Cardiovascular Journal of Africa: Vol 29 No 3 (May/Junel 2018)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 3, May/June 2018 192 AFRICA
subjects with severe PsO. There was no increased risk for MACE
in PsO patients without a family history of CVD.
Conventional cardiovascular risk factors
Patients with PsO have a higher burden of classic CV risk factors
compared to the general population.11,63 In particular, and as
discussed previously, there are higher prevalences of T2DM,
dyslipidaemia, hypertension and obesity in subjects with PsO.
Furthermore, it is known that patients with PsO have a higher
prevalence of smoking than those who do not have PsO.64
Drug therapy
Several drugs used to treat cutaneous PsO and PsA potentially
increase the risk of cardiometabolic disorders. These include
oral corticosteroids, cyclosporine and acitretrin, which may
precipitate weight gain and unmask hypertension, T2DM and
dyslipidaemia.8,65 Non-steroidal anti-inflammatory drugs, used in
the treatment of PsA, increase the risk of hypertension and CVD.66
Strategies to reduce cardiovascular risk in
psoriasis
Psoriasis management guidelines highlight the importance of
addressing cardiometabolic risk factors in PsO.67 There is a need
for further research to address whether systemic therapy for PsO
may potentially ameliorate CV risk.67,68
General measures
Several expert groups recommend clinical and biochemical
screening of PsO patients for early detection and management
of co-morbidities such as hypertension, dysglycaemia and lipid
abnormalities.69,70 The cessation of smoking, which is common in
PsO,71,72 is critical in the management of this group of patients.68
Weight reduction not only reduces CV risk but has also been
shown to attenuate the severity of PsO. A randomised, control
study investigating the impact of hypocaloric dietary intervention
and physical activity over 20 weeks in 303 overweight/obese
patients with moderate to severe plaque PsO demonstrated
a 48% reduction in PsO area and severity index score in the
interventional arm, compared to only 25.5% in the information-
only arm (p = 0.02).73 The weight loss target of ≥ 5% was achieved
in 29.8% of the interventional arm compared with 14.5% in the
information-only arm (p = 0.001). There are also anecdotal case
reports of improvement in PsO following bariatric surgery.74,75
Drug therapy
Anti-inflammatory agents used in the treatment of
psoriasis
Given the earlier discussion on chronic systemic inflammation
as a risk factor for CMD, there is emerging evidence that
controlling inflammation reduces the risk of CMD. There are
several lines of clinical and biochemical evidence suggesting that
methotrexate (MTX), a drug widely used for the treatment of
moderate–severe cutaneous PsO and PsA, has anti-inflammatory
and cardioprotective properties. MTX was found to provide a
substantial survival benefit, mainly by reducing cardiovascular
mortality rate in RA.76 The cardioprotective effect of MTX is
mediated by increased adenosine levels that bind to adenosine
A2 receptors on macrophages and block foam cell formation.77,78
In PsO, MTX and biologics such as the TNF inhibitors have
been shown to lower the risk for CVD.79 Use of these agents in
a Danish study have shown lower incidence rates of death, MI
and stroke than patients on other therapies, with incidence (95%
CI) rates of 6.0 (2.7–13.4) and 17.3 (12.3–24.3) for biologics
and MTX, respectively, compared to 44.5 (34.6–57.0) for other
therapies. Data from a small, prospective study and retrospective
analyses suggest that systemic anti-inflammatory therapies (such
as MTX or TNF blockers) in subjects with PsO or PsA may have
the potential to ameliorate cardiovascular disease.79,80 While these
have generated considerable interest, no conclusive data from
randomised clinical trials are available to date.
Impact of therapies for co-morbidities
The anti-diabetic drugs pioglitazone81 and glucagon-like peptide 1
(GLP 1) agonists82 have been shown to improve PsO. Pioglitazone
is a well-known insulin-sensitising agent, hence its efficacy may
support the role of insulin resistance in the pathogenesis of PsO.
The GLP 1 agonists are thought to be effective as a result of their
extra-pancreatic effects, particularly their anti-inflammatory
action.83 However, they may also exert indirect effects as their use
is also associated with weight loss.
Conclusions
A growing body of evidence supports the association between
cardiometabolic diseases and PsO. The risk for CMD appears
to be greatest with moderate–severe PsO and PsA. A complex
interaction seems to exist between body adiposity, chronic
inflammation and the psoriatic plaque, which leads to increased
CVD risk.57 Screening and appropriate intervention, including
lifestyle modification, to reduce the burden of cardiometabolic
disease are important in the overall management and health-
related quality of life of patients with PsO.
N Goolam Mahyoodeen has received a grant from the Carnegie Corporation
of New York, NY, USA (Grant Number: B 8749.RO1) and the Astra Zeneca
Research Trust.
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