Review
Heart disease in psoriasis

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Psoriasis has been traditionally viewed as an inflammatory skin disorder of unknown origin. Recent advances in the immunopathogenesis and genetics of psoriasis have broadened our understanding of psoriasis. Psoriasis is now considered a systemic inflammatory condition analogous to other inflammatory immune disorders. Patients with other immune disorders, such as systemic lupus erythematosus or rheumatoid arthritis, are known to be at increased risk of heart disease. Similarly, patients with psoriasis may carry an excess risk of heart disease, which would represent an important previously unrecognized cause of morbidity and mortality. This review summarizes the current evidence for an increased cardiovascular risk in patients with psoriasis and outlines deficits in our knowledge in this area.

Section snippets

Evidence for an increased risk of cardiovascular disease in psoriasis

The excess risk of cardiovascular disease in psoriasis has been demonstrated in a number of observational studies.3, 18, 19, 20, 21, 22, 23, 24 In a clinic-based study by McDonald and Calabresi,18 the risk of arterial and venous vascular diseases (eg, myocardial infarction, thrombophlebitis, pulmonary embolization, and cerebrovascular accident) was 2.2 times higher among the 323 patients with psoriasis compared with 325 control patients with other dermatologic conditions. Disease duration did

Potential mechanisms for cardiovascular risk in psoriasis

The biologic mechanisms that putatively contribute to accelerated atherosclerosis and increased risk of cardiovascular events in psoriasis are largely unknown but are likely to be multifactorial. Plausible, yet still putative mechanisms are explored below.

First, psoriasis and cardiovascular disease may share common risk factors, such as smoking and alcohol consumption (Fig 1). Second, patients with psoriasis may have a higher prevalence of conventional cardiovascular risk factors compared with

Role of conventional cardiovascular risk factors

The role of conventional cardiovascular risk factors in psoriasis is particularly relevant because patients with psoriasis have a higher prevalence of smoking, alcohol consumption, lipid abnormalities, and hypertension compared with their peers without psoriasis, as summarized in this section.

Role of nonconventional cardiovascular risk factors

In addition to the above conventional risk factors, another potential cardiovascular risk factor in psoriasis is altered homocysteine metabolism. In a small clinic-based study, patients with psoriasis had significantly higher plasma homocysteine levels compared with control subjects.80 Hyperhomocysteinemia may be an adverse effect of systemic medications, such as methotrexate.26 In both psoriasis and rheumatoid arthritis, methotrexate use was associated with a reduced risk of cardiovascular

Chronic inflammation as the mechanism for the excess risk of coronary heart disease in psoriasis

Inflammation has been implicated in the etiology of atherosclerosis, unstable coronary syndromes, and heart failure.13, 85, 86 Inflammatory immune activation may lead to increased blood levels of proinflammatory cytokines and acute phase reactants. Low-grade inflammation, as evidenced by increased levels of acute-phase reactants and proinflammatory cytokines, are strongly associated with the risk and outcomes of coronary events. Little is known about the presence of these mechanisms in patients

Conclusions

Preliminary epidemiologic evidence suggests that psoriasis is associated with a long-term risk of cardiovascular disease in affected patients. The molecular mechanism or mechanisms that may underlie this added risk are poorly defined but likely include both conventional and nonconventional cardiovascular risk factors. There is a need to confirm the risk of cardiovascular disease in psoriasis and to better understand its determinants to identify effective prevention strategies.

Indicators of

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    Funding sources: None.

    Disclosure: Dr Dann is an employee of Amgen Inc. Aside from Dr Dann's intellectual contributions, no funding or other support from industry was received for this work. Drs Maradit Kremers, McEvoy, and Gabriel have received funding from Amgen Inc for separate research on a related topic.

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