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

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.

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.

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.

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.

Figure 1.

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.

(0.38MB).

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.

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.