Coronary Plaque Characterization in Psoriasis Reveals High-Risk Features That Improve After Treatment in a Prospective Observational Study

Abstract

Background: Psoriasis, a chronic inflammatory disease associated with an accelerated risk of myocardial infarction, provides an ideal human model to study inflammatory atherogenesis in vivo. We hypothesized that the increased cardiovascular risk observed in psoriasis would be partially attributable to an elevated subclinical coronary artery disease burden composed of noncalcified plaques with high-risk features. However, inadequate efforts have been made to directly measure coronary artery disease in this vulnerable population. As such, we sought to compare total coronary plaque burden and noncalcified coronary plaque burden (NCB) and high-risk plaque (HRP) prevalence between patients with psoriasis (n=105), patients with hyperlipidemia eligible for statin therapy under National Cholesterol Education Program-Adult Treatment Panel III guidelines (n=100) who were ≈10 years older, and healthy volunteers without psoriasis (n=25).

Methods: Patients underwent coronary computed-tomography angiography for total coronary plaque burden and NCB quantification and HRP identification, defined as low attenuation (<30 hounsfield units), positive remodeling (>1.10), and spotty calcification. A consecutive sample of the first 50 patients with psoriasis was scanned again 1 year after therapy.

Results: Despite being younger and at lower traditional risk than patients with hyperlipidemia, patients with psoriasis had increased NCB (mean±SD: 1.18±0.33 versus 1.11±0.32, P=0.02) and similar HRP prevalence (P=0.58). Furthermore, compared to healthy volunteers, patients with psoriasis had increased total coronary plaque burden (1.22±0.31 versus 1.04±0.22, P=0.001), NCB (1.18±0.33 versus 1.03±0.21, P=0.004), and HRP prevalence beyond traditional risk (odds ratio, 6.0; 95% confidence interval, 1.1-31.7; P=0.03). Last, among patients with psoriasis followed for 1 year, improvement in psoriasis severity was associated with improvement in total coronary plaque burden (β=0.45, 0.23-0.67; P<0.001) and NCB (β=0.53, 0.32-0.74; P<0.001) beyond traditional risk factors.

Conclusions: Patients with psoriasis had greater NCB and increased HRP prevalence than healthy volunteers. In addition, patients with psoriasis had elevated NCB and equivalent HRP prevalence as older patients with hyperlipidemia. Last, modulation of target organ inflammation (eg, skin) was associated with an improvement in NCB at 1 year, suggesting that control of remote sites of inflammation may translate into reduced coronary artery disease risk.

Keywords: coronary computed tomography angiography; high-risk plaque; inflammation; noncalcified burden; psoriasis.

Figure 1. High-risk plaque in a psoriasis patient that was subsequently found to be culprit for a ST-elevation myocardial infarction during follow-up

This figure demonstrates baseline high-risk plaque characteristics in a psoriasis patient, who during longitudinal follow-up was found to have an acute ST-Elevation Myocardial Infarction, with catheterization identified culprit lesion corresponding to the previously identified RPDA high-risk plaque (HRP). A – 3-Dimensional Reconstruction of baseline CCTA, demonstrating stenosed vessel in RPDA. B- Planar reconstruction of vessel demonstrating HRP. C – Clinical catheterization identified culprit lesion (yellow arrow). D: Color coded curved multiplanar reconstruction. Green: Vessel lumen, blue: Non-calcified plaque component, yellow: Calcified plaque component. E and F: Cross sectional images. The plaque is only partially calcified, showing spotty calcification and some positive remodeling. Stenosis was graded as moderate-severe.