Psoriasis, a chronic inflammatory skin condition, has long been associated with an increased risk of cardiovascular disease. Studies have shown that patients with psoriasis are more likely to develop conditions such as atherosclerosis and premature coronary artery disease. The underlying mechanism behind this association has remained unclear. However, a recent prospective study conducted by Stefano Piaserico, MD, PhD, and his colleagues at the University of Padua in Italy has shed new light on the connection between psoriasis and cardiovascular disease.
The study found that almost a third of patients with severe psoriasis had echocardiographic evidence of asymptomatic coronary microvascular dysfunction (CMD). Using Doppler echocardiography, the researchers discovered that 31.5% of the 448 psoriasis patients included in the study had CMD. Furthermore, they observed that every 1-point increase in the Psoriasis Area and Severity Index (PASI) score, as well as a 1-year increase in the duration of psoriasis, correlated with a 5% to 6% increase in the risk of CMD.
Possible Mechanistic Explanation
The findings of this study provide a possible mechanistic explanation for the well-established association between psoriasis and cardiovascular disease. The researchers suggest that systemic inflammation, a key characteristic of psoriasis, contributes to the development of atherosclerosis and affects coronary microvascular function. The presence of CMD in psoriasis patients indicates that the immune-mediated injury associated with psoriasis may also occur in the coronary microcirculation. This novel insight highlights the importance of diagnosing and actively searching for microvascular dysfunction in patients with psoriasis, as they are at particularly high risk of cardiovascular events.
Implications for the Diagnosis and Treatment of Cardiovascular Risk in Psoriasis
The study findings have significant implications for the diagnosis, stratification, and treatment of cardiovascular risk in psoriasis patients. Assessing coronary microvascular function, particularly through the measurement of coronary flow reserve (CFR), might offer valuable insights into the individual’s cardiovascular risk status. As CMD is largely independent of traditional cardiovascular risk factors, CFR could serve as a useful tool for monitoring vascular function during psoriasis therapy. Improvements in CFR could potentially indicate a reduced risk of subsequent cardiovascular events.
Underdiagnosis and Undertreatment of Psoriasis Patients for Cardiovascular Risk Factors
Despite the established association between psoriasis and cardiovascular risk, there is evidence of underdiagnosis and undertreatment of psoriasis patients for cardiovascular risk factors. A majority of patients have not received adequate evaluation and management of conditions such as diabetes, hypertension, and hyperlipidemia. Furthermore, a significant proportion of patients with treated cardiovascular risk factors fail to achieve the recommended treatment goals. This highlights the need for healthcare providers, particularly dermatologists, to actively identify and address cardiovascular risk factors in psoriasis patients.
The study also emphasizes the significance of early and effective treatment for psoriasis in reducing cardiovascular risk. The severity of psoriasis, the presence of psoriatic arthritis, and the duration of the disease were found to be independently associated with a lower CFR. Therefore, it can be hypothesized that timely and targeted treatment of psoriasis may restore coronary microvascular function and prevent the future risk of myocardial infarction and heart failure.
Promising Role of TNF-alpha Inhibitors in Improving Coronary Microvascular Function
Preliminary studies have shown that treatment with TNF-alpha inhibitors, ustekinumab (Stelara), or secukinumab (Cosentyx) can lead to a significant increase in coronary flow reserve after 4-6 months. This suggests that these medications may have a therapeutic effect on improving microvascular function in psoriasis patients. Further research is needed to explore the potential benefits of these treatments in reducing cardiovascular risk.
The Road Ahead: Towards Better Cardiovascular Care for Psoriasis Patients
The study by Piaserico and colleagues provides valuable insights into the connection between psoriasis and cardiovascular disease. By identifying asymptomatic coronary microvascular dysfunction as a common occurrence in psoriasis patients, this research opens doors for improved diagnosis and management of cardiovascular risk in this population. With a better understanding of the underlying mechanisms of cardiovascular disease in psoriasis, healthcare providers can strive to deliver comprehensive care that addresses both skin-related symptoms and cardiovascular risk factors.
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