Echocardiographic findings in subjects with psoriatic arthropathy

Inflammatory dilated cardiomyopathy associated with psoriasis: a case report

BACKGROUND

Psoriasis is a chronic inflammatory skin disease with a genetic basis. Psoriasis is accepted as a systemic, immune-mediated disease. Hypertension, obesity, metabolic disorders including diabetes mellitus and hyperlipidemia, and psychiatric disorders are more prevalent among children with psoriasis compared to children without psoriasis. In this study, we report a case of dramatic response of inflammatory cardiomyopathy to anti-inflammatory treatment of psoriasis; which might reveal similar pathogenesis basis of these two diseases.

CASE PRESENTATION

A 9-year-old Caucasian boy presenting with signs and symptoms of heart failure refractory to conventional therapies was admitted to our pediatric cardiology service. As the patient also had psoriasis, and considering the fact that there might be an association between the two conditions, immunosuppressive drugs were administered, which led to a dramatic improvement in heart function.

CONCLUSIONS

The results of this study add to evidence linking psoriasis with inflammatory dilated cardiomyopathy. Clinicians, particularly cardiologists, must pay special attention to the cardiac complications of systemic diseases.

Incidence of and Risk Factors for Heart Failure in Patients with Psoriatic Disease - A Cohort Study

OBJECTIVES

To assess the incidence and risk factors for heart failure (HF) in patients with psoriatic disease (PsD) and describe their electrocardiographic and echocardiographic findings.

METHODS

A cohort analysis was conducted involving patients with PsD followed prospectively from 1978 to 2018. Participants were assessed according to a standard protocol every 6 to 12-months. The primary outcome was the time to first event of HF, further classified into ischemic and non-ischemic HF (secondary outcomes). The association between cardiovascular risk factors, measures of disease activity and HF events was assessed using Cox proportional hazards regression. Electrocardiographic and echocardiographic findings associated with HF events were described.

RESULTS

A total of 1994 patients with PsD were analyzed with 64 incident HF events (38 ischemic, 26 non-ischemic). The incidence rate of first HF event was 2.85 per 1000 patient years. In all events, most common electrocardiographic findings were atrial fibrillation (22%) and bundle branch blocks (29%). Echocardiogram revealed 37% reduced ejection fraction and 63% preserved ejection fraction. In multivariable analysis, independent risk factors for all HF events were ischemic heart disease, adjusted mean (AM)-tender joint count, AM-swollen joint count, AM-erythrocyte sedimentation rate, AM-C-reactive protein, and physical function (by health assessment questionnaire) (all p<0.05). Minimal disease activity state was protective for all HF (p<0.05).

CONCLUSIONS

Increased risk of HF is associated with a combination of known cardiovascular risk factors and measures of disease activity, particularly in non-ischemic HF. The effect of inflammation on HF may be partially independent of atherosclerotic disease.

A Study of Intima Media Thickness and Their Cardiovascular Risk Factors in Patients with Psoriatic Arthritis

Introduction: Psoriatic Arthritis (PsA) is an inflammatory arthritis associated with Psoriasis. Its recognition as an inflammatory disease distinct from Rheumatoid Arthritis has put forward for consideration several questions regarding its specific CVS mortality and morbidity (9, 11, 16, 26). Carotid intima media thickness is a useful surrogate and sensitive marker to determine atherosclerosis even in its subclinical stages (6, 14, 22, 27, 32). Objective: Prevalence of carotid intima media thickness in patients with Psoriatic arthritis is unknown in Asian population. We aim to identify the presence of subclinical atherosclerosis in patients with psoriatic arthritis and disease activity association and its predictors in a series of patients with PsA attended to the rheumatology clinic, tertiary hospitals. Methods: A total of 63 patients with PsA who fulfilled the CASPAR criteria were recruited from UKM Medical Centre and Hospital Putrajaya. Common carotid intima media thickness (IMT) was measured in both right and left carotid artery by using high resolution B-mode ultrasound. This was a cross sectional study first done in Malaysia for PsA patients. Results: The positive IMT (IMT >1.00 mm) among PsA was observed in 10 out of 63 patients (15.9 %) regardless of background cardiovascular risk. The mean±SD of IMT was 0.725 ±0.260 mm for this study. Variables significantly associated with positive IMT (p<0.05) included age at the time of study (p=0.005), waist circumference (p=0.001), Hypertension (p=0.007), Diabetes (p=0.002) and Metabolic syndrome (p=0.001) and not associated with gender, ethnicity, duration of PsA disease, pattern of PsA, disease activity and severity. Above all, only age had positive IMT independent predictor (p=0.032), with OR 1.116; 95 % CI (1.010–1.234). Conclusions: There was a significant association between CVS risk and positive Intima Media Thickness in Psoriatic Arthritis patients. Otherwise, there was no association in disease activity, disease severity and DMARDS therapy with positive Intima Media Thickness in Psoriatic Arthritis patients. The study was approved by Research and Ethics Committee of the faculty of medicine, Universiti Kebangsaan Malaysia with project code FF-114-2008 and by Community Research Center (CRC) of National Institutes of Health (NIH) for the case study in Hospital Putrajaya with the project code NMRR-08- 970-2125.

Echocardiographic and Clinical Abnormalities in Patients with Psoriasis

We investigated the incidence and severity of echocardiographic and clinical abnormalities in patients with psoriasis and their relationship to the severity, duration and type of psoriasis and other related factors. A total of 216 psoriasis patients and 216 control subjects were included in this study. Left and right heart dimensions, wall thicknesses, wall motion abnormalities, valvular disturbances, and systolic and diastolic functions were examined using two-dimensional and Doppler echocardiographic techniques. Left ventricular hypertrophy, left ventricular diastolic dysfunction, left ventricular wall motion abnormalities and valvular pathologies, especially mitral and tricuspid valve prolapse, were significantly more frequent in patients with psoriasis. Systolic and diastolic blood pressures were significantly higher in psoriasis patients. Significant correlations were found between: (i) psoriasis vulgaris and tricuspid valve prolapse; (ii) palmo-plantar psoriasis and valvular pathologies; and (iii) disease duration and left ventricular diastolic dysfunction and systolic and diastolic blood pressures. Physicians should be aware that cardiovascular abnormalities are common in patients with psoriasis.

Influence of psoriasis on circulatory system function assessed in echocardiography

Psoriasis vulgaris is a chronic disease with a multifactorial pathogenesis. It affects about 2–4 % of the population all over the world. In course of psoriatic arthritis, joints’ damages are observed. In patients with psoriasis vulgaris and psoriatic arthritis, there is increased morbidity and mortality caused by cardiovascular diseases observed. The aim of the study is to analyze the echocardiography of patients with psoriasis vulgaris and psoriatic arthritis on the basis of the literature available in PubMed database. Abnormalities found in echocardiography of patients with psoriasis include valvular defects (40.7 % of the patients), left ventricle diastolic dysfunction (27.8 %), and left ventricle hypertrophy (11.1 %). Left ventricle’s systolic disorders, increased aorta stiffness index and increased pulmonary artery blood pressure were also observed in this group of patients.

Assessment of left ventricular dyssynchrony in patients with psoriasis

BACKGROUND

Psoriasis is an inflammatory disorder, which has been reported to be associated with cardiovascular (CV) risks. Although increased CV risks in psoriasis are well established, there are no data about changes of contraction synchrony in psoriasis. Therefore, we aimed to study the left ventricular (LV) contraction synchrony in patients with psoriasis with narrow QRS and normal ejection fraction.

METHODS

Fifty patients with psoriasis and 50 age- and sex-matched control subjects were included in the study. LV dyssynchrony was investigated by color-coded tissue Doppler imaging.

RESULTS

In the psoriasis group, the mean high-sensitive C-reactive protein values were significantly higher compared with the controls. Peak A velocity, deceleration time, isovolumetric relaxation time, and E/E' values were higher in the psoriasis group; however, E/A ratio and average Em were higher in the control group. LV systolic dyssynchrony parameters [including standard deviation of Ts of the 12 LV segments (Ts-SD-12), maximal difference in Ts between any two of the 12 LV segments, standard deviation of Ts of the six basal LV segments, and maximal difference in Ts between any two of the six basal LV segments] were found to be higher in the psoriasis group. The patients with ventricular dyssynchrony (a Ts-SD-12 >34.4 ms) were higher in the psoriasis group than the control group (34% vs. 6%, P < 0.01).

CONCLUSION

In patients with psoriasis with normal ejection fractions and narrow QRS, LV systolic dyssynchrony is an early manifestation of heart involvement and may coexist with diastolic dysfunction.

Increased risk of atrial and ventricular arrhythmia in long-lasting psoriasis patients

BACKGROUND

Several reports have demonstrated an association between psoriasis and cardiovascular diseases. P wave dispersion (PWD) is the most important electrocardiographic (ECG) markers used to evaluate the risk of atrial arrhythmias. QT dispersion (QTD) can be used to assess homogeneity of cardiac repolarization and may be a risk for ventricular arrhythmias.

AIM

To search PWD and QTD in patients with psoriasis.

METHODS

Ninety-four outpatient psoriasis patients and 51 healthy people were evaluated by physical examination, 12-lead ECG, and transthoracic echocardiography. Severity of the psoriasis was evaluated by psoriasis area and severity index (PASI).

RESULTS

Mean disease duration was 129.4 ± 83.9 (range, 3-360) months and PASI ranged from 0 to 34.0 (mean ± SD; 7.6 ± 6.7). Compared to control group, psoriatic patients had significantly shorter Pmax and Pmin durations, longer QTcmax, and greater PWD and QTcD. Transmitral deceleration time (DT) and isovolumetric relaxation time (IVRT) were significantly longer among psoriasis patients. QTcD and PWD were significantly correlated with disease duration (r = 0.693, P < 0.001, and r = 0.368, P = 0.003, resp.).

CONCLUSIONS

In this study, we found that both PWD and QTcD are increased in psoriasis patients compared to healthy subjects. In addition, they had longer DT and IVRT.

Impaired coronary microvascular function and its association with disease duration and inflammation in patients with psoriasis

SUBJECTS

Thirty-six patients with psoriasis and 56 healthy volunteers were included in this study.

METHODS

Echocardiographic examination included transmitral peak flow velocities of the early phase (E) and late phase (A) of the mitral inflow, left ventricular myocardial velocity measurements, and coronary flow reserve (CFR) measurement.

RESULTS

Baseline coronary diastolic peak flow velocity (DPFV) of left anterior descending artery (LAD) was significantly higher in the psoriasis group. However, hyperemic DPFV was slightly lower and CFR (2.19 ± 0.39 vs. 2.60 ± 0.31, P < 0.0001) was significantly lower in the psoriasis group than in the control group. CFR was significantly and inversely correlated with disease duration, Psoriasis Area and Severity Index (PASI) score, and hsCRP.

CONCLUSION

CFR is decreased in patients with psoriasis, and it correlates to disease duration, PASI score, and inflammation.

High Prevalence of Subclinical Left Ventricular Dysfunction in Patients with Psoriatic Arthritis

Objective.

Endothelial dysfunction and early atherosclerosis have been found in patients with psoriatic arthritis (PsA) without cardiovascular disease (CVD) risk factors. Few studies have investigated whether there is any early impairment of myocardial function. The aims of our study were to determine the prevalence of subclinical left ventricular (LV) dysfunction in PsA patients and the disease-related risk factors.

Methods.

Ninety-four PsA patients without clinical evidence of CVD and 63 healthy subjects were enrolled. All underwent conventional echocardiography and tissue Doppler imaging.

Results.

Sixty-one (65%) patients with PsA had evidence of subclinical LV dysfunction as defined by mean myocardial peak systolic velocity (Sm) of basal 6 segments < 4.4 cm/s, lateral E’ < 11.5 cm/s, and/or lateral E/E’ > 10. Thirty-six (38%) patients had only diastolic dysfunction, 4 (4%) had only systolic dysfunction, and 21 (22%) had both systolic and diastolic dysfunction. PsA patients with subclinical LV dysfunction were older, had a higher age at diagnosis of PsA and of psoriasis, a longer disease duration, a higher prevalence of hypertension and hyperlipidemia, higher levels of serum creatinine, and more antihypertensive treatment than those with normal LV function. Multivariate regression showed that age at diagnosis of PsA > 40 years (OR 3.388, 95% CI 1.065–10.777, p = 0.039) and hypertension (OR 4.732, 95% CI 1.345–16.639, p = 0.015) were independent predictors of subclinical LV dysfunction.

Conclusion.

PsA patients without established CVD disease and in the absence of traditional CV risk factors have a high prevalence of subclinical LV dysfunction.

Psoriasis and cardiovascular disease

Current epidemiological data support the association between psoriasis and cardiovascular (CV) risk, in apparent correlation with psoriasis severity. Although less unanimously, evidence of an increased prevalence of CV diseases among psoriasis patients has been reported, including ischemic heart disease, cerebrovascular, peripheral vascular and heart structural disorders. In particular, various studies showed a correlation between psoriasis and major CV events (i.e., myocardial infarction, stroke), while others investigated subclinical changes of blood vessels, such as intima-media thickness increase, arterial stiffness and coronary artery calcification. A series of different mechanisms, like traditional CV risk or iatrogenic risk factors, inflammation, hemostasis dysregulation, hyperhomocysteinemia, and shared genetic susceptibility, are thought to underlie this epidemiological association. Among these elements, inflammation and its related cytokine milieu, including Th1-mediated response and Th17/Treg imbalance, C reactive protein and the newly implicated osteopontin are considered to play a primary role, even if yet to be fully understood.

Psoriatic arthritis in Asia

Geographic or ethnic differences in the occurrence of disease often provide insights into causes of disease and possible opportunities for disease prevention. A wide variation on the incidence and prevalence of PsA was reported in different countries. The prevalence in China was similar to the rest of the world, whereas the incidence and prevalence of PsA was much lower in Japan. Among patients with psoriasis, 6-42% of the Caucasians were reported to have PsA, but figures were lower from Asian countries (1-9%). Divergent distribution of HLA in different ethnic groups and other genetic determinants may account for these differences in prevalence. PsA affects men and women almost equally in Chinese, Japanese and Iranians, which is similar to their Caucasian counterparts. Polyarthritis developing in the fourth decade was the commonest pattern of arthritis among Chinese, Indians, Iranians, Kuwaiti Arabs and Malays. Arthritis mutilans and eye lesions have rarely been reported in Asian countries. Chinese patients with nail disease and DIP joints involvement have a significantly higher risk of developing deformed joints. More data are required on the safety, efficacy and cost effectiveness of TNF blockers for the treatment of PsA in Asia. Premature atherosclerosis has been recognized as an important co-morbidity in Asian patients with PsA. Increased prevalence of traditional cardiovascular risk factors associated with PsA suggested that the two conditions may share the same inflammatory pathway. Carotid intima-media thickness can identify PsA patients with subclinical atherosclerosis who may benefit from early intervention.

Clinical characteristics of psoriatic arthritis and psoriasis in dermatologists' offices

OBJECTIVE

To describe the skin and joint disease of patients with psoriatic arthritis being treated in dermatology clinics.

METHODS

A total of 1122 patients who had active psoriatic arthritis were enrolled in a Phase 4, non-randomized, open-label, single-arm, 24-week study. They were treated at 108 community and 17 academic dermatology centers. These patients experienced clinically stable, plaque psoriasis involving > or =10% body surface area and joint disease (either > or = two swollen and > or = two tender/painful joints for > or =3 months, or > or = one joint with sacroiliitis or spondylitis).

RESULTS

In general, patient demographics and disease characteristics did not appear to differ between academic and community dermatology sites. Based on patient-reported assessments, patients rated the severity of their baseline joint symptoms lower than the severity of their skin disease. Baseline skin and joint disease measures were not correlated. Psoriatic arthritis was newly diagnosed in 23% of the patients. Most had received prior therapy for psoriasis, but only half had received systemic therapy for psoriatic arthritis.

CONCLUSION

Assessment for joint disease in psoriasis patients being treated at dermatology clinics may facilitate earlier psoriatic arthritis diagnosis and treatment initiation, which may prevent disability and other negative impacts.

Lack of Echocardiographic and Doppler Abnormalities in Psoriatic Arthritis Patients Without Clinically Evident Cardiovascular Disease or Classic Atherosclerosis Risk Factors

OBJECTIVE

To assess the prevalence of echocardiographic and Doppler abnormalities in psoriatic arthritis (PsA) patients without clinically evident cardiovascular manifestations or classic atherosclerosis risk factors.

METHODS

Fifty PsA patients were recruited from Hospital Xeral-Calde, Lugo, Spain. Patients seen during the period of recruitment that had classic cardiovascular risk factors or had suffered cardiovascular or cerebrovascular events were excluded. Fifty healthy matched controls were also studied. Echocardiographic and Doppler studies were performed in all cases and controls.

RESULTS

In PsA patients the frequency of aortic and tricuspid (10%) and mitral regurgitation (16%) was not different from that seen in matched controls (10, 4, and 12%). Also, the pulmonary artery systolic pressure was normal in the group of PsA patients (23.4+/-3.9 mm Hg). The prevalence of diastolic dysfunction, in all cases due to impaired relaxation, was similar in PsA patients (28%) and controls (24%) (P=0.65). In addition, no significant echocardiographic and Doppler differences were observed when PsA patients with polyarticular pattern were compared with the remaining PsA patients.

CONCLUSIONS

The present study shows that actively treated PsA patients without cardiovascular risk factors or clinically evident cardiovascular disease do not exhibit silent subclinical echocardiographic abnormalities.

Long term safety of etanercept in elderly subjects with rheumatic diseases

OBJECTIVES

To determine the long term safety profile of the tumour necrosis factor (TNF) antagonist etanercept in subjects with rheumatoid arthritis (RA), psoriatic arthritis (PsA), or ankylosing spondylitis (AS) aged > or =65 years in comparison with subjects aged <65 years.

METHODS

Safety data from an integrated database of 4322 subjects enrolled in 18 RA trials, 2 PsA trials, and 2 AS trials were analysed. Safety end points included subject incidence of all adverse events (AE), serious adverse events (SAE), infectious events (IE), medically important infections (MII), and deaths. Events of particular interest in subjects treated with TNF modulating biological treatments, including demyelinating diseases, tuberculosis, lymphomas, and cardiovascular diseases, were also evaluated.

RESULTS

The incidence of AE, SAE, IE, MII, and malignancies was not significantly raised in elderly subjects in comparison with subjects aged <65 years. No cases of tuberculosis were reported in the trials. Demyelinating diseases were seen only in subjects aged <65 years. The incidence and types of death in the elderly subjects were consistent with the expected rates for subjects of comparable age.

CONCLUSIONS

Etanercept is a generally safe and well tolerated biological agent for treatment of rheumatological diseases in the elderly, and the risk of AE in these studies was no greater in subjects aged > or =65 years than in younger subjects.