Update on Cardiovascular Risk and Obesity in Psoriatic Arthritis

Abstract

PsA is characterized by a high prevalence of cardiovascular (CV) comorbidities. Recognizing these comorbidities is critical due to their influence on the quality of life and the choice of therapy. Imaging techniques also play an important role in the evaluation of the CV risk in psoriatic disease, improving the prediction of CV events when combined with clinical scores as a predictive tool. Meta-analyses point to a significant reduction in the incidence of CV events associated with the suppression of inflammatory activity when using systemic therapies. Consequently, the mortality rate in PsA patients has fallen in the last 40 years and is now similar to that of the general population, including cardiovascular causes. Obesity is an especially relevant CV comorbidity in patients with psoriatic disease, most of whom are overweight/obese. Body mass index (BMI) is a risk factor for PsA and a causal relationship with psoriasis has been demonstrated by Mendelian randomized studies. The study of fat distribution shows that patients with psoriasis are characterized by visceral fat accumulation, which correlates with CV risk measurements. These findings suggest that approaches to the prevention and treatment of psoriatic disease might come from targeting adiposity levels, in addition to the immune pathways. Weight loss treatment with low energy diets in patients with PsA has been associated with significant improvements in disease activity. Novel strategies using a multimorbidity approach, focused more on patients outcomes, are necessary to better address comorbidities, improve clinical outcomes and the quality of life of patients with psoriatic disease.

Keywords: cardiovascular risk; comorbidities; obesity; psoriasis; psoriatic arthritis.

Figure 1

Cardiovascular comorbidities in patients with psoriatic arthritis. Although PsA can be associated with a higher prevalence of cardiovascular risk factors, these conditions do not fully account for the greater incidence of cardiovascular events. Associated factors, such as chronic systemic inflammation, a predisposing genetic background, or the baseline treatment, must contribute to the higher cardiovascular risk. Comorbidity is defined as the existence of any additional entity during the clinical course of a patient who has the index disease under study, such as PsA. In the comorbidity concept, the management and treatment are primarily focused on the index disease and the effect quantified by evaluating the disease activity. In the multimorbidity concept, the patient is of central concern and all coexisting diseases are of equal importance with interactions between each other. In the multimorbidity concept, the management and treatment focus on the patient and effectiveness is quantified by overall indicators such as quality of life or physical function (5). This new approach compels us to tackle with PsA patients from a multidisciplinary perspective. PsO, psoriasis; PsA, psoriathic arthritis; LDL, Low-density lipoprotein; NAFLD, Nonalcoholic fatty liver disease.

Figure 2

Cardiovascular risk stratification in Immunomediated diseases. According to the prevalence of cardiovascular risk factors and the incidence of cardiovascular events, we should consider SLE as the IMID with highest cardiovascular risk burden, followed by RA, PsO, PsA, and IBD (20). The severity of skin involvement could be essential to classify the cardiovascular profile of psoriatic disease (21). IBD, inflammatory bowel disease; PsA, psoriatic Arthritis; PsO, Psoriasis; RA, Rheumatoid Arthritis; SLE, systemic lupus erythematosus.