Association between psoriasis and coronary calcium score

Psoriasis Comorbidities and Their Treatment Impact

Psoriasis, a systemic inflammatory disease classically presenting with cutaneous lesions, has significant involvement in other organ systems. This article explores the prevalence, clinical manifestations, screening mechanisms, and laboratory testing by which to evaluate these comorbidities. Treatment approach for these comorbidities must combine patient preference with established treatment algorithms while recognizing innovative therapeutics currently under development.

Carotid intima-media thickness in adults with and without psoriasis - a nested case-control study from baseline data of ELSA-Brasil cohort

There is a lack of consensus about the association between psoriasis (PSO) and carotid intima-media thickness (cIMT) in literature, since previous studies considered dermatologic clinic patients or general population. This study aimed to compare cIMT levels according to PSO in a sample of 10,530 civil servants form the ELSA-Brasil cohort study and analyze its association with the disease. The PSO cases and disease duration were identified by medical diagnosis self-reported at study enrollment. A paired group was identified by propensity score matching among all the participants without PSO. Mean cIMT values were considered for continuous analysis while cIMT above 75th percentile was considered for categorical analysis. Multivariate conditional regression models were used to analyze association between cIMT and PSO diagnosis, by comparing PSO cases against paired controls and overall sample without disease. A total of n = 162 PSO cases were identified (1.54%) and no difference in cIMT values was observed between participants with PSO and overall sample or control group. PSO was not associated with linear increment of cIMT (vs. overall sample: β = 0.003, p = 0.690; vs. matched controls: β = 0.004, p = 0.633) neither with increased chance of having cIMT above 75th percentile (vs. overall sample: OR = 1.06, p = 0.777; vs. matched controls: OR = 1.19, p = 0.432; conditional regression: OR = 1.31, p = 0.254). There was no relationship between disease duration and cIMT (β = 0.000, p = 0.627). Although no significant relationship between mild cases of psoriasis and cIMT was observed among a wide cohort of civil servants, longitudinal investigation about cIMT progression and severity of disease are still needed.

Psoriasis and associated risk factors: a cross-sectional analysis of the Brazilian Longitudinal Study of Adult Health

OBJECTIVE

This study investigated the association of psoriasis with cardiovascular risk factors and psychological aspects among participants of the Brazilian Longitudinal Study of Adult Health.

METHODS

This is a cross-sectional study from the baseline data of the Brazilian Longitudinal Study of Adult Health cohort, collected between 2008 and 2010 in six state capitals of Brazil (i.e., Belo Horizonte, Porto Alegre, Rio de Janeiro, Salvador, São Paulo, and Vitória). Participants were active and retired civil servants from college and research institutions, aged between 35 and 74 years. Exclusion criteria included the intention to quit working at the institution, pregnancy, severe cognitive impairment, and, if retired, residence outside of a study center's corresponding area. Psoriasis case identification was based on a previous medical diagnosis of psoriasis. Cardiovascular risk profile, psychological aspects, and sociodemographic variables were investigated.

RESULTS

Data from 15,105 participants were analyzed (mean age of 52.3 years, 51.3% women). The prevalence of psoriasis was 1.6% (n=236). Psoriasis was associated with higher education (OR 1.94 [CI 1.07-3.52]), health insurance plan (OR 1.56 [CI 1.08-2.25]), central obesity (OR 1.63 [CI 1.10-2.40]), smoking status (former OR 1.40 [CI 1.03-1.88]; current OR 1.61 [CI 1.08-2.40]), and very bad self-perception of health (OR 7.22 [CI 2.41-21.64]), remaining significant even after multivariate adjustment. Self-reported Black participants were less likely to have psoriasis (OR 0.45 [CI 0.26-0.75]).

CONCLUSION

In a sample of healthy workers, psoriasis was associated with central obesity, smoking, and a very bad self-perception of health, which may contribute to future cardiovascular disease.

Association between psoriasis and coronary artery calcification: A systematic review and meta-analysis

Background

Psoriasis and atherosclerosis have overlapping pathophysiological mechanisms. However, the association between psoriasis and coronary artery calcification (CAC), a hallmark of atherosclerosis and a predictor of poor cardiovascular prognosis, remains to be determined. We performed a systematic review and meta-analysis to comprehensively evaluate the association between these related inflammatory conditions.

Methods

Observational studies evaluating the relationship between psoriasis and CAC were retrieved by searching PubMed, Cochrane's Library, and Embase databases. Presence of CAC was confirmed according to an Agatston's Score >0 upon computed tomography examination. A random-effect model incorporating between-study heterogeneity was used to pool the results.

Results

Sixteen studies involving 3,039 patients with psoriasis and 46,191 controls without psoriasis were included in the meta-analysis. All participants were without previously known cardiovascular diseases. Pooled results showed that psoriasis was associated with overall CAC [odds ratio (OR): 1.54, 95% confidence interval: 1.23-1.91, p < 0.001; I 2 = 57%], after matching or adjusting the conventional cardiovascular risk factors. Subgroup analyses showed that study country, comorbidity of psoriatic arthritis, baseline Psoriasis Area and Severity Index, and duration of psoriasis (p for subgroup difference all >0.05) did not significantly affect the association of psoriasis and CAC. However, a stronger association was observed in younger patients (mean age <50 years, OR: 2.63, p < 0.001) compared to older patients (≥50 years, OR: 1.24, p = 0.02; p for subgroup difference <0.001).

Conclusion

Psoriasis is associated with CAC, and the association may be stronger in younger patients.

Prevalence of Atherosclerosis in Psoriatic Patients Detected with Epiaortic Color Doppler Ultrasound and Computed Tomography Angiography

INTRODUCTION

Psoriasis (PsO), a chronic inflammatory, multisystemic, and multifactorial disease can cause endothelial dysfunction, artery calcification, and atherosclerotic disease. A higher incidence of vascular occlusive events has been observed in psoriatic patients compared to healthy controls, and multiple studies confirm the association between moderate-severe PsO and atherosclerosis, coronary artery calcification, and higher cardiovascular risk.

OBJECTIVE

We sought to analyze atherosclerotic disease prevalence in epiaortic vessels of psoriatic and non-psoriatic patients to understand if PsO could represent an independent risk factor predisposing to atherosclerotic disease.

METHODS

We evaluated 47 psoriatic patients without cardiovascular risk factors with color Doppler ultrasound (CDUS). If atheromatous plaques were detected, a computed tomography angiography (CTA) was performed. We evaluated 47 non-psoriatic patients without cardiovascular risk factors with CDUS. Atherosclerosis prevalence in both groups were statistically analyzed. CDUS performance was compared to CTA.

RESULTS

In the psoriatic group (mean age 50.9 years), 6 had atheromatous plaques and 12 had an intima-media thickness (IMT) > 1 mm (overall prevalence of atherosclerotic disease: 38.2%). All plaques detected with CDUS were confirmed at CTA. In the control group (mean age 51.3 years), CDUS revealed atheromatous plaques in 4 patients and IMT > 1 mm in 4 ones (overall prevalence of 17%). The difference of atherosclerotic disease prevalence between the groups was statistically significant (P < 0.05).

CONCLUSION

Our results highlight that PsO could be considered a predisposing factor for atherosclerotic disease development in epiaortic vessels, as it causes an increased IMT, that is also considered an independent cardiovascular risk factor.

Atherosclerosis attacks in patients with psoriasis vulgaris but without a relationship with the severity and course of the disease

Introduction

In recent years numerous research studies have indicated that chronic inflammation in psoriasis can be associated with an increased risk of developing atherosclerosis.

Aim

The presented study was aimed at demonstrating whether patients suffering from psoriasis vulgaris are at a greater risk of developing atherosclerosis depending on the presence of selected cardiovascular risk factors and the course and severity of the disease.

Material and methods

Sixty-two patients with diagnosed psoriasis vulgaris and 42 healthy volunteers were included in the study. All the patients underwent carotid ultrasound with the assessment of the common carotid artery intima-media thickness (IMT) and the computed tomography with determination of coronary artery calcification (CAC).

Results

The IMT was significantly higher in the study group (1.030 ±0.303 mm vs. 0.838 ±0.151 mm, p < 0.0001). We also found a significantly increased severity of Calcium Score (CS) in Agatston units (168.20 ±309.63 vs. 24.52 ±43.21, p = 0.0207) of CAC in patients with psoriasis. There was no significant correlation between the degree of atherosclerosis and psoriasis severity determined in the PASI (Psoriasis Area and Severity Index) scale, duration of the disease, number of exacerbations per year or C-reactive protein values.

Conclusions

The study showed an increased risk of developing atherosclerosis in patients diagnosed with psoriasis vulgaris, but no correlation was found between the degree of atherosclerosis and the severity of the disease.

New Frontiers in Psoriatic Disease Research, Part II: Comorbidities and Targeted Therapies

Although psoriasis and psoriatic arthritis (PsA) have been classically considered to be diseases of the skin and joints, respectively, emerging evidence suggests that a combination of innate and environmental factors creates widespread immune dysfunction, affecting multiple organ systems. A greater understanding of the pathogenesis of psoriasis and the systemic effects of psoriatic inflammation has allowed for the development of new, more effective treatments. The second portion of this two-part review series examines the comorbidities associated with psoriasis and PsA as well as the most recent advances in targeted systemic therapies for these conditions.

Psoriasis and Cardiovascular Disease: A Narrative Review

Psoriasis is a chronic, autoimmune, and inflammatory disease that affects 2% of the world's population. In recent years, it has been demonstrated that psoriasis confers a 25% increase in relative risk of cardiovascular disease, independent of factors such as hyperlipidemia, smoking, and obesity. The objective of this review was to analyze and describe the association between psoriasis and cardiovascular disease. In this review, we describe the epidemiological association of psoriasis and cardiovascular disease, pathophysiology, mechanisms, and its association with the well-known cardiovascular risk calculators. In addition, we describe diagnostic tools, such as imaging techniques and novel biomarkers, that are useful in the evaluation of atherosclerotic cardiovascular disease. Finally, we present different systemic therapies that are used in patients with psoriasis and their effect on atherosclerotic cardiovascular disease. This article provides an overview of the current literature on psoriasis and cardiovascular risk, which can be useful for primary care physicians in their daily clinical practice.

Chronic inflammatory diseases and coronary heart disease: Insights from cardiovascular CT

Epidemiological and clinical studies have demonstrated a consistent relationship between increased systemic inflammation and increased risk of cardiovascular events. In chronic inflammatory states, traditional risk factors only partially account for the development of coronary artery disease (CAD) but underestimate total cardiovascular risk likely due to the residual risk of inflammation. Computed coronary tomography angiography (CCTA) may aid in risk stratification by noninvasively capturing early CAD, identifying high risk plaque morphology and quantifying plaque at baseline and in response to treatment. In this review, we focus on reviewing studies on subclinical atherosclerosis by CCTA in individuals with chronic inflammatory conditions including rheumatoid arthritis (RA), systemic lupus erythematous (SLE), human immunodeficiency virus (HIV) infection and psoriasis. We start with a brief review on the role of inflammation in atherosclerosis, highlight the utility of using CCTA to delineate vessel wall and plaque characteristics and discuss combining CCTA with laboratory studies and emerging technologies to complement traditional risk stratification in chronic inflammatory states.

HDL in Immune-Inflammatory Responses: Implications beyond Cardiovascular Diseases

High density lipoproteins (HDL) are heterogeneous particles composed by a vast array of proteins and lipids, mostly recognized for their cardiovascular (CV) protective effects. However, evidences from basic to clinical research have contributed to depict a role of HDL in the modulation of immune-inflammatory response thus paving the road to investigate their involvement in other diseases beyond those related to the CV system. HDL-C levels and HDL composition are indeed altered in patients with autoimmune diseases and usually associated to disease severity. At molecular levels, HDL have been shown to modulate the anti-inflammatory potential of endothelial cells and, by controlling the amount of cellular cholesterol, to interfere with the signaling through plasma membrane lipid rafts in immune cells. These findings, coupled to observations acquired from subjects carrying mutations in genes related to HDL system, have helped to elucidate the contribution of HDL beyond cholesterol efflux thus posing HDL-based therapies as a compelling interventional approach to limit the inflammatory burden of immune-inflammatory diseases.

Psoriasis: Comorbidities

Psoriasis has long been known as a disease with many complications, but was attributed to diet and obesity. However, in recent years, psoriasis itself has been recognized as a series of systemic inflammatory diseases, and that the cytokines involved can induce a variety of other diseases. Individuals with psoriasis were also found to have higher incidences of cerebral and cardiovascular diseases and a younger age at death compared to healthy individuals. However, no clear guidelines have been defined regarding how much vascular lesion testing should be performed in patients with psoriasis. In this report, I attempt to unravel the objective data on psoriasis and its complications from various reviews and reports, and introduce the impact of biologics, which are currently the main treatment for psoriasis, on cardiac vascular disease.

Chronic Systemic Inflammatory Skin Disease as a Risk Factor for Cardiovascular Disease

Chronic systemic skin disease and cardiovascular disease are multisystem disorders which have been associated with each other for centuries. Recent research has strengthened this association, particularly in systemic inflammatory disease. Here we explore the current literature on psoriasis, hidradenitis suppurativa, lupus erythematosus, acanthosis nigricans, atopic dermatitis, and bullous pemphigoid. Psoriasis is a chronic inflammatory disorder that has been labeled as a risk-modifier for hyperlipidemia and coronary artery disease by the American College of Cardiology ACC lipid guidelines. Cardiovascular disease is also found at a significantly higher rate in patients with hidradenitis suppurativa and lupus erythematosus. Some associations have even been noted between cardiovascular disease and acanthosis nigricans, atopic dermatitis, and bullous pemphigoid. While many of these associations have been attributed to a shared underlying disease process such as chronic systemic inflammation and shared underlying risk factors, these dermatologic manifestations can help to identify patients at higher risk for cardiovascular disease.

High-Density Lipoprotein (HDL) in Allergy and Skin Diseases: Focus on Immunomodulating Functions

From an evolutionary perspective, lipoproteins are not only lipid transporters, but they also have important functions in many aspects of immunity. High-density lipoprotein (HDL) particles are the most abundant lipoproteins and the most heterogeneous in terms of their composition, structure, and biological functions. Despite strong evidence that HDL potently influences the activity of several immune cells, the role of HDL in allergies and skin diseases is poorly understood. Alterations in HDL-cholesterol levels have been observed in allergic asthma, allergic rhinitis, atopic dermatitis (eczema), psoriasis, urticaria, and angioedema. HDL-associated apolipoprotein (apo) A-I, apoA-IV, and apoC-III, and lyso-phosphatidylcholines potently suppress immune cell effector responses. Interestingly, recent studies provided evidence that allergies and skin diseases significantly affect HDL composition, metabolism, and function, which, in turn, could have a significant impact on disease progression, but may also affect the risk of cardiovascular disease and infections. Interestingly, not only a loss in function, but also, sometimes, a gain in function of certain HDL properties is observed. The objective of this review article is to summarize the newly identified changes in the metabolism, composition, and function of HDL in allergies and skin diseases. We aim to highlight the possible pathophysiological consequences with a focus on HDL-mediated immunomodulatory activities.

GlycA measured by NMR spectroscopy is associated with disease activity and cardiovascular disease risk in chronic inflammatory diseases

GlycA is a biomarker of systemic inflammation, quantifying both the protein concentrations and glycosylation states of several acute phase proteins. GlycA has been shown to be associated with both subclinical atherosclerosis and with cardiovascular disease (CVD). GlycA levels are higher in acute and chronic inflammation. During ongoing systemic inflammatory processes, GlycA specific acute phase reactants and proteins undergo circulating concentration and glycosylation pattern changes, and these alterations are reflected in the GlycA NMR signal. Additionally, levels associate with ongoing disease severity in individuals with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and psoriasis thus capturing active inflammation. Furthermore, in these disease states, GlycA is associated with cardiovascular disease (CVD) independent of traditional risk factors including C-reactive protein (CRP). Finally, GlycA levels decrease with exercise, weight loss, and systemic anti-inflammatory agents. Therefore, GlycA appears to be a promising new composite biomarker of active systemic inflammation including assessing CVD risk in patients with inflammatory diseases.

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Patients with chronic inflammatory disorders are at increased risk for cardiovascular diseasenot captured by traditional risk factors.

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GlycA is a biomarker of acute phase reactants by NMR spectroscopy which captures disease activity in human inflammatory diseases.

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GlycA associates with cardiovascular disease and offers a tool to monitor primary disease activity and assess CVD risk in inflammatory diseases.

Psoriasis and Cardiovascular Risk: A Comprehensive Review

Psoriasis is a systemic inflammatory disorder that involves complex pathogenic interactions between the innate and adaptive immune systems. Individuals with psoriasis have an increased risk of developing other chronic health diseases such cardiovascular disorders. The high incidence of cardiovascular events in the population with psoriasis could be explained by several mechanisms. The high prevalence of traditional cardiovascular risk factors and metabolic abnormalities contributes to the high cardiovascular burden in patients with psoriasis. Likewise, the presence of systemic inflammation in combination with metabolic abnormalities may act in a synergistic manner to increase cardiovascular risk in these patients. This review focused on epidemiologic and clinical evidence linking psoriasis to cardiovascular risk factors and cardiovascular disease. We described the possible pathophysiological mechanisms that justify this association and analyzed the best way to stratify the cardiovascular risk in patients with psoriasis. We also described the usefulness of the therapies frequently used in cardiovascular prevention and analyzed the impact of the specific psoriasis medication on cardiovascular risk factors or major atherosclerotic events. Knowledge of the application of different cardiovascular prevention strategies could mean an advantage in performing the difficult task of estimating cardiovascular risk and treating cardiovascular risk factors in this particular group of patients.

The Oxidative Stress-Induced miR-200c Is Upregulated in Psoriasis and Correlates with Disease Severity and Determinants of Cardiovascular Risk

Psoriasis is a chronic inflammatory skin disease associated with reactive oxygen species (ROS) increase and a higher risk of cardiovascular (CV) events. We previously showed that the miR-200 family (miR-200s) is induced by ROS, miR-200c being the most upregulated member responsible for apoptosis, senescence, ROS increase, and nitric oxide decrease, finally causing endothelial dysfunction. Moreover, circulating miR-200c increases in familial hypercholesterolemic children and in plaques and plasma of atherosclerotic patients, two pathologies associated with increased ROS. Given miR-200s' role in endothelial dysfunction, ROS, and inflammation, we hypothesized that miR-200s were modulated in lesional skin (LS) and plasma of psoriatic patients (Pso) and that their levels correlated with some CV risk determinants at a subclinical level. All Pso had severe psoriasis, i.e., Psoriasis Area and Severity Index (PASI) > 10, and one of the following: at least two systemic psoriasis treatments, age at onset < 40 years, and disease duration > 10 years. RNA was extracted from plasma (Pso, N = 29; Ctrl, N = 29) and from nonlesional skin (NLS) and LS of 6 Pso and 6 healthy subject skin (HS) biopsies. miR-200 levels were assayed by quantitative RT-PCR. We found that all miR-200s were increased in LS vs. NLS and miR-200c was the most expressed and upregulated in LS vs. HS. In addition, circulating miR-200c and miR-200a were upregulated in Pso vs. Ctrl. Further, miR-200c positively correlated with PASI, disease duration, left ventricular (LV) mass, LV relative wall thickness (RWT), and E/e', a marker of diastolic dysfunction. Multiple regression analysis indicates a direct association between miR-200c and both RWT and LV mass. Circulating miR-200a correlated positively only with LV mass and arterial pressure augmentation index, a measure of stiffness, although the correlations were nearly significant (P = 0.06). In conclusion, miR-200c is upregulated in LS and plasma of Pso, suggesting its role in ROS increase and inflammation associated with CV risk in psoriasis.

Management of psoriasis as a systemic disease: what is the evidence?

Background

Psoriasis is a chronic, systemic immune‐mediated disease characterized by development of erythematous, indurated, scaly, pruritic and often painful skin plaques. Psoriasis pathogenesis is driven by proinflammatory cytokines and psoriasis is associated with increased risk for comorbidities, including, but not limited to, psoriatic arthritis, cardiovascular disease, diabetes mellitus, obesity, inflammatory bowel disease and nonalcoholic fatty liver disease compared with the general population.

Objectives

To explore the pathophysiological relationship between psoriasis and its common comorbidities and discuss the need for new treatment paradigms that include strategies to reduce systemic inflammation in patients with moderate‐to‐severe psoriasis.

Methods

This narrative review summarizes the published evidence related to the ability of biological therapies to ameliorate the consequences of systemic inflammation in patients with psoriasis.

Results

Current evidence suggests that preventing damage associated with inflammation, and preventing development of future inflammatory damage and comorbidities, may be a potentially achievable treatment goal for many patients with moderate‐to‐severe plaque psoriasis when biological therapies are utilized early in the disease. Encouraging data from recent studies suggest that the loftier goal of reversing existing inflammatory damage and improving signs and symptoms of inflammatory comorbidities could also possibly be attainable.

Conclusions

Results from ongoing prospective studies regarding the effects of biologics on markers of systemic inflammation in patients with psoriasis will strengthen the clinical evidence base that can be used to inform treatment decisions for patients with moderate‐to‐severe psoriasis.

What's already known about this topic?

Psoriasis is a systemic inflammatory disease and treatments are needed to optimize patient outcomes.

What does this study add?

This review discusses new psoriasis treatment paradigms that may potentially reduce effects of systemic inflammation.

Evidence demonstrating that biological treatment may prevent or reverse inflammatory damage associated with psoriasis comorbidities is reviewed.

Linked Comment:https://doi.org/10.1111/bjd.18456

Coronary Artery Disease Assessed by Computed Tomography in Patients with Psoriasis: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with psoriasis have an increased risk of coronary artery disease (CAD) but data on coronary calcium score (CCS) and cardiac computed tomography angiography (CCTA) are inconsistent.

OBJECTIVES

The present study quantitatively summarizes the literature data on the prevalence and burden of CAD in patients with psoriasis compared with controls using CCS and CCTA.

METHODS

A systematic review and meta-analysis was conducted. The search included all studies examining CAD prevalence and burden detected by CCS with or without CCTA in patients with psoriasis without prior CAD compared with controls, between the year 2000 and May 30, 2018.

RESULTS

Fourteen eligible studies provided data on 1,427 patients with psoriasis and 9,670 controls. Pooled data provided the estimated risk ratio (RR) of CAD and weighted mean differences of CCS in psoriasis patients versus controls. Meta-analysis of the prevalence and burden of CCS showed that patients with psoriasis had an increased risk of CAD (RR 1.14, 95% CI 1.04-1.26; p = 0.004), and for more severe CAD (CCS >100) the risk was further increased (RR 1.71, 95% CI 1.28-2.30; p < 0.001) compared with controls. Weighted mean difference for CCS was significantly higher in patients with psoriasis (12.74, 95% CI 10.70-14.78; p < 0.001). The risk of high-risk coronary plaques identified by CCTA was also significantly higher in psoriasis patients compared with controls (RR 1.77, 95% CI 1.37-2.28; p < 0.001).

CONCLUSIONS

Patients with psoriasis have a higher prevalence of subclinical CAD, a higher burden of the disease, and more high-risk coronary plaques compared with controls without psoriasis.

A clinical model for identifying an inflammatory phenotype in mood disorders

Increasingly, clinical research has found inflammatory correlates of psychiatric disorders, particularly mood symptomatology. Biological measures may provide greater precision in many cases and may capture clinically-relevant inflammatory signposts, such as central obesity risk, inflammation-associated co-morbid medical conditions, or proinflammatory lifestyle choices. In order to expand understanding of the role of inflammation in mood disorders, we propose a more inclusive clinical model for capturing an inflammatory phenotype of depression by identifying clinically-relevant inflammatory phenotypes grounded in biology. Our model includes chronic conditions and lifestyle behaviors associated with clinically elevated inflammation in mood disorders. Elements of this "inflamed depression" model include: obesity, low HDL concentrations, elevated triglyceride concentrations, chronically elevated blood pressure, clinical diagnosis of hypothyroidism, migraines, rheumatoid arthritis, adult onset diabetes, inflammatory bowel diseases, inflammatory skin conditions, and lifestyle factors including smoking cigarettes and chronic stress.

Psoriasis and cardiovascular disease: the elusive link

Psoriasis, an autoimmune inflammatory disease, with its most common coexisting condition, psoriatic arthritis, seem to be more than just a local skin or joint disease, as evidence has accumulated over the years that it is associated with cardiovascular disease (CVD), which may confer an increased cardiovascular event and death rate. The data come mostly from observational studies and meta-analyses and indicate a potential pathogenetic link between these two systemic diseases, however definite proof of this detrimental relationship awaits further prospective studies. Newer anti-psoriatic biologic therapies seem to confer a cardiovascular benefit, but this needs future randomized controlled studies to confirm. All these intricate issues of a potential link between psoriasis and CVD are discussed and elaborated in this overview, in an attempt to shed further light on pivotal aspects of the association between psoriasis and CVD.

Interleukin 17, inflammation, and cardiovascular risk in patients with psoriasis

In addition to being recognized as a chronic inflammatory disease that manifests in the skin, psoriasis is increasingly understood to be a systemic disease that causes immune dysregulation throughout the body. The systemic nature of psoriasis is evidenced by the higher burden of comorbidities and shorter life expectancies of patients with psoriasis, particularly those with early-onset and severe disease. Notably, psoriasis is associated with an increased risk for cardiovascular disease, which is the most common cause of morbidity and mortality in patients with psoriasis. In this review, we examine the association between psoriasis and cardiovascular disease and specifically focus on the role of interleukin 17-mediated inflammation as a potential mechanistic link between psoriasis and cardiovascular disease. Moreover, we describe potential treatment approaches to reduce the burden of cardiovascular disease in patients with psoriasis and discuss the clinical importance of the association of these 2 diseases with respect to patient management and education.

Cardiometabolic Comorbidities in Psoriasis and Psoriatic Arthritis

There is solid epidemiologic evidence linking psoriasis and psoriatic arthritis (PsA) to cardiovascular risk factors and an increased risk of developing cardiovascular disease. Chronic inflammation, with shared pathways and cytokines common to metabolic syndrome, atherosclerosis and psoriasis, might provide the basis for the cardiovascular and metabolic comorbidities of psoriasis and PsA. The purpose of this manuscript is to review recent evidence about the epidemiology and underlying mechanisms of cardiovascular risk factors and cardiovascular disease in patients with psoriasis and/or PsA; the use of analytical determinations, physiologic measures and imaging techniques as surrogate biomarkers of atherosclerosis, endothelial dysfunction and cardiovascular disease in these patients; and the epidemiological and clinical data, including results of clinical trials, supporting a cardioprotective role of anti-inflammatory and disease-modifying treatment in psoriasis and PsA.

Psoriasis and Cardiovascular Comorbidities: Focusing on Severe Vascular Events, Cardiovascular Risk Factors and Implications for Treatment

Psoriasis is a common and chronic inflammatory disease of the skin. It may impair the physical and psychosocial function of patients and lead to decreased quality of life. Traditionally, psoriasis has been regarded as a disease affecting only the skin and joints. More recently, studies have shown that psoriasis is a systemic inflammatory disorder which can be associated with various comorbidities. In particular, psoriasis is associated with an increased risk of developing severe vascular events such as myocardial infarction and stroke. In addition, the prevalence rates of cardiovascular risk factors are increased, including hypertension, diabetes mellitus, dyslipidemia, obesity, and metabolic syndrome. Consequently, mortality rates have been found to be increased and life expectancy decreased in patients with psoriasis, as compared to the general population. Various studies have also shown that systemic treatments for psoriasis, including methotrexate and tumor necrosis factor-α inhibitors, may significantly decrease cardiovascular risk. Mechanistically, the presence of common inflammatory pathways, secretion of adipokines, insulin resistance, angiogenesis, oxidative stress, microparticles, and hypercoagulability may explain the association between psoriasis and cardiometabolic disorders. In this article, we review the evidence regarding the association between psoriasis and cardiovascular comorbidities, focusing on severe vascular events, cardiovascular risk factors and implications for treatment.

Visceral Adiposity in Psoriasis is Associated With Vascular Inflammation by 18F-Fluorodeoxyglucose Positron-Emission Tomography/Computed Tomography Beyond Cardiometabolic Disease Risk Factors in an Observational Cohort Study

OBJECTIVES

The authors sought to examine the relationship between visceral adipose tissue (VAT) and vascular inflammation (VI) by ¹⁸F-Fluorodeoxyglucose (¹⁸F-FDG) positron-emission tomography (PET)/computed tomography (CT) in psoriasis (PSO). Furthermore, we evaluated whether treatment of PSO modulated VAT and VI.

BACKGROUND

PSO, a chronic inflammatory skin disease, is associated with VI by ¹⁸F-FDG PET/CT and increased cardiometabolic risk including adipose tissue dysregulation. Recently, VI was associated with future cardiovascular events; however, the relationship of visceral and subcutaneous adiposity with VI in PSO has yet to be evaluated.

METHODS

Consecutive PSO patients (N = 77) underwent ¹⁸F-FDG PET/CT scans to measure VI and abdominal adiposity. A subset of PSO patients with severe skin disease was scanned at 1 year following PSO treatment (N = 13).

RESULTS

The cohort was middle aged (51.8 ± 12.6 years), predominantly male (n = 44, 57%), had low cardiovascular risk by Framingham 10-year risk (median 4 years [interquartile range (IQR): 2 to 7 years]), and mild-to-moderate skin disease (5.2 [IQR: 3.0 to 8.5]). PSO disease severity associated with VAT (β = 0.33; p = 0.004) beyond SAT (β = 0.30; p = 0.005). VAT (β = 0.55; p < 0.001), but not SAT (β = 0.15; p = 0.11), associated with VI beyond cardiovascular risk factors. We followed a subset of severe PSO patients treated aggressively for PSO and observed improvement in PSO severity and VAT, which was associated with an improvement in VI at 1 year beyond cardiovascular risk factors (β = 0.53; p = 0.049).

CONCLUSIONS

Volume-based CT measurement of VAT may capture metabolic risk associated with VI compared to subcutaneous adipose tissue in PSO. PSO treatment associated with a decrease in VAT as well as decrease in VI suggesting VAT as a relevant biomarker related to VI in PSO.

Psoriasis as a human model of disease to study inflammatory atherogenesis

Inflammation is known to play a significant role in the process of atherogenesis and cardiovascular disease (CVD). Indeed, patients with chronic inflammatory diseases are at increased risk for cardiovascular events. However, the mechanisms linking chronic inflammation and CVD remain poorly understood. Psoriasis, a chronic inflammatory skin disease associated with a greater risk of early cardiovascular events, provides a suitable human model to study the pathophysiology of inflammatory atherogenesis in humans. Additionally, cytokines such as TNF-α, IL-17A, and other immune pathways are the common links between the pathogenesis of psoriasis and atherosclerosis, and hence the approved treatments for psoriasis, which include selective cytokine inhibition (e.g., anti-TNF, anti-IL-17A, and anti-IL-12/23) and immune modulation (e.g., methotrexate or cyclosporine), provide an opportunity to examine the effect of modulating these pathways on atherogenesis. We have been using this human model in a large, prospective cohort study, and this review summarizes our approach and results of using this human model to study inflammatory atherogenesis. Specifically, we review simultaneous multimodal imaging of several vascular beds using ¹⁸fludeoxyglucose positron emission tomography/computed tomography, ¹⁸fludeoxyglucose positron emission tomography/MRI, and coronary computed tomography angiography as well as cardiovascular biomarkers to better understand how modulation of inflammation may impact vascular diseases.

Association between interleukin-6 and the risk of cardiac events measured by coronary computed tomography angiography

Interleukin-6 (IL-6) has been found to be a predictor of heart attack. We aimed to investigate the relationship of risk factor IL-6 with extent and severity of the coronary artery disease (CAD) evaluated using coronary computed tomography angiography (CCTA). A total of 303 participants without history of CAD undergoing CCTA were enrolled. Using the model of risk-adjusted Cox proportional-hazards, the association of IL-6 level with major adverse cardiac events (MACE) was detected. The participants were assigned into three study groups based on serum IL-6 level. Compared with those in the lowest tertile, patients with highest IL-6 level displayed higher atherosclerotic burden such as plaque extent defined as prevalence of obstructive CAD and segments with any plaque. After a median 3.0 year follow-up period, we also found that patients with highest IL-6 level experienced higher MACE risk and all-cause death compared with those from the lowest tertile. Among participants without CAD history who underwent CCTA, patients with high level of IL-6 had increased burden of atherosclerosis and higher MACE risk compared to participants of low level of IL-6.

Calcium Signaling in Interstitial Cells: Focus on Telocytes

In this review, we describe the current knowledge on calcium signaling pathways in interstitial cells with a special focus on interstitial cells of Cajal (ICCs), interstitial Cajal-like cells (ICLCs), and telocytes. In detail, we present the generation of Ca²⁺ oscillations, the inositol triphosphate (IP₃)/Ca²⁺ signaling pathway and modulation exerted by cytokines and vasoactive agents on calcium signaling in interstitial cells. We discuss the physiology and alterations of calcium signaling in interstitial cells, and in particular in telocytes. We describe the physiological contribution of calcium signaling in interstitial cells to the pacemaking activity (e.g., intestinal, urinary, uterine or vascular pacemaking activity) and to the reproductive function. We also present the pathological contribution of calcium signaling in interstitial cells to the aortic valve calcification or intestinal inflammation. Moreover, we summarize the current knowledge of the role played by calcium signaling in telocytes in the uterine, cardiac and urinary physiology, and also in various pathologies, including immune response, uterine and cardiac pathologies.

GlycA Is a Novel Biomarker of Inflammation and Subclinical Cardiovascular Disease in Psoriasis

RATIONALE

GlycA, an emerging inflammatory biomarker, predicted cardiovascular events in population-based studies. Psoriasis, an inflammatory disease associated with increased cardiovascular risk, provides a model to study inflammatory biomarkers in cardiovascular disease (CVD). Whether GlycA associates with psoriasis and how it predicts subclinical CVD beyond high-sensitivity C-reactive protein in psoriasis is unknown.

OBJECTIVE

To investigate the relationships between GlycA and psoriasis and between GlycA and subclinical CVD.

METHODS AND RESULTS

Patients with psoriasis and controls (n=412) participated in a 2-stage study. We measured GlycA by nuclear magnetic resonance spectroscopy. National Institutes of Health (NIH) participants underwent 18-F Fluorodeoxyglucose Positron Emission Tomography Computed Tomography (18-FDG PET/CT) scans to assess vascular inflammation (VI) and coronary computed tomographic angiography to quantify coronary artery disease burden. Psoriasis cohorts were young (mean age=47.9), with low cardiovascular risk and moderate skin disease. high-sensitivity C-reactive protein and GlycA were increased in psoriasis compared with controls (GlycA: [PENN: 408.8±75.4 versus 289.4±60.2, P<0.0001; NIH: 415.8±63.2 versus 346.2±46, P<0.0001]) and demonstrated a dose-response with psoriasis severity. In stage 2, VI (β=0.36, P<0.001) and coronary artery disease (β=0.29, P=0.004) associated with GlycA beyond CV risk factors in psoriasis. In receiver operating characteristic analysis, GlycA added value in predicting VI (P=0.01) and coronary artery disease (P<0.01). Finally, initiating anti-tumor necrosis factor therapy (n=16) reduced psoriasis severity (P<0.001), GlycA (463.7±92.5 versus 370.1±78.5, P<0.001) and VI (1.93±0.36 versus 1.76±0.19, P<0.001), whereas GlycA remained associated with VI (β=0.56, P<0.001) post treatment.

CONCLUSIONS

GlycA associated with psoriasis severity and subclinical CVD beyond traditional CV risk and high-sensitivity C-reactive protein. Moreover, psoriasis treatment reduced GlycA and VI. These findings support the potential use of GlycA in subclinical CVD risk assessment in psoriasis and potentially other inflammatory diseases.

Psoriasis, non-alcoholic fatty liver disease, and cardiovascular disease: Three different diseases on a unique background

Psoriasis is a chronic inflammatory immune-mediated skin disease, frequently associated with systemic comorbidities. According to recent data, patients with psoriasis show a greater prevalence of metabolic syndrome, which confers a higher cardiovascular risk. The link between these pathological conditions appears to be a chronic low-grade inflammatory status. The aim of this review is to focus on the multiple epidemiological and physio-pathogenetic aspects linking non-alcoholic fatty liver disease, psoriasis, and cardiovascular disease.

Decreased brain-derived neurotrophic factor plasma levels in psoriasis patients

Brain-derived neurotrophic factor (BDNF) is associated with neuroplasticity and synaptic strength, and is decreased in conditions associated with chronic stress. Nevertheless, BDNF has not yet been investigated in psoriasis, a chronic inflammatory systemic disease that is exacerbated by stress. Therefore, our aim was to determine BDNF plasma levels in psoriasis patients and healthy controls. Adult patients (n=94) presenting with psoriasis for at least 1 year were enrolled, and age- and gender-matched with healthy controls (n=307) from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Participants had neither a previous history of coronary artery disease nor current episode of major depression. BDNF plasma levels were determined using the Promega ELISA kit. A general linear model was used to compare BDNF levels in psoriasis patients and controls, with age, gender, systolic blood pressure, serum fasting glucose, blood lipid levels, triglycerides, smoking status, and body mass index examined. After adjusting for clinical and demographic variables, significantly decreased BNDF plasma levels were observed in psoriasis patients (P=0.01) (estimated marginal means of 3922 pg/mL; 95%CI=2660-5135) compared with controls (5788 pg/mL; 95%CI=5185-6442). Similar BDNF levels were found in both mild and severe cases of psoriasis. Our finding, that BDNF is decreased in psoriasis, supports the concept of a brain-skin connection in psoriasis. Further studies should determine if BDNF is increased after specific psoriasis treatments, and associated with different disease stages.