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Review
. 2021 Apr 6;77(13):1670-1680.
doi: 10.1016/j.jacc.2021.02.009.

Cardiovascular Risk in Patients With Psoriasis: JACC Review Topic of the Week

Michael S Garshick  1 , Nicole L Ward  2 , James G Krueger  3 , Jeffrey S Berger  4
Affiliations
Review

Cardiovascular Risk in Patients With Psoriasis: JACC Review Topic of the Week

Michael S Garshick et al. J Am Coll Cardiol. .

Abstract

Psoriasis is a chronic inflammatory skin disease that affects 2% to 3% of the U.S. population. The immune response in psoriasis includes enhanced activation of T cells and myeloid cells, platelet activation, and up-regulation of interferons, tumor necrosis factor-α, and interleukins (ILs) IL-23, IL-17, and IL-6, which are linked to vascular inflammation and atherosclerosis development. Patients with psoriasis are up to 50% more likely to develop cardiovascular disease (CV) disease, and this CV risk increases with skin severity. Major society guidelines now advocate incorporating a psoriasis diagnosis into CV risk prediction and prevention strategies. Although registry data suggest treatment targeting psoriasis skin disease reduces vascular inflammation and coronary plaque burden, and may reduce CV risk, randomized placebo-controlled trials are inconclusive to date. Further studies are required to define traditional CV risk factor goals, the optimal role of lipid-lowering and antiplatelet therapy, and targeted psoriasis therapies on CV risk.

Keywords: cardiovascular disease; cardiovascular risk; inflammation; psoriasis.

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Conflict of interest statement

Funding Support and Author Disclosures Financial support was provided, in part, by an American Heart Association Career Development Grant 18CDA34080540 and National Psoriasis Foundation Bridge Grant, (to Dr. Garshick). Dr. Ward was supported, in part, by National Institutes of Health grants P50AR070590, R01AR063437, and R01AR073196. Dr. Krueger has received grants from Novartis, Pfizer, Amgen, Lilly, Boehringer, Innovaderm, Bristol Myers Squibb, Janssen, Abbvie, Paraxel, Leo Pharma, Vitae, Akros, Regeneron, Allergan, Novan, Biogen MA, Sienna, UCB, Celgene, Botanix, Incyte, Avillion, and Exicure; has received personal fees from Novartis, Pfizer, Amgen, Lilly, Boehringer, BiogenIdec, Abbvie, Leo Pharma, Escalier, Valeant, Aurigne, Allergan, Asana, UCB, Sienna, Celgene, Nimbus, Menlo, Aristea, Sanofi, Sun Pharma, Almirall, Arena, and Bristol Myers Squibb. Dr. Berger was supported, in part, by National Institutes of Health grants R01HL139909, R01HL114978, and R35HL144993.

Figures

Figure 1.
Figure 1.. Pathogenesis of Psoriasis.
External stimuli combined with genetic pre-disposition generates an inflammatory cascade and activation of dendritic cells. Upregulated cytokines, including IL-23, lead to T cell activation and differentiation (Th17 cells). Synergistic action between IL-17 isoforms (A/F) along with TNF-α and IL-1 amplify inflammation and drive keratinocyte proliferation in the skin. IFN; Interferon, IL; Interleukin, TNF; Tumor necrosis factor.
Figure 2.
Figure 2.. Factors Influencing Cardiovascular Disease in Psoriasis.
The suspected pathogenesis of cardiovascular disease in psoriasis includes a combination of cutaneous and systemic immune system activation along with the contribution of co-existing cardiometabolic conditions. HDL; High-density lipoprotein, IFN; interferon, IL; Interleukin, LDL; Low-density lipoprotein, Lp(a); Lipoprotein(a), Ox; oxidized, TNF; Tumor necrosis factor.
Figure 3.
Figure 3.. Association between Psoriasis and Traditional Cardiovascular Risk Factors.
From the American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities. *Some studies find less robust associations between psoriasis, hypertension, and, dyslipidemia. †In a meta-analysis encompassing 42,000 psoriasis patients, the odds ratio for metabolic syndrome was as high as 2.26 (95% CI 1.70 - 3.01). ‡Association between smoking and psoriasis. CI; Confidence interval.
Figure 4.
Figure 4.. Approach to Primary Prevention in Psoriasis.
A suggested approach to cardiovascular (CV) risk management in psoriasis including early screening, the appropriate use of diagnostic tests, and therapeutic interventions.
See this image and copyright information in PMC

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