Psoriatic arthritis

Cardiovascular disease the most common cause of death in PsA

Clinicians have been reminded that patients with psoriatic disease are at increased cardiovascular risk compared to the general population and they appear to be underdiagnosed and undertreated. 

Professor Dafna Gladman, director of the Psoriatic Arthritis Program at Toronto Western Hospital, told the EULAR 2020 Congress that cardiovascular disease was the most common cause of death in psoriatic arthritis.

Earlier work from her team had shown the prevalence of hypertension (standardised prevalence ratio 1.90), myocardial infarction (SPR 2.57) and angina (SPR 1.97) was higher in patients with PsA than the general population.

The study found the predictors for cardiovascular comorbidities were male gender, diabetes and hyperlipidemia but, less expected, that the extent of psoriasis was also a predictor of cardiovascular disease (CVD) among patients with psoriatic disease.

Professor Gladman said another study of more than 1,000 patients with a median follow-up of ten years had again shown that traditional risk factors such as hypertension (RR 1.81) and diabetes (RR 2.72) but also disease related factors such as dactylitis count (RR 1.21) and ESR in women (RR 1.87) predicted cardiovascular in PsA.

She said a meta-analysis of 11 studies, comprising  more than 32,000 patients with PsA had revealed a cardiovascular risk increase of 43% in PsA patients compared to controls.

Individually, nine of the eleven studies had shown the increased risk of MI, cardiovascular disease, cardiovascular mortality or stroke in patients with PsA.

And a more recent and larger meta-analysis of 26 observational studies with more than 17,000 psoriasis and 66,000 non-psoriasis patients found a significantly increased risk of hypertension (OR 2.31), abdominal obesity (OR 1.90), and triglycerides (OR 1.80) in psoriasis compared to non-psoriasis patients. 

A series of smaller studies had shown the Framingham risk score underestimates subclinical atherosclerosis in psoriatic disease and that there was an association between disease-related variables such as high ESR and DAPSA and the severity of atherosclerosis as measured by total plaque area.

TNFi reduces vascular inflammation 

“It’s important to note that it’s not only cardiovascular disease but there is an increased prevalence of and risk factors for diabetes in PsA,” Professor Gladman said. 

The standardised prevalence of diabetes was 11.3% in one study of 1,300 PsA patients compared to 7.5% in a reference population (SPR 1.43).

She noted that the study showed a levelling off in the increase in diabetes over the last decade in the reference population, but not in the patients with PsA.

The risk factors for incident diabetes in PsA were tender joint count (RR 1.68) and ESR (RR 1.21) which remained significant in the multivariate model. PASI and dactylitis count were also significant in the univariate analysis.

Professor Gladman said it was of interest that there seems to be a treatment effect on subclinical atherosclerosis in PsA.

In a study of 319 patients with psoriatic disease, total plaque areas were assessed at baseline and 2-3 years later.

Men were found to have significantly higher atherosclerosis progression than women but TNFi use was associated with a reduced progression of atherosclerosis in these men after controlling for cardiovascular risk factors and the use of statins.

“Interestingly, DMARDs did not help at all,” Professor Gladman said.

In a second part of the study, 21 PsA patients receiving a TNFi were compared with 12 PsA patients not receiving a biologic.

It found patients treated with TNFi had a reduction in vascular inflammation in the first year from baseline while patients not receiving biological therapy had no change from baseline.

The factors associated with improvement were TNFi treatment, low density lipoprotein and lipid lowering therapy. 

Diagnosis and treatment gaps

“Unfortunately there are gaps in the diagnosis and treatment of cardiovascular risk factors in PsA.” she said. 

In a real world setting of more than 2,000 patients with psoriatic disease and at least one modifiable cardiovascular risk factor, a large proportion of patients were underdiagnosed and undertreated for hypertension and dyslipidaemia. 

“This was particularly noticeable in people under the age of 50 years, in males, and in people with psoriasis versus PsA. The conclusion was that strategies to improve the management of cardiovascular risk factors in psoriatic patients are warranted.”

A recently published study found similar results including that blood pressure screening was performed less commonly in outpatient visits related to psoriasis (36.4%) than in other visits (62.5%).

“Again, the conclusion was that screening rates for cardiometabolic comorbidities are suboptimal,” she said.

“So in summary there is an increased risk of cardiovascular events in psoriatic disease – a higher prevalence and incidence compared to the general population. Traditional and disease-related factors predict the risk for cardiovascular disease in psoriatic disease but the risk is mitigated by treatment. We need to do better in screening and treating traditional risk factors and psoriatic disease.”

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