Psoriatic Arthritis, RA, Psoriasis May Increase CV Risk

Diedtra Henderson

November 05, 2014

Patients with psoriatic arthritis (PsA), rheumatoid arthritis (RA), or psoriasis were at elevated risk of experiencing major cardiovascular (CV) events, such as myocardial infarction, cerebrovascular accidents, or CV death, if they had not been prescribed antirheumatic medication, according to a large study. The elevated risk remained for patients with RA or psoriasis even with disease-modifying antirheumatic drug (DMARD) treatment.

Alexis Ogdie, MD, MSCE, from the Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, and colleagues report the findings of their population-based longitudinal cohort study in an article published online October 28 in the Annals of the Rheumatic Diseases.

According to the National Institutes of Health, more than 3% of the US population has psoriasis, and up to 30% of these people develop PsA, according to the National Psoriasis Foundation. The National Institutes of Health also estimate that about 0.6% of the US population, or 1.5 million people, has RA.

The study authors note that PsA has been associated with CV risk factors, and RA has been linked to heightened composite heart risks, or major adverse CV events.

The researchers tapped data from 1994 to 2010 housed in the Health Improvement Network, a UK database that includes records for patients seen by general practitioners, to explore whether major adverse CV event risks were higher not only among patients with RA but also for patients with PsA or psoriasis.

They included 8706 patients with PsA, 41,752 patients with RA, and 138,424 patients with psoriasis but no known PsA. Participants were aged 18 to 89 years. About half of the patients with RA and PsA were prescribed a disease-modifying antirheumatic drug (DMARD), the researchers write. For a control group, the researchers matched up to 10 patients per patient with PsA; the 82,258 control patients did not have one of the ailments and were not taking such medicines, which include azathioprine, methotrexate, and sulfasalazine.

Dr Ogdie and coauthors detected an elevated incidence of major adverse CV events among patients with all three diseases if they were not prescribed DMARDs, with hazard ratios (HRs) of 1.24 (95% confidence interval [CI], 1.03 - 1.49), 1.39 (95% CI, 1.28 - 1.50), and 1.42 (95% CI, 1.17 - 1.73), respectively, for patients with PsA, RA, and severe psoriasis.

Whereas DMARD treatment did not attenuate the risk in patients with RA (HR, 1.58; 95% CI, 1.46 - 1.70) or psoriasis (HR, 1.42; 95% CI, 1.17 to 1.73), the risk was no longer statistically significant for patients with PsA and DMARD treatment (HR, 1.17; 95% CI, 0.95 - 1.46).

"All three diseases had statistically similar risks for the development of incident CV events after adjustment for age, sex, calendar year of cohort entry and traditional CV risk factors," the authors write.

Dr Ogdie told Medscape Medical News that the study results were segregated by people who were or were not using DMARDs. The medications have the potential to prevent CV outcomes by reducing systemic inflammation.

"But when you're looking at this retrospectively, it's a little more difficult than that," she said. The research team suggests performing prospective trials that randomly assign patients to receive or not to receive therapy to clarify the effect of systemic therapy in blunting major adverse CV event risk.

She said clinicians should "recognize that [CV] risk is not just for patients with RA or PsA, but also patients with psoriasis," and noted that they should screen such patients for CV risk factors that would be managed either by them or by primary care physicians.

In addition, patients with RA, PsA, or psoriasis, knowing they are at "a slightly increased risk" for CV outcomes, should be proactive and do what they can to prevent them, such as not smoking, losing weight, and maintaining a healthy weight. "It's not a reason for fear, but a reason to take action before these things develop," Dr Ogdie explained.

The study extends traditional CV risks, such as smoking, age, weight, and cholesterol levels, that are factored into Framingham risk scores, according to Eric Matteson, MD, a rheumatologist at the Mayo Clinic, which created a Cardio-Rheumatology Clinic to prevent, detect, treat, and study CV disease in people with inflammatory arthritis.

"I think an important message from the study is that, in addition to these risks, poorly controlled rheumatologic disease, like psoriatic arthritis and [RA], increases [CV] risk," Dr Matteson, rheumatology chair at Mayo Clinic, Rochester, Minnesota, told Medscape Medical News.

"So, doing the standard risk assessment is important. But, it may be necessary, especially in patients with persistently active disease, to go further. Assessment of carotid intimal thickening and stress testing in patients who one otherwise might not recommend it are considerations," Dr Matteson said.

"In conclusion, we report an increased incidence of [major adverse CV events] in PsA, psoriasis and RA," Dr Ogdie and colleagues write. "The [hazard ratios] for RA and psoriasis were similar to risk estimates in previous studies providing internal validity for the study results in patients with PsA and external validity for the study as a whole. These results suggest the need for improved screening and management of traditional CV risk factors in patients with inflammatory diseases."

The American College of Rheumatology provided financial support for the study and for one of the coauthors. Another coauthor disclosed serving as a paid consultant to Abbott, Amgen, Celgene, Centocor, Eli Lilly, Novartis, and Pfizer and disclosed receiving grants from Abbott, Amgen, Eli Lilly, Genentech, Novartis, and Pfizer. Two authors disclosed a sponsored research agreement between their university and AstraZeneca and Bristol-Myers Squibb; one of the pair further disclosed being a consultant for AstraZeneca, Bayer Healthcare, and Bristol-Myers Squibb and having received institutional support for pharmacoepidemiology training from Pfizer. The remaining authors have disclosed no relevant financial relationships.

Ann Rheum Dis. Published online October 28, 2014. Abstract

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