Editorial
Psoriatic arthritis (PsA) is a chronic inflammatory skeletal and dermatological disease with heterogeneous clinical features and a strong relationship with spondyloarthritis group, sharing several genetic, clinical and radiographic characteristics [1] and with a prevalence in the western country populations around 0.07-0.42 [2]. Therapeutics options for both skin and joint disease have dramatically improved allowing efficient control of inflammatory activity of patients, including control of comorbidities such as metabolic and cardiovascular diseases (CVD), as well as depression and anxiety that were reported like negative predictors of PsA remission [3]. Inflammatory charge of the psoriasis disease seems an independent risk factor for CVD in those patients with severe joint or skin disease [4] even in patients without traditional CVD risk factors and having a high frequency of subclinical atherosclerosis than matched controls [5,6]. Severe psoriasis is associated with a risk of more than 50% ischemic heart attack type acute myocardial infarction [7] with rates almost equal to coronary involvement caused by Type 2 Diabetes Mellitus [8]. Moreover, Husted et al. demonstrated that patients with psoriatic arthritis are more prone to cardiovascular comorbidity than patients with psoriasis without arthritis [9] and patients with PsA are at increased risk of cardiovascular morbidities compared with the general population [10]. In addition to known risk factors for CVD, severe psoriasis is an important predictor in patients with PsA.
Data from the baseline visit of a 10-year Spanish cardiovascular prospective study (CARMA project) that includes a cohort of patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS), PsA and another cohort of matched individuals without inflammatory diseases show prevalence of CV morbidity, CV risk factors and systematic coronary risk evaluation (SCORE) assessment higher in patients with inflammatory diseases and it is of particular relevance as almost half of them were receiving biological therapy and most patients had low disease activity at the time of assessment [11].
Mortality seems to be increased in PsA patients because they could have a high prevalence of risk factors for CVD including hypertension, hyperlipidemia, diabetes and others like obesity or smoke habit [12]. Cardiovascular events (CVE) are increased in PsA patients as was observed by Gladman et al. [10] who show significantly increased risk of hypertension, myocardial infarction (MI) and angina in PsA.
Other comorbidities are increased, such as depression and anxiety or non-alcoholic fatter liver disease (NAFLD), that they have been associated with CVD as well [13,14]. A systematic review and meta-analysis found anxiety and depression were highly prevalent among PsA patients and they had reported greater disease activity [15], which we know to be related with CVD. NAFLD is one of the most frequent cause of chronic liver disease with a prevalence of 10%-25% in the general population and itself represents a further independent cardiovascular risk factor for atherosclerosis which is likely linked to arterial stiffness [16,17] and several studies have demonstrated the presence of a direct association between NAFLD and CVD suggesting that NALFD should be considered a significant independent risk factor in the absence of traditional cardiovascular (CV) risk factors and metabolic syndrome for subclinical and clinical CVD [14].
Treatments such as conventional synthetic disease-modifying antirheumatic drugs (csDMARD) or some non-steroidal anti-inflammatory drugs (NSAIDs) may also exacerbate heart disease [18] although in others studies patients with RA treated with methotrexate and especially with anti-TNF-α drugs have been associated with lowering the risk of CV events [19-21]. Recent advances in the management of treatment with biological disease-modifying antirheumatic drugs (bDMARD) may improve the outcome of patients with Pso and PsA [22], but not all studies support this conclusion and did not find the association between the treatment of biological agents and CVE in patients with Psoriasis and PsA [23].
In summary, there is an increased prevalence of CV risk factors and CVD in patients with PsA when compared with general population and with those with psoriasis only. Inflammation appears as an important feature explaining the increased cardiovascular risk in PsA, by participating in the atherosclerotic process and increasing the established conventional cardiovascular risk factors.
References
2. Ogdie A, Weiss P. The Epidemiology of Psoriatic Arthritis. Rheumatic Disease Clinics of North America. 2015 Nov 1;41(4):545-68.
3. Michelsen B, Kristianslund EK, Sexton J, Hammer HB, Fagerli KM, Lie E, et al. Do depression and anxiety reduce the likelihood of remission in rheumatoid arthritis and psoriatic arthritis? Data from the prospective multicentre NOR-DMARD. study. Annals of the Rheumatic Diseases. 2017 Nov 1;76(11):1906-10.
4. Ogdie A, Yu Y, Haynes K, Love TJ, Maliha S, Jiang Y, et al. Risk of major cardiovascular events in patients with psoriatic arthritis, psoriasis and rheumatoid arthritis: a population-based cohort study. Annals of the Rheumatic Diseases. 2015 Feb 1;74(2):326-32.
5. Gonzalez‐Juanatey C, Llorca J, Miranda‐Filloy JA, Amigo‐Diaz E, Testa A, Garcia‐Porrua C, et al. Endothelial dysfunction in psoriatic arthritis patients without clinically evident cardiovascular disease or classic atherosclerosis risk factors. Arthritis Care & Research. 2007 Mar 15;57(2):287-93.
6. Gonzalez‐juanatey C, Llorca J, Amigo‐Diaz E, Dierssen T, Martin J, Gonzalez‐Gay MA. High prevalence of subclinical atherosclerosis in psoriatic arthritis patients without clinically evident cardiovascular disease or classic atherosclerosis risk factors. Arthritis Care & Research. 2007 Aug 15;57(6):1074-80.
7. Gelfand JM, Dommasch ED, Shin DB, Azfar RS, Kurd SK, Wang X, et al. The risk of stroke in patients with psoriasis. Journal of Investigative Dermatology. 2009 Oct 1;129(10):2411-8.
8. Mansouri B, Kivelevitch D, Natarajan B, Joshi AA, Ryan C, Benjegerdes K, et al. Comparison of coronary artery calcium scores between patients with psoriasis and type 2 diabetes. JAMA Dermatology. 2016 Nov 1;152(11):1244-53.
9. Husted JA, Thavaneswaran A, Chandran V, Eder L, Rosen CF, Cook RJ, et al. Cardiovascular and other comorbidities in patients with psoriatic arthritis: a comparison with patients with psoriasis. Arthritis Care & Research. 2011 Dec;63(12):1729-35.
10. Gladman DD, Ang M, Su L, Tom BD, Schentag CT, Farewell VT. Cardiovascular morbidity in psoriatic arthritis. Annals of the Rheumatic Diseases. 2009 Jul 1;68(7):1131-5.
11. Castañeda S, Martín-Martínez MA, González-Juanatey C, Llorca J, García-Yébenes MJ, Pérez-Vicente S, et al. Cardiovascular morbidity and associated risk factors in Spanish patients with chronic inflammatory rheumatic diseases attending rheumatology clinics: Baseline data of the CARMA Project. Seminars in Arthritis and Rheumatism. 2015 Jun; 44(6):618-26.
12. Jafri K, Bartels CM, Shin D, Gelfand JM, Ogdie A. Incidence and Management of Cardiovascular Risk Factors in Psoriatic Arthritis and Rheumatoid Arthritis: A Population-Based Study. Arthritis Care & Research. 2017 Jan;69(1):51-7.
13. Dunbar JA, Reddy P, Davis-Lameloise N, Philpot B, Laatikainen T, Kilkkinen A, et al. Depression: an important comorbidity with metabolic syndrome in a general population. Diabetes Care. 2008 Dec 1; 31(12):2368-73.
14. Ekstedt M, Hagström H, Nasr P, Fredrikson M, Stål P, Kechagias S, et al. Fibrosis stage is the strongest predictor for disease-specific mortality in NAFLD after up to 33 years of follow-up. Hepatology. 2015 May; 61(5):1547-54.
15. Zhao SS, Miller N, Harrison N, Duffield SJ, Dey M, Goodson NJ. Systematic review of mental health comorbidities in psoriatic arthritis. Clinical Rheumatology. 2020 Jan 1;39(1):217-25.
16. Chung GE, Choi SY, Kim D, Kwak MS, Park HE, Kim MK, et al. Nonalcoholic fatty liver disease as a risk factor of arterial stiffness measured by the cardioankle vascular index. Medicine (Baltimore). 2015 Mar; 94(12):e654.
17. Ganzetti G, Campanati A, Molinelli E, Offidani A. Psoriasis, non-alcoholic fatty liver disease, and cardiovascular disease: three different diseases on a unique background. World Journal of Cardiology. 2016 Feb 26;8(2):120-31.
18. Kitas GD, Erb N. Tackling ischaemic heart disease in rheumatoid arthritis. Rheumatology (Oxford) 2003 May;42(5):607-13.
19. Choi HK, Hernán MA, Seeger JD, Robins JM, Wolfe F. Methotrexate and mortality in patients with rheumatoid arthritis: a prospective study. The Lancet. 2002 Apr 6;359(9313):1173-7.
20. Dixon WG, Watson KD, Lunt M, Hyrich KL, Silman AJ, Symmons DP. Reduction in the incidence of myocardial infarction in patients with rheumatoid arthritis who respond to anti–tumor necrosis factor α therapy: results from the British Society for Rheumatology Biologics Register. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology. 2007 Sep;56(9):2905-12.
21. Greenberg JD, Kremer JM, Curtis JR, Hochberg MC, Reed G, Tsao P, et al. Tumour necrosis factor antagonist use and associated risk reduction of cardiovascular events among patients with rheumatoid arthritis. Annals of the Rheumatic Diseases. 2011 Apr 1;70(4):576-82.
22. Mahil SK, Smith CH. Psoriasis biologics: a new era of choice. Lancet. 2019 Sep;394(10201):807-8.
23. Ahlehoff O, Skov L, Gislason G, Gniadecki R, Iversen L, Bryld LE, et al. Cardiovascular outcomes and systemic anti‐inflammatory drugs in patients with severe psoriasis: 5‐year follow‐up of a Danish nationwide cohort. Journal of the European Academy of Dermatology and Venereology. 2015 Jun;29(6):1128-34.