Psoriatic Arthritis: Systemic Burden Tied to Atherosclerosis

Lara C. Pullen, PhD

May 22, 2014

Patients who have psoriatic arthritis (PsA) and an increased burden of inflammation are also likely to have more severe atherosclerosis.

Lihi Eder, MD, PhD, from the Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, Ontario, Canada, and colleagues present their analysis of a large (n = 235) PsA cohort in an article published online May 14 in the Annals of Rheumatic Disease. The study used atherosclerosis as a surrogate for clinical cardiovascular events.

Patients with PsA have many of the traditional cardiovascular risk factors. The investigators explain in their discussion that although the association between PsA and increased cardiovascular disease has been established, few studies have investigated the underlying cause behind the link. Atherosclerosis is a chronic vascular inflammation, and the investigators propose that the association between PsA and atherosclerosis is mediated by traditional cardiovascular risk factors.

The investigators found that patients with severe atherosclerosis were more likely to be older (P < .0001), obese (P = .01), smokers (P = .008), and have hypertension (P = .001), diabetes (P < .0001), and dyslipidemia (P < .0001). When the authors performed a multivariate regression model adjusted for age and sex, higher erythrocyte sedimentation rate (P = .009), white blood cell count (P = .015), and Disease Activity for PsA (P = .04) were all associated with more severe atherosclerosis. In other words, patients with a higher inflammatory burden had more evidence of atherosclerosis.

The associations were no longer significant, however, once the researchers adjusted for traditional cardiovascular risk factors.

In addition, the investigators found no association between disease duration and atherosclerosis. Nor did they find an association between C-reactive protein and atherosclerosis, despite its association with increased cardiovascular risk in the general population.

"Our paper highlights the fact that it is the burden of inflammation, not just evidence of inflammation at one point, which is important. Generally, we adjust for items that might have an effect on the outcome. When we adjusted for items that are known to be related to atherosclerosis, such as features of the metabolic syndrome, which [are] also increased among patients with PsA, the effect of inflammatory markers was lost, suggesting that the metabolic features may mediate the effect of inflammation," coauthor Dafna D. Gladman, MD, FRCPC, also from Toronto Western Hospital, told Medscape Medical News.

The investigators suggest that control of inflammation and metabolic factors via systemic therapies may prevent the progression of atherosclerotic plaques and reduce the risk for cardiovascular events. "[The study] supports the notion that patients with inflammatory arthritis should be treated aggressively to control inflammation in order to prevent this comorbidity," Dr. Gladman noted.

Joseph Merola, MD, dermatologist at Brigham and Women's Hospital in Boston, Massachusetts, partially agrees.

"This means 2 things for physicians taking care of patients: (1) appropriate control of traditional risk factors (lipid/cholesterol management, diabetic control, weight loss, smoking cessation), [which] remain the most important factors to control the development of atherosclerotic disease and subsequent cardiovascular disease; (2) exposure to the increased inflammation of psoriatic arthritis likely contributes to the severity of disease to some degree; however, further data and studies are needed to know whether control of this inflammation will have any effect on preventing the formation of these plaques and impact cardiovascular disease risk. Those patients with higher, persistent levels of systemic inflammatory markers may be at increased risk for cardiovascular disease," said Dr. Merola, who was not involved in the study.

The authors, Dr. Gladman, and Dr. Merola have disclosed no relevant financial relationships.

Ann Rheum Dis. Published online May 14, 2014. Abstract

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