Patients with psoriasis and psoriatic arthritis (PsA) are at high risk for developing cardiovascular (CV) diseases, explains Lihi Eder, MD, PhD. “Primary prevention measures, such as initiation of lipid lowering therapies, require identification of patients who are at high risk for developing these events,” Dr. Eder says. “However, conventional CV risk scores, such as the Framingham Risk Score, tend to underestimate CV risk in patients with psoriatic disease.”
For a study published in Arthritis & Rheumatology, Dr. Eder and colleagues examined whether the use of cardiac biomarkers could assist with CV event prediction in this patient population. “We assessed the association between two cardiac biomarkers (cardiac troponin I [cTnI] and N-terminal pro-brain-type natriuretic peptide [NT-pro-BNP]) used in clinical practice for CV risk assessment” she says. “The first part of the study explored the link between these biomarkers and the extent of atherosclerosis in the carotid artery as determined by ultrasound. Past research has shown that carotid ultrasound can help predict CV events in this patient population, and we wanted to evaluate the link between these two surrogate biomarkers of CV risk.”
Risk for CV Disease Linked to Psoriatic Disease
“In the second part of the study, we used a cohort of 1,000 patients with psoriasis and PsA who were followed regularly in the University of Toronto Psoriatic Disease cohort since the late 1970s,” Dr. Eder continues. “All clinical information was collected using standard protocols and serum samples that have been stored in a biobank were used for analysis of cardiac biomarkers. We then linked this database with provincial hospitalization databases to identify whether these patients developed CV events.”
The study team found that the risk for CV disease is high in patients with psoriatic disease and is likely mediated by atherosclerosis and possibly by direct cardiac damage, as evident by the independent association of both cTnI and NT-Pro-BNP with clinical CV events. “cTnI assesses ischemic damage to the heart that is usually related to atherosclerosis and NT-pro-BNP is a marker of cardiac strain typically associated with heart failure,” Dr. Eder notes. “The link between these biomarkers and carotid atherosclerosis was partially independent of traditional CV risk factors, suggesting that PsA-related factors may play a role.”
Biomarkers Not Recommended for Asymptomatic Patients
In both unadjusted and adjusted models, cTnI was linked with the extent of atherosclerosis independently of traditional CV risk factors, suggesting that elevated cTnI may be linked with early carotid artery vascular changes and may help indicate patients who are at increased myocardial injury risk outside of traditional CV risk factors (Table).
These finding, Dr. Eder explains, reinforce the evidence of the strong link between atherosclerotic disease and PsA and psoriasis. “Physicians should be aware of this association, screen for traditional CV risk factors, and manage these risk factors to reduce CV risk. Our study found that cardiac biomarkers did not improve CV risk stratification, so these biomarkers should not be ordered routinely for primary prevention in people who are asymptomatic,” she adds.
Although cardiac biomarkers may help identify patients who are at high risk for CV events, their utility beyond conventional risk score systems should be further studied, according to Dr. Eder. “We need to study the effect of biologic therapies for psoriasis and PsA on cardiac risk, it is not clear that all biologic therapies affect the heart and vasculature system the same way,” she says. “We also need to assess whether implementation of interventions to optimize CV risk management actually reduce the risk.”