To the Editor:
Cardiac magnetic resonance (CMR) has established utility in demonstrating myocardial inflammation with a high sensitivity and specificity consistent with myocardial biopsies.1 Cardiovascular disease in psoriasis has been previously studied using techniques such as positron-emission tomography (PET) and cardiac computed tomography (cCT).2 Ionizing radiation makes these less-appealing modalities, particularly in younger patients and for repeated measures. Our goal was to determine if myocardial edema and inflammation are differentially increased in psoriasis patients, consistent with what has been detected in patients with myocarditis and systemic lupus erythematosus using techniques previously described.3
This study identified 47 patients diagnosed with psoriasis and 159 controls (125 with atopic dermatitis and 34 with rosacea) who had undergone CMR between 2011 and 2018. CMR data including quantitative T1 mapping with estimates of myocardial extracellular volume fraction (ECV) evaluating edema/interstitial space, T2 mapping to detect inflammation/edema,3 and late gadolinium enhancement for myocardial fibrosis were evaluated.
Psoriasis and control patients were generally well-matched in demographic features and cardiac risk factors, although psoriasis patients were more likely to be men (55% versus 32%, p=0.0057) and to have a higher BMI (31.1 versus 28.7, p=0.032) (Table 1). After analyzing the univariate outcomes from the cardiac data (table 2), a multivariate analysis was run (data not shown). When controlling for sex and BMI, T2 imaging still showed that psoriasis patients had more abnormalities in the septum wall, which is indicative of inflammation and edema (p = 0.0483).
Table 1.
: Demographic features of patients with psoriasis versus atopic dermatitis and rosacea controls.
| Variable | Psoriasis (n=47) | Controls (n=159) (Rosacea + Atopic Dermatitis) |
P-value |
|---|---|---|---|
| Age at MRI | 52.5 ± 16.7 | 51.3 ± 15.2 | 0.328 (Prob > t) |
| Men | 26 (55%) | 51 (32%) | 0.0057 |
| Body Mass index | 31.12 ± 7.54 | 28.71 ± 6.86 | 0.0320 (Prob > t) |
| Top Indications for cMR | Cardiomyopathy (6) (13%) | Cardiomyopathy (21) (13%) | |
| Chest Pain (4) (9%) | Chest Pain (19) (12%) | ||
| Evaluate a Mass (3) (6%) | Left Ventricular Dysfunction (10) (6%) | ||
| Ventricular Arrhythmia (3) (6%) | |||
| Average Body Surface Area Affected at time of MRI | 7.2% ± 13.8 | -- | |
| Systemic Therapy Used | 10* (21%) | -- | |
*Methotrexate = 5, *Acitretin = 2, *Light Therapy = 2, *Adalimumab = 1, *Infliximab = 1
Continuous variables analyzed by t-testing and values represent mean ± standard deviation, categorical variables by χ2 testing.
Table 2:
Cardiac parameters detected by CMR between psoriasis and controls.
| Variable | Psoriasis (n=47) | Controls (n=159) (Rosacea + Atopic Dermatitis) |
P-value |
|---|---|---|---|
| Total Positive LGE | 23 (50%) | 45 (29%) | 0.0122 |
| ECV Septal (%) Recentered (25) | 4 ± 7.34 | 0.365 ± 5.07 | 0.02 |
| ECV Lateral (%) Recentered (25) | 1.14 ± 6.14 | −0.47 ± 5.3 | 0.14 |
| Abnormal T2 septal (normal: 52.18 ± 3.4) | 18 (60%) | 28 (34%) | 0.0168 |
| Abnormal T2 lateral (normal: 52.18 ± 3.4) | 14 (48%) | 45 (54%) | 0.6675 |
| Abnormal EF (<55%) | 14 (30%) | 33 (21%) | 0.2355 |
| Abnormal MRI (any finding) | 34 (72%) | 86 (54%) | 0.0291 |
Hematocrit reported for normalization of extracellular fracture volume. Late gadolinium enhancement differences were not detected in terms of absolute occurrence or by coronary artery distribution. Continuous variables analyzed by t-testing and values represent mean ± standard deviation, categorical variables by χ2 testing.
This data provides insight into cardiac issues faced by psoriasis patients. Previously, it has been shown that psoriasis patients have increased rates of vascular events and increased numbers of inflammatory markers, including Th1, Th17, interleukin-8, homocysteine, and others.4 Furthermore, patients given systemic anti-inflammatory medications have been shown to have fewer vascular events, further substantiating evidence for systemic inflammatory-driven mechanisms in psoriasis.4 The presence of inflammation and edema corresponds with greater relaxation times on T2 imaging, which can accurately detect not only acute inflammation, but also subacute inflammation seen in systemic inflammatory conditions, including rheumatoid arthritis, lupus erythematosus, and others.5 The psoriasis patients in this study showed increased edema and inflammation by T2 mapping of the septal wall. Our study has multiple limitations, most prominently a small sample of active psoriasis patients, who were likely to be heavier men. Further, all patients underwent CMR for cardiac symptoms and it is unclear if the results would generalize to patients without symptoms. A strength of this study is that all of the CMRs were conducted at The Ohio State University Wexner Medical Center, which limited potential differences that could have arisen with a multicenter study. CMR may potentially offer a valuable non-ionizing imaging biomarker for cardiac disease in psoriasis patients. Further analyses and prospective CMR mapping in greater numbers of psoriasis patients is necessary to determine the prevalence and prognostic significance of these abnormalities.
Funding Sources:
This work was supported in part by the OSU College of Medicine Roessler research scholarship (MG).
The project described was supported by Award Number Grant UL1TR002733 from the National Center For Advancing Translational Sciences. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Advancing Translational Sciences or the National Institutes of Health.
Abbreviation List
- CMR
Cardiac magnetic resonance imaging
- cCT
Cardiac computed tomagraphy
- PET
Positron emission tomography
- LGE
Late gadolinium enhancement
- ECV
Extracellular volume fraction
Footnotes
IRB Approval Status: This work was reviewed and approved by the Biomedical Sciences Institutional Review Board of The Ohio State University Wexner Medical Center with The Ohio State University’s OHRP Federalwide Assurance #00006378
Conflicts of Interest: BHK is an investigator for Biogen, Celgene, Eli Lilly Co, Veloce Biopharmaceuticals, and XBiotech, and he has received grants not related to this work from the Dermatology Foundation and the Rosacea Society. JK is an investigator for Jannsen, Novartis, Abbvie, AnaptysBio, Bristol-Myers, Celgene, Regeneron, Corrona, Eli Lilly Co, Pfizer, and XBiotech. The other investigators do not have conflicts of interest to disclose.
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