Evidence indicates that psoriasis is associated with increased systemic and vascular inflammation, heightened prevalence of cardiovascular (CV) risk factors, and obesity, which all accelerates the development of coronary artery disease (CAD). “Approximately 50% to 60% of patients with psoriasis are obese or overweight, but little is known about how obesity and adipose tissue are related to cardiovascular disease in inflammation,” explains Nehal N. Mehta, MD, MSCE, FAHA. “With the rising prevalence of cardiometabolic disease, obesity has emerged as a key driver of residual inflammatory risk.”
Considering that CAD is a multifactorial disease, psoriasis serves as a useful model to understand the interplay between obesity, chronic inflammation, and dyslipidemia (Figure), according to Dr. Mehta. Studies have linked visceral adipose tissue (VAT) with vascular inflammation and CV events, independent of obesity or subcutaneous adiposity. “Visceral adiposity is associated with increased inflammation in those with diabetes and advanced CAD,” Dr. Mehta says. However, interplay between inflammation, VAT, and CAD has not been previously studied, particularly in a high-risk inflammatory disease state like psoriasis. “Understanding these connections may lead to new strategies for targeting VAT to reduce cardiometabolic and CV disease development,” says Dr. Mehta.
Inflammation & Visceral Adiposity in Psoriasis
For a study published in JCI Insight, Dr. Mehta and colleagues investigated whether inflammation is associated with volume of visceral adiposity in psoriasis and whether the volume of VAT correlates with CV risk factors, markers of inflammation, and early CAD. “We wanted to see if persistent inflammation was linked to the development of more VAT at 1 year and if a reduction in the volume of VAT at 1 and 4 years would be associated with improvements in noncalcified coronary artery burden (NCB),” adds Dr. Mehta.
In the study, 237 patients with psoriasis underwent coronary CT angiography to quantify NCB and an abdominal CT to calculate VAT. At 1 year and 4 years, 176 and 50 patients were reassessed, respectively. Overall, the entire psoriasis sample was middle-aged, predominantly male, and had mild-to-moderate skin disease severity at baseline based on their Psoriasis Area Severity Index (PASI) score.
A Durable, Long-Term Effect
Patients with psoriasis who had high levels of high sensitivity-C reactive protein (hs-CRP)—a marker of systemic inflammation—had significantly greater visceral adiposity and NCB than those with low hs-CRP. Those with higher VAT had more systemic inflammation and had more coronary artery disease with 50% higher NCB. At 1-year follow-up, patients with worsening hs-CRP had an increase in VAT, and those with improved hs-CRP also improved their VAT. At 1 year, a 10.3% reduction in NCB was seen in those who decreased VAT, a finding that persisted in patients who were assessed at 4 years.
“Our findings suggest that visceral adiposity imparts a durable, long-term effect on early vascular disease progression,” says Dr. Mehta. “The amount of skin inflammation appears to be associated with the development of visceral fat in the body. Importantly, patients with higher visceral adiposity had higher cardiometabolic risk and were at higher risk for CAD.”
Assessing the Implications
Collectively, the findings suggest inflammation plays an important role in the development of visceral adiposity and has an impact on early atherogenesis, according to Dr. Mehta. “Efforts to reduce inflammation may help curb the downstream risks associated with cardiometabolic disease,” he says. “Clinicians should be aware of the risks associated with obesity in patients who have psoriasis. These individuals should be encouraged to not only treat their skin disease but also to participate in lifestyle interventions to reduce CV risks, such as intensive weight loss, diet, exercise, and lipid management.”
A better understanding of the biological mechanisms involved in inflammatory-modulated adipose dysfunction is needed. “With more research, we hope to better understand why this is occurring,” Dr. Mehta says. “VAT is a hotbed of cardiometabolic activity and inflammation, but we need to determine what we can do to intervene and stop the vicious cycle of inflammation. Ultimately, we need to find the best treatment approaches for patients with psoriasis who are obese and prone to development of CAD.”