Actas Dermo-Sifiliográficas (English Edition) Actas Dermo-Sifiliográficas (English Edition)
Actas Dermosifiliogr 2017;108:800-8 - Vol. 108 Num.9 DOI: 10.1016/j.adengl.2017.08.021
Review
Clinical, Diagnostic, and Therapeutic Implications in Psoriasis Associated With Cardiovascular Disease
Implicaciones Clínicas, Diagnósticas Y Terapéuticas De La Psoriasis Y Enfermedad Cardiovascular
C. Bonanada,, , E. González-Parrab, R. Riverac, J.M. Carrascosad, E. Daudéne, A. Olveiraf, R. Botella-Estradag
a Servicio de Cardiología, Hospital Clínico Universitario, Valencia, Spain
b Servicio de Nefrología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
c Servicio de Dermatología, Hospital Doce de Octubre, Madrid, Spain
d Servicio de Dermatología, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
e Servicio de Dermatología, Hospital Universitario La Princesa, Madrid, Spain
f Servicio de Aparato Digestivo, Hospital La Paz, Madrid, Spain
g Servicio de Dermatología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
Received 03 October 2016, Accepted 06 December 2016
Abstract

In recent years the concept of psoriasis as a systemic disease has gained acceptance due to its association with numerous comorbid conditions, particularly atherosclerosis and cardiovascular disease. Several studies have shown that patients with psoriasis, especially younger patients and those with more severe forms of psoriasis or with psoriatic arthritis, have a higher prevalence of risk factors and metabolic syndrome, as well as an increased risk of major cardiovascular events such as myocardial infarction, cerebrovascular disease, and peripheral arterial disease. Furthermore, it remains unclear which of the current treatments might be more effective in reducing cardiovascular risk in these patients. It is therefore important for dermatologists to be aware of this increased risk, to be able to detect modifiable risk factors early and, when appropriate, refer patients to other specialists for the prevention of major cardiovascular events.

Resumen

En los últimos años el concepto de psoriasis como enfermedad sistémica se ha ido extendiendo debido a su asociación con múltiples comorbilidades, entre las que destaca la arterioesclerosis y la enfermedad cardiovascular. En diferentes estudios a lo largo de los años se ha demostrado que en los pacientes con psoriasis, sobre todo en aquellos más jóvenes, con formas más graves y/o artritis psoriásica, existe una mayor prevalencia de factores de riesgo y síndrome metabólico, así como un mayor riesgo de presentar eventos cardiovasculares mayores, como el infarto de miocardio, la enfermedad cerebrovascular y la arteriopatía periférica. Además, aún no queda claro cuáles de los tratamientos actuales podrían ser más beneficiosos en cuanto a reducción del riesgo cardiovascular en estos pacientes. Por eso, es importante la difusión entre dermatólogos de este riesgo aumentado, con el fin de diagnosticar precozmente aquellos factores de riesgo modificables, y derivar al paciente a otros especialistas en el momento oportuno para prevenir el desarrollo de eventos cardiovasculares mayores.

Keywords
Psoriasis, Hypertension, Diabetes, Obesity, Dyslipidemia, Comorbidity, Atherosclerosis, Cardiovascular disease
Palabras clave
Psoriasis, Hipertensión arterial, Diabetes, Obesidad, Dislipidemia, Comorbilidad, Ateroesclerosis, Enfermedad cardiovascular

Psoriasis is a chronic systemic inflammatory disease that can be associated with multiple comorbidities, of which cardiovascular (CV) disease due to atherosclerosis is one of the most significant.1 Advances in our understanding of the association between psoriasis and CV disease could facilitate early diagnosis and treatment. Assessment of the risk factors for potential comorbid conditions and of the signs and symptoms of such diseases is an important aspect of the care of patients with psoriasis. This article reviews the current evidence on the association between moderate to severe psoriasis and CV disease, the impact of systemic treatments for psoriasis on this association, and recommendations for the clinical monitoring and referral of these patients.

Association Between Psoriasis and Cardiovascular Disease

Moderate to severe psoriasis is associated with a increased risk of developing CV disease, including coronary heart disease, cerebrovascular disease, and peripheral artery disease. Observational studies have detected an elevated risk of myocardial infarction in patients with psoriasis.2–6In a prospective cohort of over 130 000 adults with psoriasis, the incidence of myocardial infarction (adjusted for CV risk factors) per 1000 person-years was 3.58 (95% CI, 3.52-3.65) for the control group, 4.04 (95% CI, 3.88-4.21) for patients with moderate psoriasis, and 5.13 (95% CI, 4.22-6.17) for patients with severe psoriasis (defined as those requiring systemic therapy). The impact on risk was greater in younger patients (relative risk [RR], 3.10 with a 95% CI, 1.98-4.86 in patients under 60 years versus RR, 1.36 with a 95% CI, 1.13-1.64 in patients older than 60 years).3

Other forms of CV disease besides coronary heart disease also occur with greater frequency in patients with psoriasis.5–7 Prodanovich et al. found a significant increase in the prevalence of cerebrovascular disease in patients with psoriasis (OR, 1.70; 95% CI, 1.33-2.17) and peripheral vascular disease (OR 1.98, 95% CI, 1.32-2.82).8 Once again, it is in patients with severe psoriasis that a significant increase in the risk of stroke has been observed (hazard ratio [HR], 1.43; 95% CI, 1.1-1.9) compared to a modest increase in patients with mild forms of the disease (HR, 1.06; 95% CI, 1.01-1.1).9

However, this epidemiological association between psoriasis and CV disease has not been confirmed in all studies.10–12 The inconsistency appears to be due largely to variations in impact relating to the severity of psoriasis.

Current evidence indicates that the association between psoriasis and CV disease is due to the underlying chronic inflammation present in both conditions. Common pathophysiological pathways have been identified, including the involvement of T-helper 1 cells, cytokines (interferon-γ, tumor necrosis factor [TNF] α, and interleukin-2) and vascular endothelial growth factor-mediated angiogenesis.13–18

Association Between Psoriasis and Cardiovascular Risk Factors

Observational studies have found an independent relationship between moderate to severe psoriasis and certain risk factors for CV disease, including diabetes mellitus,19,20 hypertension,21–23 obesity, and dyslipidemia.24 A higher prevalence of smoking has also been observed among patients with psoriasis.25

The available evidence indicates that psoriasis also has an influence on the severity of hypertension and diabetes mellitus. Epidemiological studies show that patients with psoriasis and diabetes mellitus more often receive pharmacological treatment and have a higher risk of microvascular and macrovascular complications.26,27 In population-based studies, a relationship has also been observed between the severity of psoriasis and uncontrolled hypertension.20

Furthermore, multiple epidemiological studies support the association between psoriasis and metabolic syndrome or some of its components, such as abdominal obesity, hypertriglyceridemia, and low levels of high-density lipoprotein.28–30

However, the origin of the association between psoriasis and CV risk factors and atherosclerotic disease is, as yet, poorly understood. Since, our knowledge of the association is based on epidemiological studies, it is unclear whether psoriasis is the pathogenic factor that favors the onset of the other conditions (because of the inflammation it causes in the body) or whether what we are seeing is a set of comorbid conditions with no shared pathogenic basis.

Clinical Implications of Cardiovascular Disease in Psoriasis

The association between psoriasis and CV disease has important prognostic implications. Patients with psoriasis appear to have a worse prognosis following a first-time myocardial infarction3,31 as well as an increased risk of CV mortality.32 In a meta-analysis, CV mortality was significantly higher in patients with severe psoriasis than in the general population (RR, 1.37; 95% CI, 1.17-1.60).6 Similarly, a cohort of 3603 patients with severe psoriasis was observed to have a higher risk of dying from a cardiac or cerebrovascular disease (HR, 1.57; 95% CI, 1.26-1.96) compared to a control group.33

Impact on Cardiovascular Disease of Drugs Used to Treat Psoriasis

Since psoriasis is associated with a risk of CV disease, probably as a result of systemic inflammation, the therapies used to treat psoriasis, which are designed to reduce inflammation, could theoretically reduce CV risk. However, the evidence for this hypothesis, derived mainly from observational studies, is scant and inconsistent.34 Abuabara et al. studied a cohort of 25 554 patients that included a group receiving systemic immunomodulatory therapy (methotrexate, ciclosporin, alefacept, efalizumab, adalimumab, etanercept, or infliximab) and a control group treated with phototherapy.35They found no differences in risk of myocardial infarction between the 2 groups.

Other authors have also failed to confirm the beneficial effect of systemic treatment in general; however, there is evidence indicating that certain therapies may have a potentially beneficial effect.36

Methotrexate

A hypothesis has been advanced that the anti-inflammatory properties of methotrexate (MTX) could reduce CV risk in patients with chronic inflammatory diseases through the modulation of nucleotide metabolism and the inhibition of cytokine signaling.37,38 This hypothesis has led to the design of clinical trials (currently under way) to assess the use of low-dose treatment with MTX in myocardial infarction with ST-segment elevation (the TETHYS trial) and in patients with chronic coronary artery disease and persistent elevations in C-reactive protein (the CIRT trial).39,40 The results of these and other studies will improve our understanding of the association between inflammation and CV disease and the role of MTX.

Several epidemiological studies have observed a possible beneficial effect of treatment with MTX on CV risk in patients with underlying autoimmune diseases. The authors of a retrospective cohort study of patients with psoriasis found treatment with MTX to be associated with a lower risk of CV and cerebrovascular disease and arteriosclerosis.41 Similarly, the authors of a retrospective study of 2400 patients with severe psoriasis reported a lower risk for CV disease events in patients treated with biologic agents or MTX compared to patients on other treatments.42However, in another retrospective study, no differences were found in the hospitalization rate for ischemic heart disease between patients with psoriasis receiving MTX and those being treated with other nonbiologic antipsoriatic drugs.43A meta-analysis investigating the relationship between MTX use and risk of CV disease in patients with rheumatoid arthritis or psoriasis (mainly the former) found a reduction in the risk of CV events and myocardial infarction of 21% and 18%, respectively in patients on methotrexate.38

Ciclosporin

Treatment with ciclosporin is associated with a dose-dependent increase in blood pressure, serum triglycerides, and total cholesterol levels.44,45 Ciclosporin has been shown to generate reactive oxygen species, to cause cellular death in the myocardium, and to inhibit the migration of endothelial cells and angiogenesis induced by vascular endothelia growth factor (VEGF).46 In spite of these effects, there is evidence that ciclosporin use may help to protect the heart against reperfusion injury after myocardial infarction.47 It has also been associated with a possible reduction in infarct size in animal models.48 However, in a placebo-controlled randomized clinical trial in which ciclosporin was administered before primary angioplasty in patients with myocardial infarction, no differences were found with respect to the primary outcome (mortality, readmission due to heart failure or adverse remodeling at 1 year).49

With respect to the possible influence of ciclosporin treatment on CV risk in patients with psoriasis, a prospective analysis of CV events in an observational cohort of 6902 patients with severe psoriasis and a maximum follow-up of 5 years, ciclosporin use was not found to be associated with any protective effect (HR, 1.06; 95% CI, 0.26-4.27), in contrast with the reduced risk of such events seen in patients treated with MTX.42

Retinoids

Retinoids increase triglyceride and total cholesterol levels (particularly low-density lipoproteins) but they have not been shown to increase CV risk.50 The triglyceride and cholesterol elevations appears to be dose-dependent, but they can be controlled with diet and changes in dose. As in the case of ciclosporin, treatment with retinoids was not associated with any reduction in the number of CV events in the follow-up of the Danish cohort of 6902 patients with severe psoriasis.42

Tumor Necrosis Factor Inhibitors

The association between TNF antagonist therapy and CV disease has been studied in a number of different settings:

Cardiovascular risk factors

TNF antagonist therapy appears to have metabolic effects that could improve the patient's CV risk profile. Etanercept, infliximab, and adalimumab have been associated with an improvement in insulin resistance in patients with inflammatory diseases, including psoriasis, and with a decrease in fasting blood sugar and a lower risk of developing diabetes mellitus.51–54The effect on the lipid profile is more nebulous and these drugs do not appear to significantly modify serum levels, although there may be an antiatherogenic effect (which in the long term is clearer with etanercept than with infliximab).55–58

Biomarkers, such as C-reactive protein, adiponectin and resistin are considered to be markers of both inflammation and CV risk.59,60While initial findings suggest a possible beneficial effect on levels of adiponectin and other markers, the evidence is controversial and does not support firm conclusions.61 Treatment with TNF inhibitors in patients with psoriatic joint disease has been shown to reduce carotid artery intima-media thickness and arterial rigidity, both predictors of CV disease.62–64

Ischemic heart disease

The authors of a retrospective study of 8845 patients with psoriasis or psoriatic arthritis report a reduction in the risk of myocardial infarction in the patients on TNF antagonist therapy compared to those receiving topical therapies (HR, 0.50, 0.32-0.79).65Further evidence of the potential beneficial effect of TNF blockers on CV risk can be extrapolated from studies in patients with rheumatoid arthritis, which have shown reduced rates of CV events in patients on TNF antagonist therapy.66,67

Heart failure

TNF-α levels are elevated in patients with heart failure. These elevations may contribute to cardiac dysfunction, deterioration of peripheral perfusion, and cachexia and have a negative impact on prognosis.68–70 This finding led to the suggestion that treatment with TNF inhibitors could be a possible therapeutic strategy in patients with heart failure.71,72 Initial clinical trials showed a good safety profile and suggested a clinical benefit in terms of quality of life, ventricular remodeling, and endothelial function.73–75 However, subsequent randomized clinical trials with etanercept (RENAISSANCE, RECOVER, and RENEWAL) and infliximab (ATTACH) in the treatment of heart failure were stopped early because of lack of efficacy.76–78 In the case of infliximab, all-cause mortality was increased in the high-dose arm of the trial (10 mg/kg).78

In view of the results of these trials, TNF inhibitors went from being a possible therapeutic strategy to being a cause for concern in heart failure. In 2002, the Food and Drug Administration (FDA) published a series of 47 cases of heart failure (38 of which were new-onset) associated with treatment with infliximab or etanercept. These cases had been reported on the FDA MedWatch program. After TNF antagonist therapy was discontinued and heart failure therapy was started, most of these patients presented considerable improvement or complete resolution.79 In a study of etanercept in patients with psoriasis, heart failure was rare and no increased risk was demonstrated.80

In a recent meta-analysis, no significant differences were found between patients treated with biologic drugs and controls in the prevalence of heart failure.81 In safety analyses of adalimumab in patients with rheumatoid arthritis both in clinical trials and postmarketing surveillance, the rate for heart failure was very low.82,83

In summary, the data on the risk of heart failure associated with TNF antagonist therapy administered at the doses approved by the FDA are inconclusive.84 However, infliximab is contraindicated at doses higher than 5 mg/kg in patients with moderate to severe heart failure (New York Heart Association [NYHA] III-IV), and it is recommended that etanercept and adalimumab be used with caution in patients who have symptomatic heart failure or a low ejection fraction [EF] (EF < 50%). In patients who develop new-onset heart failure while on treatment with a TNF blocker, cessation of the treatment is recommended.34

Ustekinumab

A meta-analysis of controlled clinical trials found no significant increase in the risk of major CV events in patients treated with ustekinumab.85 These results are confirmed by the data from the 12 093 patients on the PSOLAR registry, collected to evaluate the risk of adverse events of particular interest in patients with psoriasis treated with ustekinumab and other psoriasis treatments.86 Ustekinumab is not, therefore, contraindicated in patients with heart failure. However, by contrast to what was observed in other studies, a modest increase in CV events in patients treated with MTX or ciclosporin was observed on that registry.86

Secukinumab

Secukinumab has been shown to be highly effective in clearing psoriatic lesions, with higher rates of response than 2 of the currently available alternative treatment options in patients with moderate to severe psoriasis following failure to respond to conventional immunosuppressants. The available data does not suggest that secukinumab increases the risk of CV events. However, since there is little long-term data available, additional studies are needed to investigate the CV safety of this drug.87

Risk Stratification Concepts and Strategies

CV risk refers to the probability of a person having a CV event within a defined period. It is calculated by assessing the most important risk factors: age, sex, smoking status, blood pressure, and lipid levels. It is essential for clinicians to be able to assess a patient's risk profile quickly and accurately when making decisions about how to manage their condition. In general, screening for risk factors is recommended for men over 40 years of age and in women who are over 50 or postmenopausal.88 The use of risk scales to assess overall risk is recommended. These scales must be validated for the population to which they are applied. Table 1 lists some of the advantages of risk stratification.

Table 1.

Advantages of Using Risk Tables.

Intuitive and easy-to-use tool 
Takes into account the multifactorial nature of cardiovascular disease 
Allows flexibility in management when the risk profile is not ideal: total risk can be lowered by reducing individual risk factors 
Allows a more objective assessment of risk over time 
Establishes a common language for risk in clinical practice 
Shows how risk increases with age 
The calculation of an individual “age risk” can also be useful in this situation 

In the USA, the Framingham Risk Score is the most widely used risk calculator and the one recommended in the American Heart Association's clinical guidelines.89 This scoring system is based on data from the Framingham epidemiological study, which has been collecting information on succeeding generations since it started in 1948. The recommended model estimates the 10-year risk of heart disease.90 There is an easy-to-use calculator available online (https://www.framinghamheartstudy.org/risk-functions/index.php).

The Framingham model has been adapted for use in the Spanish population using a carefully checked calibration process. The adapted score was subsequently validated and the result is the REGICOR scale and risk calculator.91–93

The SCORE system is the risk scale recommended by the European guidelines on CV disease prevention based on data from the cohorts included in 12 European studies (205 178 patients examined for the first time between 1970 and 1988 with 2.7 million years of follow-up and 7934 deaths from CV disease) and amply validated.88 SCORE estimates the 10-year risk of a first CV event leading to death. Although there is no universal risk threshold, the intensity of advice should increase with increased risk. In general, people with a risk of CV death of 5% or more require intensive counseling and may benefit from pharmacological treatment. At risk levels of 10% or more, patients require pharmacological treatment.

In addition, there are complementary techniques that can be useful in assessing CV risk in individuals with a moderate risk level. At any level of exposure to risk factors, there is a substantial variation in the severity of atherosclerosis, which can probably be attributed to variations in genetic susceptibility, the combination of different risk factors, and the interaction between genetic and environmental factors. Thus, it can be useful to assess subclinical atherosclerosis to obtain a better CV risk prediction. Various non-invasive techniques (such as carotid ultrasound to measure intima-media thickness and the presence and characteristics of plaques, electron beam computed tomography, multislice computed tomography coronary imaging, the ankle-wrist vascular index, and magnetic resonance imaging) have potential for measuring and directly or indirectly monitoring atherosclerosis in asymptomatic individuals. However, the cost-benefit ratio for such techniques has not been determined.

Recommendations on Cardiovascular Follow-Up and Monitoring of Patients With Psoriasis by Dermatologists

The current recommendations for CV follow-up of patients with psoriasis by dermatologists stress the importance of informing patients with moderate to severe psoriasis about their increased risk of CV disease.94–96 CV risk should be assessed during the initial evaluation and subsequent follow-up of patients with psoriasis (Table 2). Patients should also be informed about the need for future multidisciplinary care (cardiologist, internist, endocrinologist, general practitioner) and referral criteria (Fig. 1) to ensure the best overall care in these patients with high CV risk.

Table 2.

General Recommendations for Initial and Follow-up Cardiovascular Risk Assessment in Patients with Psoriasis.

Individual and familial medical history, with a particular focus on familial history of ischemic heart disease, especially early onset (mainly during the initial visit) 
Annual blood pressure assessment (target < 120/80 mmHg) and heart rate 
Analysis of lipid profile (target values: total cholesterol < 200 mg/dL; high-density lipoprotein ≥ 50 mg/dL; low density lipoprotein < 100 mg/dL), blood glucose (fasting blood sugar < 100 mg/dL), and HbA1c). Reassess every 2 years or annually whether patients have additional risk factors 
Intensive treatment of cardiovascular risk factors 
Provide help for smoking cessation and moderation of alcohol intake 
Abdominal circumference and BMI (target < 25Kg/m2) assessed annually 
Encourage moderate aerobic exercise (30 min at least 3 times a week) 
Figure 1.
(0.38MB).

Screening of patients with psoriasis for cardiovascular risk factors and criteria for specialist referral.

BP: blood pressure; BMI: body mass index; CV: cardiovascular; DL: dyslipidemia; DM: diabetes mellitus; HDL-C: high density lipoprotein cholesterol; HT: hypertension; LDL-C: low density lipoprotein cholesterol; TC: total cholesterol; TG: triglycerides.

Conclusions

The association between psoriasis and CV disease is supported by ample observational evidence, which shows a greater prevalence of CV risk factors, higher incidence of CV disease, and worse prognosis in patients with psoriasis, particularly in the case of young patients with severe forms of the skin disease. This association is probably the result of a chronic underlying inflammatory state; certain proinflammatory cytokines are common to the pathophysiology of both diseases. However, the underlying mechanisms are still poorly understood.

When the available data is analyzed globally, systemic immunomodulatory therapy for psoriasis does not appear to influence the onset or severity of CV disease. However, when the drug therapies are analyzed separately, differences are found. There is currently insufficient evidence to recommend certain psoriasis treatments solely on the basis of their impact on CV risk. However, when considering a systemic treatment clinicians must assess the risk involved and take into account the fact that TNF inhibitors and MTX have been shown to be the treatments that offer the greatest potential benefit in the context of ischemic heart disease and that there is evidence of a possible prejudicial effect in the case of certain TNF inhibitors in patients with ischemic heart disease, systolic dysfunction and a poor functional classification.

The management of psoriasis must include a thorough assessment of CV risk and of possible signs and symptoms of CV disease, both on diagnosis and periodically thereafter, depending on the severity of the disease. This follow-up is essential to ensure the early diagnosis and treatment of CV disease as well as early referral and multidisciplinary treatment when this becomes necessary.94–96Finally, studies are needed to clarify the mechanisms underlying the association between these 2 diseases, the impact of systemic therapies, and the best clinical approach.

Recommendations and Key Points

  • 1.

    An association exists between psoriasis and certain CV risk factors: hypertension, diabetes mellitus, and metabolic syndrome.

  • 2.

    Psoriasis, and particularly severe psoriasis, is itself a CV risk factor, since these patients have an increased risk for CV disease and mortality. Although the differences vary between studies, the increase in risk is around 50%.

  • 3.

    The mechanism by which psoriasis increases CV risk is unknown. The hypothesis has been considered that it is due to systemic inflammation or to the fact that patients with psoriasis often present several CV risk factors, with psoriasis acting as an attracting factor.

  • 4.

    There is evidence that—of all the systemic treatments of psoriasis—MTX and TNF inhibitors may have a beneficial effect on CV disease. However, caution should be exercised when prescribing TNF blockers to patients who have heart failure in very advanced functional classes (NYHA III-IV) or severe ventricular dysfunction (EF ≤ 35%).

  • 5.

    CV risk must be assessed in all patients with psoriasis. Risk assessment will help prevent CV morbidity and mortality and inform the choice of the best treatment for each patient.

Ethical DisclosuresProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this investigation.

Confidentiality of data

The authors state that they have followed the protocols of their hospitals on the publication of patient data.

Right to privacy and informed consent

The authors declare that no private patient data are disclosed in this article.

Conflict Of Interests

Abbvie facilitated the meetings of the workgroup, but none of the company's employees participated in the collection of scientific evidence, group discussions, or writing the article.

Rafael Botella has served as a paid consultant for Pfizer, Abbvie and Galderma and as a speaker for Abbvie, Pfizer, Novartis, Leo Pharma and MSD. He has been an investigator for Novartis, Abbvie, Janssen, Leo Pharma, Cantabria, Biofrontera and Viñas and has been sponsored to attend conferences by Novartis, Pfizer, Abbvie, Janssen, Lilly, Cantabria and MSD.

José Manuel Carrascosa has served as a paid consultant and a speaker for Abbvie, Novartis, Janssen, Amgen, Biogen, Leo, Celgene, Lilly, and Pfizer.

Raquel Rivera has served as a paid consultant for Abbvie, Janssen, Lilly, and Pfizer, and as a speaker for MSD, Abbvie, Janssen, Leo Pharma, Novartis, and Pfizer. She has been an investigator for Abbvie, Pfizer, Janssen, Celgene, Lilly, Novartis, and Leo Pharma and has been sponsored to attend conferences by Abbvie, Janssen, Novartis, Pfizer, Leo Pharma, Celgene, and MSD.

Esteban Daudén has served as a member of the Advisory Board, has been a consultant, has received grants, undertaken research support, participated in clinical trials and been remunerated to as a speaker by the following pharmaceutical companies: Abbvie/Abbott, Amgen, Biogen, Janssen-Cilag, Leo Pharma, MSD, Pfizer, Novartis, Celgene, and Lilly.

References
1
E. Farley,A. Menter
Psoriasis: Comorbidities and associations
G Ital Dermatol Venereol, 146 (2011), pp. 9-15
2
J. Xiao,L.H. Chen,Y.T. Tu,X.H. Deng,J. Tao
Prevalence of myocardial infarction in patients with psoriasis in central China
J Eur Acad Dermatol Venereol, 23 (2009), pp. 1311-1315 http://dx.doi.org/10.1111/j.1468-3083.2009.03318.x
3
J.M. Gelfand,A.L. Neimann,D.B. Shin,X. Wang,D.J. Margolis,A.B. Troxel
Risk of myocardial infarction in patients with psoriasis
4
O. Ahlehoff,G.H. Gislason,M. Charlot,C.H. Jorgensen,J. Lindhardsen,J.B. Olesen
Psoriasis is associated with clinically significant cardiovascular risk: A Danish nationwide cohort study
J Intern Med, 270 (2011), pp. 147-157 http://dx.doi.org/10.1111/j.1365-2796.2010.02310.x
5
A.B. Kimball,A. Guerin,D. Latremouille-Viau,A.P. Yu,S. Gupta,Y. Bao
Coronary heart disease and stroke risk in patients with psoriasis: Retrospective analysis
6
E.J. Samarasekera,J.M. Neilson,R.B. Warren,J. Parnham,C.H. Smith
Incidence of cardiovascular disease in individuals with psoriasis: a systematic review and meta-analysis
J Invest Dermatol, 133 (2013), pp. 2340-2346 http://dx.doi.org/10.1038/jid.2013.149
7
J.A. Kaye,L. Li,S.S. Jick
Incidence of risk factors for myocardial infarction and other vascular diseases in patients with psoriasis
Br J Dermatol, 159 (2008), pp. 895-902 http://dx.doi.org/10.1111/j.1365-2133.2008.08707.x
8
S. Prodanovich,R.S. Kirsner,J.D. Kravetz,F. Ma,L. Martinez,D.G. Federman
Association of psoriasis with coronary artery, cerebrovascular, and peripheral vascular diseases and mortality
Arch Dermatol, 145 (2009), pp. 700-703 http://dx.doi.org/10.1001/archdermatol.2009.94
9
J.M. Gelfand,E.D. Dommasch,D.B. Shin,R.S. Azfar,S.K. Kurd,X. Wang
The risk of stroke in patients with psoriasis
J Invest Dermatol, 129 (2009), pp. 2411-2418 http://dx.doi.org/10.1038/jid.2009.112
10
R.S. Stern
Psoriasis is not a useful independent risk factor for cardiovascular disease
J Invest Dermatol, 130 (2010), pp. 917-919 http://dx.doi.org/10.1038/jid.2009.446
11
M. Wakkee,R.M. Herings,T. Nijsten
Psoriasis may not be an independent risk factor for acute ischemic heart disease hospitalizations: Results of a large population-based Dutch cohort
J Invest Dermatol, 130 (2010), pp. 962-967 http://dx.doi.org/10.1038/jid.2009.321
12
R.S. Stern,A. Huibregtse
Very severe psoriasis is associated with increased noncardiovascular mortality but not with increased cardiovascular risk
J Invest Dermatol, 131 (2011), pp. 1159-1166 http://dx.doi.org/10.1038/jid.2010.399
13
B.J. Nickoloff,H. Xin,F.O. Nestle,J.Z. Qin
The cytokine and chemokine network in psoriasis
14
G.K. Hansson,P. Libby
The immune response in atherosclerosis: A double-edged sword
Nat Rev Immunol, 6 (2006), pp. 508-519 http://dx.doi.org/10.1038/nri1882
15
R. Ghazizadeh,H. Shimizu,M. Tosa,M. Ghazizadeh
Pathogenic mechanisms shared between psoriasis and cardiovascular disease
Int J Med Sci, 7 (2010), pp. 284-289
16
H. Ranjbaran,S.I. Sokol,A. Gallo,R.E. Eid,A.O. Iakimov,A. D’Alessio
An inflammatory pathway of IFN-gamma production in coronary atherosclerosis
J Immunol, 178 (2007), pp. 592-604
17
M. Canavese,F. Altruda,T. Ruzicka,J. Schauber
Vascular endothelial growth factor (VEGF) in the pathogenesis of psoriasis--a possible target for novel therapies
J Dermatol Sci, 58 (2010), pp. 171-176 http://dx.doi.org/10.1016/j.jdermsci.2010.03.023
18
J. Herrmann,L.O. Lerman,D. Mukhopadhyay,C. Napoli,A. Lerman
Angiogenesis in atherogenesis
Arterioscler Thromb Vasc Biol, 26 (2006), pp. 1948-1957 http://dx.doi.org/10.1161/01.ATV.0000233387.90257.9b
19
A.A. Qureshi,H.K. Choi,A.R. Setty,G.C. Curhan
Psoriasis and the risk of diabetes and hypertension: a prospective study of US female nurses
Arch Dermatol, 145 (2009), pp. 379-382 http://dx.doi.org/10.1001/archdermatol.2009.48
20
A.W. Armstrong,S.W. Lin,C.J. Chambers,M.E. Sokolow,D.L. Chin
Psoriasis and hypertension severity: Results from a case-control study
21
J. Shapiro,A.D. Cohen,M. David,E. Hodak,G. Chodik,A. Viner
The association between psoriasis, diabetes mellitus, and atherosclerosis in Israel: A case-control study
J Am Acad Dermatol, 56 (2007), pp. 629-634 http://dx.doi.org/10.1016/j.jaad.2006.09.017
22
J.M. Carrascosa,V. Rocamora,R.M. Fernandez-Torres,R. Jimenez-Puya,J.C. Moreno,N. Coll-Puigserver
Obesidad y psoriasis: naturaleza inflamatoria de la obesidad, relación entre psoriasis y obesidad e implicaciones terapéuticas
Actas Dermosifiliogr, 105 (2014), pp. 31-44 http://dx.doi.org/10.1016/j.ad.2012.08.003
23
E. Daudén,S. Castañeda,C. Suárez,J. García-Campayo,A.J. Blasco,M.D. Aguilar,for the Working Group on Psoriasis-associated Comorbidities
Abordaje integral de la comorbilidad del paciente con psoriasis
Actas Dermosifiliogr, 103 (2012), pp. 1-64 http://dx.doi.org/10.1016/S0001-7310(12)70001-7
24
C. Ma,C.T. Harskamp,E.J. Armstrong,A.W. Armstrong
The association between psoriasis and dyslipidaemia: A systematic review
Br J Dermatol, 168 (2013), pp. 486-495 http://dx.doi.org/10.1111/bjd.12101
25
A.W. Armstrong,A. Guérin,M. Sundaram,E.Q. Wu,E.S. Faust,R. Ionescu-Ittu
Psoriasis and risk of diabetes associated microvascular and macrovascular complications
J Am Acad Dermatol, 72 (2015), pp. 968-977 http://dx.doi.org/10.1016/j.jaad.2015.02.1095
26
J. Takeshita,S. Wang,D.B. Shin,N.N. Metha,S.E. Kimmel,D.J. Margolis
Effect of psoriasis severity on hypertension control: A population based study in the United Kingdom
JAMA Dermatol, 151 (2015), pp. 161-169 http://dx.doi.org/10.1001/jamadermatol.2014.2094
27
C. Bonifati,A. Mussi,M. Carducci,A. Pittarello,L. D??Auria,A. Venuti
Endothelin-1 levels are increased in sera and lesional skin extracts of psoriatic patients and correlate with disease severity
Acta Derm Venereol, 78 (1998), pp. 22-26
28
M. Gyldenløve,H. Storgaard,J.J. Holst,T. Visbøll,F.K. Knop,L. Skov
Patients with psoriasis are insulin resistant
J Am Acad Dermatol, 72 (2015), pp. 599-605 http://dx.doi.org/10.1016/j.jaad.2015.01.004
29
K. Danielsen,T. Wilsgaard,A.O. Olsen,A.E. Eggen,K. Olsen,P.A. Cassano
Elevated odds of metabolic syndrome in psoriasis: A population-based study of age and sex differences
Br J Dermatol, 172 (2015), pp. 419-427 http://dx.doi.org/10.1111/bjd.13288
30
T.J. Love,A.A. Qureshi,E.W. Karlson,J.M. Gelfand,H.K. Choi
Prevalence of the metabolic syndrome in psoriasis: Results from the National Health and Nutrition Examination Survey, 2003-2006
Arch Dermatol, 147 (2011), pp. 419-424 http://dx.doi.org/10.1001/archdermatol.2010.370
31
O. Ahlehoff,G.H. Gislason,J. Lindhardsen,J.B. Olesen,M. Charlot,L. Skov
Prognosis following first-time myocardial infarction in patients with psoriasis: A Danish nationwide cohort study
J Intern Med, 270 (2011), pp. 237-244 http://dx.doi.org/10.1111/j.1365-2796.2011.02368.x
32
N.N. Mehta,R.S. Azfar,D.B. Shin,A.L. Neimann,A.B. Troxel,J.M. Gelfand
Patients with severe psoriasis are at increased risk of cardiovascular mortality: Cohort study using the general practice research database
Eur Heart J, 31 (2010), pp. 1000-1006 http://dx.doi.org/10.1093/eurheartj/ehp567
33
K. Abuabara,R.S. Azfar,D.B. Shin,A.L. Neimann,A.B. Troxel,J.M. Gelfand
Cause-specific mortality in patients with severe psoriasis: A population-based cohort study in the U.K
Br J Dermatol, 163 (2010), pp. 586-592 http://dx.doi.org/10.1111/j.1365-2133.2010.09941.x
34
J. Hugh,A.S. Van Voorhees,R.I. Nijhawan,J. Bagel,M. Lebwohl,A. Blauvelt
From the Medical Board of the National Psoriasis Foundation: The risk of cardiovascular disease in individuals with psoriasis and the potential impact of current therapies
J Am Acad Dermatol, 70 (2014), pp. 168-177 http://dx.doi.org/10.1016/j.jaad.2013.09.020
35
K. Abuabara,H. Lee,A.B. Kimball
The effect of systemic psoriasis therapies on the incidence of myocardial infarction: A cohort study
Br J Dermatol, 165 (2011), pp. 1066-1073 http://dx.doi.org/10.1111/j.1365-2133.2011.10525.x
36
A.W. Armstrong,E.A. Brezinski,M.R. Follansbee,E.J. Amstrong
Effects of biologic agents and other disease-modifying antirheumatic drugs on cardiovascular outcomes in psoriasis and psoriatic arthritis: A systematic review
Curr Pharm Des, 20 (2014), pp. 500-512
37
S.L. Westlake,A.N. Colebatch,J. Baird,P. Kiely,M. Quinn,E. Choy
The effect of methotrexate on cardiovascular disease in patients with rheumatoid arthritis: A systematic literature review
Rheumatology (Oxford), 49 (2010), pp. 295-307
38
R. Micha,F. Imamura,M. Wyler von Ballmoos,D.H. Solomon,M.A. Hernan,P.M. Ridker
Systematic review and meta-analysis of methotrexate use and risk of cardiovascular disease
Am J Cardiol, 108 (2011), pp. 1362-1370 http://dx.doi.org/10.1016/j.amjcard.2011.06.054
39
D.M. Moreira,M.E. Lueneberg,R.L. da Silva,T. Fattah,C.A. Mascia Gottschall
Rationale and design of the TETHYS trial: The effects of methotrexate therapy on myocardial infarction with ST-segment elevation
Cardiology, 126 (2013), pp. 167-170 http://dx.doi.org/10.1159/000351972
40
P.M. Ridker
Testing the inflammatory hypothesis of atherothrombosis: Scientific rationale for the Cardiovascular Inflammation Reduction Trial (CIRT)
J Thromb Haemost, 7 (2009), pp. 332-339 http://dx.doi.org/10.1111/j.1538-7836.2009.03404.x
41
S. Prodanovich,F. Ma,J.R. Taylor,C. Pezon,T. Fasihi,R.S. Kirsner
Methotrexate reduces incidence of vascular diseases in veterans with psoriasis or rheumatoid arthritis
J Am Acad Dermatol, 52 (2005), pp. 262-267 http://dx.doi.org/10.1016/j.jaad.2004.06.017
42
O. Ahlehoff,L. Skov,G. Gislason,J. Lindhardsen,S.L. Kristensen,L. Iversen
Cardiovascular disease event rates in patients with severe psoriasis treated with systemic anti-inflammatory drugs: A Danish real-world cohort study
43
Y.J. Chen,Y.T. Chang,J.L. Shen,T.T. Chen,C.B. Wang,C.M. Chen
Association between systemic antipsoriatic drugs and cardiovascular risk in patients with psoriasis with or without psoriatic arthritis: A nationwide cohort study
Arthritis Rheum, 64 (2012), pp. 1879-1887 http://dx.doi.org/10.1002/art.34335
44
N. Robert,G.W. Wong,J.M. Wright
Effect of cyclosporine on blood pressure
Cochrane Database Syst Rev, (2010), pp. CD007893
45
M.J. Stiller,G.H. Pak,C. Kenny,L. Jondreau,I. Davis,S. Wachsman
Elevation of fasting serum lipids in patients treated with low-dose cyclosporine for severe plaque-type psoriasis
J Am Acad Dermatol, 27 (1992), pp. 434-438
46
G.L. Hernandez,O.V. Volpert,M.A. Iniguez,E. Lorenzo,S. Martínez-Martínez,R. Grau
Selective inhibition of vascular endothelial growth factor-mediated angiogenesis by cyclosporin A: roles of the nuclear factor of activated T cells and cyclooxygenase 2
J Exp Med, 193 (2001), pp. 607-620
47
D. Hausenloy,E. Boston-Griffiths,D. Yellon
Cyclosporin A and cardioprotection: From investigative tool to therapeutic agent
Br J Pharmacol, 165 (2011), pp. 1235-1245 http://dx.doi.org/10.1111/j.1476-5381.2011.01700.x
48
W.Y. Lim,C. Messow,C. Berry
Cyclosporin variably and inconsistently reduces infarct size in experimental models of reperfused myocardial infarction: A systematic review and meta-analysis
Br J Pharmacol, 165 (2011), pp. 2034-2043 http://dx.doi.org/10.1111/j.1476-5381.2011.01691.x
49
T.T. Cung,O. Morel,G. Cayla,G. Rioufol,D. Garcia-Dorado,D. Angoulvant
Cyclosporine before PCI in patients with acute myocardial infarction
N Engl J Med, 373 (2015), pp. 1021-1031 http://dx.doi.org/10.1056/NEJMoa1505489
50
L.K. Dunn,L.R. Gaar,B.A. Yentzer,J.L. O’Neill,S.R. Feldman
Acitretin in dermatology: A review
J Drugs Dermatol, 10 (2011), pp. 772-782
51
D.H. Solomon,E. Massarotti,R. Garg,J. Liu,C. Canning,S. Shneeweis
Association between disease-modifying antirheumatic drugs and diabetes risk in patients with rheumatoid arthritis and psoriasis
JAMA, 305 (2011), pp. 2525-2531 http://dx.doi.org/10.1001/jama.2011.878
52
T.L. Stanley,M.V. Zanni,S. Johnsen,S. Rasheed,H. Makimura,H. Lee
TNF-alpha antagonism with etanercept decreases glucose and increases the proportion of high molecular weight adiponectin in obese subjects with features of the metabolic syndrome
J Clin Endocrinol Metab, 96 (2011), pp. E146-E150 http://dx.doi.org/10.1210/jc.2010-1170
53
M.A. Gonzalez-Gay,J.M. De Matias,C. Gonzalez-Juanatey,C. Garcia-Porrua,A. Sanchez-Andrade,J. Martin
Anti-tumor necrosis factor-alpha blockade improves insulin resistance in patients with rheumatoid arthritis
Clin Exp Rheumatol, 24 (2006), pp. 83-86
54
T. Pina,S. Armesto,R. Lopez-Mejias,F. Genre,B. Ubilla,M.A. Gonzalez-Lopez
Anti-TNF-α therapy improves insulin sensitivity in non-diabetic patients with psoriasis: A 6-month prospective study
J Eur Acad Dermatol Venereol, 29 (2015), pp. 1325-1330 http://dx.doi.org/10.1111/jdv.12814
55
J. Channual,J.J. Wu,F.J. Dann
Effects of tumor necrosis factor-alpha blockade on metabolic syndrome components in psoriasis and psoriatic arthritis and additional lessons learned from rheumatoid arthritis
56
C. Popa,F.H. van den Hoogen,T.R. Radstake,M.G. Netea,A.E. EIjsbouts,den Heljer
Modulation of lipoprotein plasma concentrations during long-term antiTNF therapy in patients with active rheumatoid arthritis
Ann Rheum Dis, 66 (2007), pp. 1503-1507 http://dx.doi.org/10.1136/ard.2006.066191
57
S.R. Dahlqvist,S. Engstrand,E. Berglin,O. Johnson
Conversion towards an atherogenic lipid profile in rheumatoid arthritis patients during long-term infliximab therapy
Scand J Rheumatol, 35 (2006), pp. 107-111 http://dx.doi.org/10.1080/03009740500474578
58
S.P. Garces,M.J. Parreira Santos,F.M. Vinagre,R.M. Roque,J.A. da Silva
Anti-tumor necrosis factor agents and lipid profile: A class effect?
Ann Rheum Dis, 67 (2008), pp. 895-896 http://dx.doi.org/10.1136/ard.2007.078287
59
K. Walsh
Adipokines, myokines and cardiovascular disease
Circ J, 73 (2009), pp. 13-18
60
O. Melander,C. Newton-Cheh,P. Almgren,B. Hedblad,G. Berglund,G. Engström
Novel and conventional biomarkers for prediction of incident cardiovascular events in the community
61
M.J. Peters,P. Watt,L. Cherry,P. Welsh,E. Henninger,B.A. Dikmans
Lack of effect of TNF alpha blockade therapy on circulating adiponectin levels in patients with autoimmune disease: Results from two independent prospective studies
Ann Rheum Dis, 69 (2010), pp. 1687-1690 http://dx.doi.org/10.1136/ard.2009.114207
62
L.S. Tam,E.K. Li,Q. Shang,B. Tomlinson,M. Li,Y.Y. Leung
Tumor necrosis factor alpha blockade is associated with sustained regression of carotid intima-media thickness for patients with active psoriatic arthritis: A 2-year pilot study
Ann Rheum Dis, 70 (2011), pp. 705-706 http://dx.doi.org/10.1136/ard.2010.131359
63
M.N. Di Minno,S. Iervolino,R. Peluso,R. Scarpa,G. Di Minno,CaRRDs study group
Carotid intima-media thickness in psoriatic arthritis: differences between tumor necrosis factor-alpha blockers and traditional disease-modifying antirheumatic drugs
Arterioscler Thromb Vasc Biol, 31 (2011), pp. 705-712 http://dx.doi.org/10.1161/ATVBAHA.110.214585
64
K. Angel,S.A. Provan,H.L. Gulseth,P. Mowinckel,T.K. Kvien,D. Atar
Tumor necrosis factor-alpha antagonists improve aortic stiffness in patients with inflammatory arthropathies: A controlled study
65
J.J. Wu,K.Y. Poon,J.C. Channual,A.Y. Shen
Association between tumor necrosis factor inhibitor therapy and myocardial infarction risk in patients with psoriasis
66
W.G. Dixon,K.D. Watson,M. Lunt,K.L. Hyrich,A.J. Silman,D.P. Symmons,British Society for Rheumatology Biologics Register Control Centre Consortium
Reduction in the incidence of myocardial infarction in patients with rheumatoid arthritis who respond to anti-tumor necrosis factor alpha therapy: results from the British Society for Rheumatology Biologics Register
Arthritis Rheum, 56 (2007), pp. 2905-2912 http://dx.doi.org/10.1002/art.22809
67
L.T. Jacobsson,C. Turesson,A. Gülfe,M.C. Kapetanovic,I.F. Petersson,T. Saxne
Treatment with tumor necrosis factor blockers is associated with a lower incidence of first cardiovascular events in patients with rheumatoid arthritis
J Rheumatol, 32 (2005), pp. 1213-1218
68
R. Sharma,A.J. Coats,S.D. Anker
The role of inflammatory mediators in chronic heart failure: Cytokines, nitric oxide, and endothelin-1
Int J Cardiol, 72 (2000), pp. 175-186
69
D.L. Mann
Recent insights into the role of tumor necrosis factor in the failing heart
Heart Fail Rev, 6 (2001), pp. 71-80
70
S.D. Anker,P.P. Ponikowski,A.L. Clark,F. Leyva,M. Rauchhaus,M. Kemp
Cytokines and neurohormones relating to body composition alterations in the wasting syndrome of chronic heart failure
Eur Heart J, 20 (1999), pp. 683-693 http://dx.doi.org/10.1053/euhj.1998.1446
71
G. Baumgarten,P. Knuefermann,D.L. Mann
Cytokines as emerging targets in the treatment of heart failure
Trends Cardiovasc Med, 10 (2000), pp. 216-223
72
J.K. Damas,L. Gullestad,P. Aukrust
Cytokines as new treatment targets in chronic heart failure
Curr Control Trials Cardiovasc Med, 2 (2001), pp. 271-277
73
A. Deswal,B. Bozkurt,Y. Seta,S. Parilti-Eiswirth,F.A. Hayes,C. Blosch
Safety and efficacy of a soluble P75 tumor necrosis factor receptor (Enbrel, etanercept) in patients with advanced heart failure
Circulation, 99 (1999), pp. 3224-3226
74
B. Bozkurt,G. Torre-Amione,M.S. Warren,J. Whitmore,O.Z. Soran,A.M. Feldman
Results of targeted anti-tumor necrosis factor therapy with etanercept (ENBREL) in patients with advanced heart failure
Circulation, 103 (2001), pp. 1044-1047
75
S. Fichtlscherer,L. Rössig,S. Breuer,M. Vasa,S. Dimmeler,A.M. Zeiher
Tumor necrosis factor antagonism with etanercept improves systemic endothelial vasoreactivity in patients with advanced heart failure
Circulation, 104 (2001), pp. 3023-3025
76
D.L. Mann,J.J. McMurray,M. Packer,K. Swedberg,J.S. Borer,W.S. Colucci
Targeted anticytokine therapy in patients with chronic heart failure: Results of the Randomized Etanercept Worldwide Evaluation (RENEWAL)
77
S.D. Anker,A.J. Coats
How to RECOVER from RENAISSANCE? The significance of the results of RECOVER, RENAISSANCE, RENEWAL and ATTACH
Int J Cardiol, 86 (2002), pp. 123-130
78
E.S. Chung,M. Packer,K.H. Lo,A.A. Fasanmade,J.T. Willerson,Anti-TNF Therapy Against Congestive Heart Failure Investigators
Randomized, double-blind, placebo-controlled, pilot trial of infliximab in patients with moderate-to-severe heart failure: Results of the anti-TNF Therapy Against Congestive Heart Failure (ATTACH) trial
79
H.J. Kwon,T.R. Coté,M.S. Cuffe,J.M. Kramer,M.M. Braun
Case reports of heart failure after therapy with a tumor necrosis factor antagonist
Ann Intern Med, 138 (2003), pp. 807-811
80
D.M. Pariser,C.L. Leonardi,K. Gordon,A.B. Gottlieb,S. Tyring,K.A. Papp
Integrated safety analysis: short- and long-term safety profiles of etanercept in patients with psoriasis
J Am Acad Dermatol, 67 (2012), pp. 245-256 http://dx.doi.org/10.1016/j.jaad.2011.07.040
81
J.A. Singh,G.A. Wells,R. Christensen,E. Tanjong Ghogomu,L. Maxwell,J.K. Macdonald
Adverse effects of biologics: A network meta-analysis and Cochrane overview
Cochrane Database Syst Rev, (2011),
CD008794
82
Schiff MH, Burmester GR, Pangan AL, Kupper H, Spencer Green JT. Safety of adalimumab (Humira) in global clinical trials of patients with early vs longstanding rheumatoid arthritis (RA) (abstract SAT0044). Presented at the Annual European Congress of Rheumatology (EULAR), Vienna, Austria, 2005.
83
M.H. Schiff,G.R. Burmester,J.D. Kent,A.L. Pangan,H. Kupper,S.B. Fitzpatrick
Safety analyses of adalimumab (HUMIRA) in global clinical trials and US postmarketing surveillance of patients with rheumatoid arthritis
Ann Rheum Dis, 65 (2006), pp. 889-894 http://dx.doi.org/10.1136/ard.2005.043166
84
S.E. Gabriel
Tumor necrosis factor inhibition: a part of the solution or a part of the problem of heart failure in rheumatoid arthritis?
Arthritis Rheum, 58 (2008), pp. 637-640 http://dx.doi.org/10.1002/art.23280
85
C. Ryan,C.L. Leonardi,J.G. Krueger,A.B. Kimball,B.E. Strober,K.B. Gordon
Association between biologic therapies for chronic plaque psoriasis and cardiovascular events: A meta-analysis of randomized controlled trials
86
K. Papp,A.B. Gottlieb,L. Naldi,D. Pariser,V. Ho,K. Goyal
Safety surveillance for ustekinumab and other psoriasis treatments from the Psoriasis Longitudinal Assessment and Registry (PSOLAR)
J Drugs Dermatol, 14 (2015), pp. 706-714
87
R.G. Langley,B.E. Elewski,M. Lebwohl,K. Reich,C.E. Griffiths,K. Papp,ERASURE Study Group; FIXTURE Study Group
Secukinumab in plaque psoriasis —results of two phase 3 trials
N Engl J Med, 371 (2014), pp. 326-338 http://dx.doi.org/10.1056/NEJMoa1314258
88
J. Perk,G. de Backer,H. Gohlke,I. Graham,Z. Reiner,M. Verschuren,European Association for Cardiovascular Prevention & Rehabilitation (EACPR); ESC Committee for Practice Guidelines (CPG)
European guidelines on cardiovascular disease prevention in clinical practice (version 2012)
Eur Heart J, 33 (2012), pp. 1635-1701 http://dx.doi.org/10.1093/eurheartj/ehs092
89
D.C Goff Jr.,D.M. Lloyd-Jones,G. Bennett,S. Coady,R.B. D’Agostino,R. Gibbons,American College of Cardiology/American Heart Association Task Force on Practice Guidelines
2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
90
R.B. D’Agostino,R.S. Vasan,M.J. Pencina,P.A. Wolf,M. Cobain,J.M. Massaro
General cardiovascular risk profile for use in primary care: The Framingham Heart Study
91
J. Marrugat,P. Solanas,R. D’Agostino,L. Sullivan,J. Ordovas,F. Cordón
Estimación del riesgo coronario en España mediante la ecuación de Framingham calibrada
Rev Esp Cardiol, 56 (2003), pp. 253-261
92
J. Marrugat,R. D’Agostino,L. Sullivan,R. Elosua,P. Wilson,J. Ordovas
An adaptation of the Framingham coronary heart disease risk function to European Mediterranean areas
J Epidemiol Community Health, 57 (2003), pp. 634-638
93
J. Marrugat,I. Subirana,E. Comín,C. Cabezas,J. Vila,R. Elosua
Validity of an adaptation of the Framingham cardiovascular risk function: the VERIFICA Study
J Epidemiol Community Health, 61 (2007), pp. 40-47 http://dx.doi.org/10.1136/jech.2005.038505
94
V.E. Friedewald,J.C. Cather,J.M. Gelfand,K.B. Gordon,G.H. Gibbons,S.M. Grundy
AJC editor's consensus: Psoriasis and coronary artery disease
Am J Cardiol, 102 (2008), pp. 1631-1643 http://dx.doi.org/10.1016/j.amjcard.2008.10.004
95
E. Daudén,S. Castañeda,C. Suárez,J. García-Campayo,A.J. Blasco,M.D. Aguilar
Working Group on Comorbidity in Psoriasis. Clinical practice guideline for an integrated approach to comorbidity in patients with psoriasis
J Eur Acad Dermatol Venereol, 27 (2013), pp. 1387-1404 http://dx.doi.org/10.1111/jdv.12024
96
M.A. Radtke,U. Mrowietz,J. Feuerhahn,M. Härter,R. von Kiedrowski,A. Nast
Early detection of comorbidity in psoriasis: Recommendations of the National Conference on Healthcare in Psoriasis
J Dtsch Dermatol Ges, 13 (2015), pp. 674-690 http://dx.doi.org/10.1111/ddg.12643

Please cite this article as: Bonanad C, González-Parra E, Rivera R, Carrascosa JM, Daudén E, Olveira A, et al. Implicaciones Clínicas, Diagnósticas Y Terapéuticas De La Psoriasis Y Enfermedad Cardiovascular. Actas Dermosifiliogr. 2017;108:800–808.

Corresponding author. (C. Bonanad clarabonanad@gmail.com)
Copyright © 2017. Elsevier España, S.L.U. and AEDV
Actas Dermosifiliogr 2017;108:800-8 - Vol. 108 Num.9 DOI: 10.1016/j.adengl.2017.08.021