Coronary artery diseaseAJC Editor's Consensus: Psoriasis and Coronary Artery Disease
Section snippets
Acknowledgment
This CME activity is supported by an educational grant from Amgen, Thousand Oaks, California.
Disclosure
Dr. Friedewald has received honoraria for speaking from Novartis, East Hanover, New Jersey. Dr. Cather has received honoraria for speaking, consulting, and board membership from Amgen; Abbott Laboratories, Abbott Park, Illinois; Astellas, Tokyo, Japan; and Genentech, South San Francisco, California. Dr. Gelfand has received consulting fees from Amgen; Genentech; Pfizer, New York, New York; Celgene, Summit, New Jersey; and Centocor, Horsham, Pennsylvania. Dr. Gelfand is a grants investigator for
Objectives
Upon reading this activity, the reader should be able to:
- 1
Inform patients with moderate to severe psoriasis that they may be at increased risk for coronary artery disease (CAD) and other forms of atherosclerotic cardiovascular (CV) disease.
- 2
Assess patients with moderate to severe psoriasis for their risk factors for CAD.
- 3
Prescribe appropriate lifestyle and pharmacologic therapies for patients with psoriasis who are at increased risk for CAD.
- 4
Consult in the diagnosis and management of coronary risk
Needs Assessment
The need for this activity for cardiologists and other health care specialists in CV medicine is based on the following premises:
- 1
Psoriasis is a common disease involving >125 million patients worldwide and 7 million patients in the United States.
- 2
Patients with moderate to severe psoriasis have an increased prevalence of CAD and an increased risk for myocardial infarction.
- 3
Patients with psoriasis have an increased prevalence of risk factors for CAD.
- 4
Physicians and patients with psoriasis are
Overview of Psoriasis
Psoriasis is a common disease, affecting an estimated 125 million patients worldwide (2% to 3% of the global population).1 In the United States, about 7.5 million patients have psoriasis, including about 2.5% of European Americans and 1.3% of African Americans. Psoriasis is common in certain ethnic groups, affecting 12% of individuals in Arctic Kasach'ye,2 and is uncommon in other populations (e.g., only 0.3% of individuals in China3). Psoriasis may begin at any age and has 2 peak periods of
Evidence
A possible association between psoriasis and atherosclerotic CAD was first suggested in 1961.14 Many subsequent observational studies detected an increased prevalence of CAD and its risk factors in patients with psoriasis, but these studies were inconclusive in establishing a connection between the diseases because most of these studies involved only hospitalized patients and generally did not control for confounding factors.15, 16, 17, 18, 19, 20, 21, 22, 23
The largest study of nonhospitalized
Cardiovascular Risk Factors and Psoriasis
Patients with severe psoriasis have a 3- to 4-year average decrease in their life expectancy, comparable with the estimated reduction in the longevity of patients with severe hypertension.29 This shortened lifespan is likely due in part to increased prevalence of CAD, which is the most common cause of death in patients with psoriasis. Conditions that are known contributors to CAD—dyslipidemia, obesity, hypertension, and diabetes mellitus—are more prevalent in patients with psoriasis than in the
Inflammation
Inflammation may be an important link between psoriasis and CAD.69, 70, 71 Inflammation may be defined as a physiologic state in which elevated levels of circulating inflammatory cytokines provoke localized inflammation in susceptible organs throughout the body, such as the gums (periodontitis), joints (rheumatoid arthritis and osteoarthritis), and intestines (inflammatory bowel disease). Inflammation is important in the pathophysiology of psoriasis, with a central role of cytokines,72
Recommendations
(Note: Many of the following recommendations are based on psoriatic disease severity, which by convention has been designated as “mild,” “moderate,” or “severe.” This classification, however, can be confusing to nondermatologists, who should not assign disease severity for the purpose of assessing psoriasis-related CV risk factor based solely on the type of treatment used for individual patients. For example, a patient with psoriasis confined to the palms and feet, and thus not carrying a large
Recommendations for Future Research
The association between CAD and psoriasis is a relatively new observation and largely limited to retrospective analyses of large patient data sets. Additional research is needed to (1) provide better guidance in reducing the risk for CAD in patients with psoriasis and (2) provide better insight into the mechanisms underlying this association. The panel believes that the following avenues of research will help meet these objectives.
- 1
A national, controlled registry or prospective cohort should be
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