/art.40925