The Association Between Psoriasis and Atherosclerotic Cardiovascular Disease: A Systematic Review and Meta-Analysis of Observational Studies

Abstract

Psoriasis is a chronic immune-mediated disease affecting the skin, nails, and/or joints. It is associated with systemic inflammation and may also be linked to an increased risk of atherosclerotic cardiovascular disease (ASCVD). The objectives of this study were to determine the overall risk of ASCVD in patients with psoriasis and to evaluate the risk according to ASCVD type and the severity of psoriasis. This was a systematic review and meta-analysis of observational studies reporting the association between psoriasis and one or more of the clinical types of ASCVD. We searched Medical Literature Analysis and Retrieval System Online (MEDLINE) via PubMed, Excerpta Medica Database (EMBASE), Scopus, Bielefeld Academic Search Engine (BASE), and Google Scholar for relevant studies in the English language from the beginning of their records to July 2023. Study selection and data extraction were conducted by four independent reviewers. A total of 21 observational studies (three cross-sectional, one case-control, and 17 cohort) were included in this review, representing a total of 778,049 patients with psoriasis and 16,881,765 control subjects without psoriasis. The included studies had varying degrees of covariate adjustment, and thus, their findings may have been subject to residual confounding. All the meta-analyses used the adjusted effect sizes and were based on the random-effects model. However, the cohort studies were analysed separately from the non-cohort studies (the case-control and cross-sectional studies). There was a significant association between psoriasis and ASCVD (cohort studies: hazard ratio (HR), 1.21; 95% confidence interval (CI), 1.14 to 1.28; I² = 63%; p < 0.001; non-cohort studies: odds ratio (OR), 1.60; 95% CI, 1.34 to 1.92; I² = 31%; p = 0.23). Psoriasis was also significantly associated with myocardial infarction (cohort studies: HR, 1.20; 95% CI, 1.10 to 1.31; I² = 60%; p < 0.001; non-cohort studies: OR, 1.57; 95% CI, 1.15 to 2.15; I² = 74%; p = 0.05), coronary artery disease (cohort studies: HR, 1.20; 95% CI, 1.13 to 1.28; I² = 67%; p < 0.001; non-cohort studies: OR, 1.60; 95% CI, 1.34 to 1.92; I² = 31%; p = 0.23), aortic aneurysm (HR, 1.45; 95% CI, 1.04 to 2.02; I² = 67%; p = 0.08) but not with ischaemic stroke (HR, 1.14; 95% CI, 0.96 to 1.36; I² = 44%; p = 0.17). Pooled analysis in terms of the severity of psoriasis showed that both mild (cohort studies: HR, 1.17; 95% CI, 1.08 to 1.26; I² = 74%; p < 0.001; non-cohort studies: OR, 1.54; 95% CI, 1.25 to 1.90; I² = 0%; p = 0.50) and severe (cohort studies: HR, 1.43; 95% CI, 1.23 to 1.65; I² = 65%; p < 0.001; non-cohort studies: OR, 1.65; 95% CI, 1.29 to 2.12; I² = 25%; p = 0.26) psoriasis were significantly associated with ASCVD. Psoriasis (including mild and severe disease) is associated with an increased risk of ASCVD, including coronary artery disease (CAD) and aortic aneurysm (AA). ASCVD risk assessment and prevention should be prioritised in all adult psoriasis patients. Future observational studies investigating the association between psoriasis and ASCVD should conduct a more comprehensive adjustment of covariates.

Keywords: atherosclerotic cardiovascular disease; cardiovascular disease; case-control studies; cohort studies; cross-sectional studies; meta-analysis; observational studies; psoriasis; systematic review.

Figure 1. PRISMA flow diagram

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Figure 2. Funnel plot for the pooled analysis of overall ASCVD (cohort studies)

ASCVD: atherosclerotic cardiovascular disease; HR: hazard ratio

Figure 3. Funnel plot for the pooled analysis of MI (cohort studies)

MI: myocardial infarction; HR: hazard ratio

Figure 4. Funnel plot for pooled analysis of CAD (cohort studies)

CAD: coronary artery disease; HR: hazard ratio

Figure 5. Funnel plot for the pooled analysis of mild psoriasis and ASCVD (cohort studies)

ASCVD: atherosclerotic cardiovascular disease; HR: hazard ratio

Figure 6. Funnel plot for the pooled analysis of severe psoriasis and ASCVD (cohort studies)

ASCVD: atherosclerotic cardiovascular disease; HR: hazard ratio

Figure 7. Forest plot of the association between psoriasis and ASCVD (cohort studies)

ASCVD: atherosclerotic cardiovascular disease

Figure 8. Forest plot of the association between psoriasis and ASCVD (non-cohort studies)

ASCVD: atherosclerotic cardiovascular disease

Figure 9. Forest plot of the association between psoriasis and ischaemic stroke

Figure 10. Forest plot of the association between psoriasis and MI (cohort studies)

MI: myocardial infarction

Figure 11. Forest plot of the association between psoriasis and MI (non-cohort studies)

MI: myocardial infarction

Figure 12. Forest plot of the association between psoriasis and CAD (cohort studies)

CAD: coronary artery disease

Figure 13. Forest plot of the association between psoriasis and CAD (non-cohort studies)

CAD: coronary artery disease

Figure 14. Forest plot of the association between psoriasis and AA

AA: aortic aneurysm

Figure 15. Forest plot of the association between mild psoriasis and ASCVD (cohort studies)

ASCVD: atherosclerotic cardiovascular disease

Figure 16. Forest plot of the association between severe psoriasis and ASCVD (cohort studies)

ASCVD: atherosclerotic cardiovascular disease

Figure 17. Forest plot of the association between mild psoriasis and ASCVD (non-cohort studies)

ASCVD: atherosclerotic cardiovascular disease

Figure 18. Forest plot of the association between severe psoriasis and ASCVD (non-cohort studies)

ASCVD: atherosclerotic cardiovascular disease

Figure 19. Funnel plots for meta-analyses with less than five studies

ASCVD: atherosclerotic cardiovascular disease; CAD: coronary artery disease; OR: odds ratio; HR: hazard ratio