Practical Recommendations on Cardiovascular Risk Evaluation in Patients With Psoriasis and Psoriatic Arthritis for Dermatologists, Rheumatologists, and Primary Care Physicians by the Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network

Abstract

Patients with psoriasis (PsO) and psoriatic arthritis (PsA) are at significantly increased risk for cardiovascular (CV) disease, attributed to chronic systemic inflammation and a high burden of cardiometabolic comorbidities. Despite this, CV risk factors in this population are frequently underdiagnosed and undertreated. This consensus document, developed by the Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network (PPACMAN), provides practical recommendations for dermatologists, rheumatologists, and primary care physicians to improve CV risk assessment and management in PsO and PsA. Key recommendations include conducting baseline CV risk assessments at diagnosis—particularly for patients with moderate-to-severe PsO, PsA, or those requiring biologic therapy—and routine screening for hypertension, diabetes, dyslipidemia, smoking, obesity, and metabolic syndrome. The use of biomarkers such as high-sensitivity C-reactive protein and lipoprotein(a) may help refine risk stratification. Patients at elevated risk should be referred to their primary care provider or a cardiologist for further evaluation and may require additional imaging, including coronary artery calcium scoring. Lifestyle counseling on diet, exercise, weight management, and smoking cessation is essential. Pharmacologic strategies, such as earlier initiation of statins and consideration of glucagon-like peptide-1 (GLP-1) receptor agonists, are encouraged when clinically appropriate. Systemic inflammation should be reduced using anti-inflammatory therapies, although outcome data remain mixed. Clinicians must carefully assess the risks and benefits of NSAIDs, corticosteroids, and Janus kinase (JAK) inhibitors. This document aims to bridge existing gaps in interdisciplinary care and facilitate earlier, more aggressive CV risk management in psoriatic disease, aligning with current cardiology and dermatology guidelines to reduce morbidity and mortality.

Introduction

In psoriasis (PsO) and psoriatic arthritis (PsA), traditional and non-traditional risk factors elevate cardiovascular (CV) risk, including adverse CV outcomes.^1-5 In one meta-analysis, PsO accounted for 11,000 additional CV events in the United States each year. ⁶ Recent work has further characterized CV risk in patients with PsO. Inflammation and a higher rate of cardiometabolic comorbidities play key roles in the observed rates of accelerated atherosclerosis in PsO and PsA. ⁷ In the general population, inflammation is also associated with CV events, CV mortality, and all-cause mortality. ⁸ Additionally, the severity of PsO is linked to CV events and can further predict mortality.^9,10

Current data shows that only 24% of patients with PsO eligible for a statin for primary prevention are taking them. ¹¹ There remain opportunities to enhance screening and management of CV risk factors in patients with PsO and PsA, especially by those providers that follow patients with PsO routinely, including dermatologists, rheumatologists, and primary care physicians. Over two-thirds of dermatologists and rheumatologists agreed that it is possible to screen for CV risk factors in patients with PsO. ¹²

On behalf of the Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network (PPACMAN), we aim to provide concise and practical recommendations for dermatologists, rheumatologists, and primary care physicians on CV risk screening, evaluation, and management in patients with PsO and PsA aligned with current guidelines of care^2-5,13-15, scientific evidence, and best practices.

Recommendations

• 1. Perform a cardiovascular risk assessment in all patients with PsO and PsA at the time of diagnosis, with special attention to patients with moderate or severe PsO (psoriasis area and severity index [PASI] > 10%), PsA and patients who require biologic therapy.

Patients with moderate or severe PsO, classified by PASI >10%, or PsA have worse CV outcomes, including a significantly higher likelihood of CV events than patients with mild PsO. ¹⁶ Given that the prevalence of modifiable CV risk factors is higher in patients with PsO and PsA, a CV risk screening and assessment may lower CV risk and overall disease burden (Figure 1). ¹⁷

Figure 1.

Cardiovascular risk evaluation of patients with Psoriasis and Psoriatic Arthritis.

CV = cardiovascular; Lp(a) = lipoprotein (a); hsCRP = high sensitivity C-reactive protein; ASCVD = atherosclerotic cardiovascular disease; GLP-1 = glucagon-like peptide-1; LDLc = low-density lipoprotein cholesterol.

CV risk factors that require screening in PsO and PsA include hypertension, diabetes, dyslipidemia, obesity, smoking, and metabolic syndrome.^1-7,9,13,14 For females, an obstetric history and appropriate counseling should be performed. Recent data has highlighted an enhanced risk of preeclampsia/eclampsia and cardiac arrythmias among patients with psoriatic disease.^18,19 Objective data to be obtained at the time of the initial PsO encounter includes vital signs, anthropometrics measurements, social history (eg. tobacco and alcohol use), and laboratory work (lipid levels, creatinine, and hemoglobin A1c (HbA1c)).^13,14 C-reactive protein (CRP) and lipoprotein (a) levels are also useful CV risk enhancer markers that can help guide providers in performing a more personalized CV risk assessment.^13-15

If a physician is not comfortable testing for or managing CV risk factors, then an appropriate referral should be made. For example, dermatologists may not have incorporated CV risk factor screening into their practice yet. Likewise, rheumatologists may be uncomfortable monitoring for CV risk factors and instituting appropriate interventions. It is imperative that a referral be made in these situations, especially given that a significant proportion of the US population with chronic skin disease, including PsO, does not have an established primary care provider. ²⁰

Patients with PsO and PsA with elevated CV risk on screening should be considered for referral to a cardiologist.^21,22 Early trials suggest that patients are willing to see a preventive cardiologist. ²³ These specialists may be able to manage patients with elevated CV risk factors and recommend further laboratory testing or imaging (eg. coronary computed tomography angiography and carotid artery ultrasound).^13,24,25 A cardiologist may order CT coronary artery calcium (CAC) scoring to perform further risk stratification, if indicated, and can interpret CAC results in context of overall patient risk. For example, in patients with low atherosclerotic cardiovascular disease (ASCVD) risk but with significant CV comorbidities and in patients with borderline or intermediate ASCVD risk who could benefit from more objective information if the decision about lipid-lowering medication remains uncertain at the time of shared decision-making, CAC score can provide more diagnostic certainty. If already available, review of a prior chest CT for atherosclerosis burden can be a simple way to enhance aggressiveness of prevention therapies and be helpful in a patient-physician discussion. An evolving area is the use of artificial intelligence algorithms for CAC from chest CTs ordered for other clinical indications which can quantify CAC and enhance opportunistic screening,^26,27 highlighted recently in a study which included psoriasis patients. ²⁸ A CAC score of zero (0) is a powerful negative risk factor for future CV morbidity and mortality.^{13,24,25,29,30} However, even among patients with autoimmunity, a CAC score of zero (0) still has excess risk compared to control populations.^31,32 Referral to a cardiologist may allow for other advanced cardiovascular imaging modalities to provide functional assessment or quantification of myocardial blood flow. Coronary microvascular dysfunction is more prevalent and associated with excess risk among patients with psoriasis.^33-36

• 2. Counsel all patients with PsO and PsA patients on lifestyle modification, including the benefits of regular exercise, a healthy diet, weight loss medications, and smoking cessation to lower CV risk.

Obesity and smoking are two modifiable CV risk factors that are important to address in PsA and PsO. Managing obesity, like smoking, may now be performed by non-pharmacologic (eg, physical activity and diet changes) or pharmacologic interventions.

Regular moderate to vigorous physical activity provides physical and mental health benefits to patients with PsO and PsA, including improved quality of life and disease severity. ³⁷ However, it is important to consider that PsO and PsA may affect an individual’s ability to exercise (eg. skin sensitivity, greater itch, easy fatigability, musculoskeletal pain, and embarrassment). ³⁸

Low-calorie diets or energy-restriction-intake programs for several months also provide improved disease severity. In patients with PsO, surrogate CV markers such as triglycerides and CRP decreased after maintaining low-calorie diets.^39,40

In patients with PsO who smoke, meta-analyses show the following: (1) smoking as an independent risk factor for the development of PsO, (2) patients with established PsO continue to smoke more than patients without PsO, (3) an association between tobacco and severity of PsO, and (4) that tobacco could negatively influence response to treatment.^41-43

In the general population, treatment with glucagon-like peptide-1 (GLP-1) agonists among patients with obesity with or without diabetes can lead to a reduction in weight, inflammation, and improvement in CV outcomes.^44,45 Early trials of GLP-1 agonists in PsO show lower PsO severity in patients with type II diabetes, even before achieving glycemic control or a reduction in weight.^46-49 Weight loss medications in PsO and PsA are an emerging area in dermatology.

• 3. Counsel patients with PsO and PsA on managing cardiometabolic co-morbidities, including earlier and aggressive use of statin therapy.

CV risk factors, including hypertension, diabetes, obesity, hyperlipidemia, and metabolic syndrome are higher in prevalence in PsO and PsA. ⁵⁰ Traditional CV risk scores incorporate some of the CV risk factors above. However, data shows they can underestimate CV risk in patients with PsO, PsA, and rheumatoid arthritis.^51-53 CV risk scores that incorporate inflammatory diseases as an independent risk factor have not been widely implemented clinically.

Hyperlipidemia has been reported as one of the most prevalent CV co-morbidities in patients with PsO. ⁵⁴ Additionally, though not widely used for this indication, meta-analyses show that statins may improve PASI score in patients with PsO^55,56 and that statins are associated with a lower risk of both PsO and PsA. ⁵⁷

The ACC/AHA guideline on primary prevention of CVD recognizes PsO and PsA as a risk enhancer of CVD to warrant earlier initiation of statin. When stratified by their ASCVD score, most patients in the low-risk group (<5% 10-year risk or without other CV risk enhancers beyond PsO/PsA) can be routinely screened annually or if cardiometabolic comorbidities change; in this risk group, assessment and consideration of CV risk enhancers (eg. CRP, Lp(a), family history of premature ASCVD) is important for decision on statin use. In patients with borderline risk (5–7.4% 10-year risk), a moderate-intensity statin should be considered after shared-decision making. Patients with an intermediate risk (7.5% to 19.9% 10-year risk) should initiate a moderate-intensity statin to reduce low-density lipoprotein (LDL) cholesterol by 30%-49%, and patients with a high risk (≥20% 10-year risk) should initiate a statin with the goal of lowering LDL cholesterol ≥50%. ²

Hypertension, diabetes, obesity, metabolic syndrome, nonalcoholic fatty liver disease, and chronic kidney disease are all important co-morbidities to diagnose, treat, and manage. Implementing multi-disciplinary clinical teams, particularly in academic settings, is a new approach to address CV co-morbidities in PsO and PsA.^58-60

• 4. Consider treating underlying inflammation and aiming to control disease activity with anti-inflammatory therapy.

Inflammation is causal in atherosclerosis and is thought to account for approximately 20-30% of residual risk for CV events in the general population.^7,8 Disease activity and the number and duration of flares over time contribute to the risk of CVD in patients with inflammatory polyarthritis. ⁶¹

However, studies on the effects of anti-inflammatory therapy on CV risk and CV events in patients with PsO and PsA have yielded conflicting results.^61-69 Some data indicate that tumor necrosis factor inhibitors (TNFi) may be the most cardioprotective among current PsO treatments, though the evidence is inconclusive.^62,70,71 Only canakinumab and colchicine are proven to lower CV events.^72,73 Larger trials to better understand the CV outcomes in PsO and PsA with the use of anti-inflammatory medications are necessary.

• 5. Understand the indications for continuation of NSAIDs, corticosteroids, Janus kinase and Tyrosine kinase inhibitors.

NSAIDs and corticosteroids are commonly used to treat inflammatory joint disorders, and these agents effectively lower disease activity and inflammation. However, both have been associated with an increased CVD risk and the indication for their use should be regularly assessed. ⁷⁴

Oral JAK inhibitors (JAKi) have become essential in treating autoimmune disorders because they target an alternative pro-inflammatory pathway to promote disease remission and can minimize glucocorticoid use. ⁷⁵ However, there is mixed evidence suggesting an increased risk of CV-related events, cancer, blood clots, and death. ⁷⁶

Given the controversy with oral JAKi, patients with a high pretest probability of CVD, high CV risk, or those who have had a myocardial infarction or stroke would benefit from early referral to a cardiologist. The cardiologist or cardio-derm/rheumatology specialist can perform a comprehensive cardiovascular history and laboratory evaluation, thereby aiming to identify patients who would benefit from alternative strategies and aggressive CV risk modification.^59,77 In early but large studies, tyrosine kinase inhibitors have shown a safer CV side effect profile than that of JAKi (Figure 1). ⁷⁸

Ethical statement

Ethical approval

This research did not require ethical approval as it did not involve human or animal subjects.

ORCID iDs

Samip Sheth https://orcid.org/0000-0003-2896-2298

Karla Inestroza https://orcid.org/0009-0007-6156-3869

Michael Garshick https://orcid.org/0000-0002-6649-3755