Cardiovascular Effects of Psoriasis: The Importance of Making the Connection

This transcript has been edited for clarity.

Joel M. Gelfand, MD, MSCE: Hello, everyone. My name is Dr Joel Gelfand. I'm a dermatologist at the University of Pennsylvania here in Philadelphia. I want to welcome you to this discussion by Medscape for their Psoriasis Center of Excellence. I'm joined by my colleague, Michael Garshick, who's a cardiologist at NYU, and Leah Howard, who's CEO of the National Psoriasis Foundation (NPF). Welcome, Michael and Leah.

I want to get right into it and start off talking about how cardiovascular risk is such an important component of running a Center of Excellence when taking care of patients. This is a fundamental part of their disease. We often think that psoriatic arthritis is the most common comorbidity in psoriasis, and it's probably not. The most common comorbidity is actually cardiometabolic disease — things like obesity and the combination of atherosclerosis, diabetes, and dyslipidemias.

These are major players in our patients' well-being and also in their shortened lifespan. We know that patients with psoriasis, particularly those with moderate to severe disease, die about 5 years younger than they should, based on risk factors for mortality. Much of that's based on excess cardiovascular risk. Stated another way, if we could somehow eliminate the risk for cardiovascular disease in people with psoriasis, we could add several years back to their lifespan.

Michael, as a clinical cardiologist, I know you see many patients with psoriatic disease, given that inflammation is known to be a cardiovascular risk enhancer. What are the conversations like in your clinic when you're talking to patients who have been dealing with psoriasis for a while and now are told to see you with concern about cardiovascular risk?

Michael S. Garshick, MD, MS: Thanks, Joel. Thanks for weaving me in. Again, I'm Michael Garshick. I'm a cardiologist at NYU, and I run and direct the cardio-rheumatology program here at NYU Langone Health.

We have a clinic where I'm referred patients with psoriasis, psoriatic arthritis, or other pro-inflammatory autoimmune conditions. We risk-stratify them, meaning we try to figure out what is the risk of having a cardiovascular event, either a heart attack or stroke, over 10 or even 30 years. I see many of these patients.

The conversation that always comes up is that it's not just about their psoriatic disease; the way I describe it is psoriatic disease really bad company. What I've been impressed about over the years, whether it's some of your initial studies or even more modern ones today, there's this consistent link between the traditional cardiovascular comorbidities, psoriatic disease, and future cardiovascular risk.

The way I start these conversations in every encounter is to take a psoriasis history. I try to figure out how long patients have had psoriasis, the extent of involvement, and the need for biologic or systemic therapy, because that determines risk as well. Also, have they been screened for those traditional cardiovascular risk factors — hypertension, dyslipidemia, metabolic syndrome, or diabetes, and even smoking? I try to get a really good in-depth history because that really is important for me when I try to figure out what I can do to manage their risk.

Gelfand: It's interesting. Michael — I think one of the things that the NPF has done so well over the years is talk about collaborative care of psoriasis, and especially the dermatology-rheumatology connection with psoriatic arthritis being so common. I think the newer paradigm we're trying to get across to people is exactly what you have at NYU, where you're working with dermatologists on a regular basis to co-manage patients for cardiovascular risk.

It's something I've done at Penn for many years now with our preventive cardiologists, and it's super-easy to do. The patients are very motivated, I find, to follow up and see our preventive cardiologists. It really helps, I think, to have that expertise. If I tell the patient to go see their primary doctor, what may happen is that the primary doctor may not be aware of the link between psoriasis and cardiovascular disease, and that could be very off-putting to patients. Also, they may not be as aware of the treatments we use or have a comfort level in using cardiovascular treatments and prevention in this patient population.

I think it's helpful to have folks who really understand the current guidelines of managing psoriatic disease for cardiovascular risk and could understand the issues that are involved.

Leah, from your perspective, as someone who's been involved in the psoriasis advocacy field for quite some time and now in a really important leadership role at NPF, what's your sense of the pulse of the psoriasis patient community when it comes to how they feel about psoriasis and cardiovascular risk?

Leah McCormick Howard, JD: Joel, I think you're hitting on such a critical issue. I've had the pleasure of working with the psoriasis community since 2012. Whether it was in my role doing advocacy or now as president and CEO of the NPF, I'm consistently amazed how many conversations I'm in with other individuals who live with psoriatic disease who tell me they've never heard about this connection between psoriasis and cardiovascular disease.

Even though we're out there and you all are out there talking about psoriasis as a chronic, systemic, immune-mediated disease, that message still hasn't gotten through to so many of the 8 million people in our community. I think it's really critical that we're all beating that drum so that, wherever an individual is entering the healthcare system, they're as educated as possible. If their healthcare provider isn't raising these issues, they can begin to ask those questions.

I'm always saddened to hear about an individual that is struggling with their psoriatic disease, and through the course of the conversation, they tell me that they've lost a loved one to a heart attack. To me, if they've not already heard about this connection, there's a gap in our system and we're missing opportunities to be educating patients and getting them thinking about their care differently in a more proactive way that can address that earlier life expectancy issue you already mentioned.

Gelfand: When talking to patients about this issue, it often makes sense to them if you explain to them, you see all that inflammation on your skin or the swelling in your joints? Those immune cells don't just hang out in the skin or just the joints. They can move around the body. They can inflame other organs, including the arteries, and cause atherosclerosis and cardiovascular disease.

Mike, coming back to you, I know you do basic research in this area including translational research understanding the impacts of inflammation on cardiovascular disease. What are some of the key take-home messages that clinicians need to know about when it comes to the biologic connection between psoriasis and cardiovascular disease?

Garshick: It's a good question. I will say also, just to go back to the collaborative care model for a second, I think part of the job of the collaborators with all this, that should offload the dermatologists, the rheumatologists, and the primary care doctor even, because there's only so much that you can address at one visit. These visits can be very complex, especially when you're talking about adding a biologic therapy or changing the biologic therapy.

To get back to your original question, the way I think about the pathophysiologic connection is that it's a combination of the traditional cardiovascular risk factors plus the independent contribution of underlying psoriatic inflammation that generally leads to enhanced cardiovascular risk. Of course, it's still a little vague. I think we're still trying to really pinpoint the precise mechanisms from both the traditional risk factors and the systemic inflammation in general.

My own research is focused on the vascular endothelium. The endothelium consists of small cells that line the blood vessel and protect the blood vessel. When those become damaged, the blood vessels are more susceptible to developing cholesterol buildup or atherosclerosis. I focus on that. We really see some differences as an early initiation of atherosclerosis through blood vessel wall damage.

Gelfand: I think it's amazing how many shared inflammatory pathways atherosclerosis and plaque rupture have with psoriatic disease. More recently, there have been newer genetic studies, called Mendelian randomization studies, where you look at the patient's genome and the single nucleotide polymorphisms (SNPs) they inherit from their parents. These studies show that people who inherit SNPs that are known to cause atherosclerosis are more likely to develop psoriasis over time.

That suggests that atherosclerosis could actually cause psoriasis and makes you wonder, with some of our patients who develop psoriasis in, say, middle age, maybe what we're looking at is actually atherosclerotic disease now triggering psoriasis in the skin. Do you think the arrow goes both ways? How do you think about this as a researcher and a clinician?

Garshick: I think it's a vicious circle. I think we're all still trying to figure out what comes first: psoriasis potentiating cardiometabolic comorbidities, or the cardiometabolic comorbidities potentiating psoriasis. Or maybe it doesn't even matter, because they tie so well together and it all leads to something downstream that cardiologists deeply care about, which is atherosclerosis.

I always use adipose tissue and fat as the prototypical model. I know you brought up lipids and dyslipidemia, but adipose tissue or fat cells are very angry. They produce a large amount of angry proteins or angry cytokines, such as tumor necrosis factor (TNF) alpha. If you think about it, we actually give TNF alpha inhibitors to prevent or to mitigate psoriasis. I think that really is a great case example of where there's a very powerful relationship between a comorbidity and psoriatic disease.

Gelfand: Certainly, obesity is something that many patients with psoriatic disease struggle with. We know that it's related to the risk of developing psoriasis. It relates to the risk of having more severe psoriasis.

It tends to impact how well they respond to therapy or their ability to maintain response of therapy. Of course, it probably promotes other health issues, including psoriatic arthritis, cardiovascular events, and other issues. The two are very important related comorbidities of one another.

One of the things I'm always a little jealous of with the cardiologists is that you guys do these mega-trials. You randomize thousands of patients to drug and placebo. You follow them for 5 years or so, and you really know with a great deal of certainty what treatment A or treatment B does for cardiovascular events. It's much harder to do that in the field of psoriasis or any individual inflammatory disease.

We do know that some anti-inflammatory therapies such as canakinumab, a biologic that blocks interleukin-1 beta, or colchicine, an old, oral medication that affects NETosis, prevent cardiovascular events in people at high risk. In fact, colchicine even now has an indication for that from the US Food and Drug Administration in the US.

Garshick: Yes. It's a similar indication to statins, actually, for the secondary prevention of cardiovascular disease with inflammasome or interleukin-1 beta inhibition as well.

Gelfand: I think one of the key things our colleagues need to know about this is that it's tempting to think, well, if we just treat psoriasis, we're going to treat heart attacks and stroke. Some data suggest maybe that's true, but not the level 1 data from large-scale, placebo-controlled trials that really know for sure. I think, as you mentioned earlier, so much of this is the comingling of risk factors also. To say, "Your skin is clear, we don't have to worry about this," is really doing the patient a disservice because they probably have underlying risk factors that need management.

The other pro tip, I would say, for people listening who are involved in having a Center of Excellence in psoriasis, patients will often say, "What else can I do to lower my risk for cardiovascular disease?" I'll often talk about colchicine and say, this is something you should talk to your preventive cardiologist about. Increasingly, people now are using this as a relatively inexpensive, safe, additional modality for prevention of heart disease. Oftentimes, the cardiologists need to know if it is safe to use colchicine with a biologic for psoriasis. The answer is generally yes. There's no problem with doing that. I think it's important for people to be aware of that.

Are you using much colchicine in your practice, Mike, in people with psoriatic disease?

Garshick: That's a good question. If you want to be a pure clinical trialist, these clinical trials for the secondary prevention of cardiovascular disease didn't really include many autoimmune patients on biologics. Yes, in general, adding colchicine to other immunosuppressive therapies is very safe.

I don't know if we have the perfect data to support colchicine when adding to a biologic for these patients. That being said, in my psoriatic patients who are at very high risk, they didn't have significant dyslipidemia to begin with, they didn't have significant obesity, and they had a cardiovascular event or two, I think those patients, obviously, are the right candidates for colchicine, but what else can you reach for? As a cardiologist, you have additional blood thinners or you have colchicine. In that setting, colchicine is very safe.

Joel, I wanted to ask you a question. I know we've had many conversations. When you're treating psoriatic disease and you're starting a biologic, do you tell patients it will reduce their risk for cardiovascular disease?

Gelfand: I personally do not, mainly because I really like to have definitive proof of that before I make that claim to a patient. I do explain to patients that we think treating inflammation is probably important for their overall health and well-being. I think living with psoriasis is not great for people's overall health and well-being.

We know when we clear people with psoriasis that nowadays, we have biologic benefits in terms of what we can measure in the body and the blood, but this also affects how people feel about themselves or activity levels, their lifestyle, all sorts of things that I think contribute to better global health over time.

We're going to discuss one final topic. Coming back to Leah, the NPF has been a driver in trying to help patients understand the systemic aspects of psoriasis and systemic risks related to psoriasis.

One of the challenges we've had is getting more clinicians to screen people for cardiovascular risk factors with psoriasis and having psoriasis patients be advocating for their care in this case. What's your sense of people with psoriasis? Do they feel empowered to ask their dermatologists about cardiovascular risk? Do they bring up these conversations with their primary care doctors? Do primary care doctors know to ask about these things?

Howard: We talk often about the heterogeneity of psoriasis, and I think that the community is really heterogeneous as well. When you talk to someone living with psoriatic disease, their experience and their journey are so often dictated by the place that they live, the access they have to care, what type of insurance they're on, and their whole history. One of the things that you were just talking about that I think of often is this idea of reminding patients about the evolution in care in our space.

When I think about my time at the NPF in the past 12 years, it's amazing to see the progress in the space, not just in new treatments but also in this understanding of psoriatic disease and the other conditions that are connected to it. We spend a large amount of time talking to the community about this idea of beginning a dialogue if you haven't had one with your healthcare provider in a while, or returning to that dialogue with them about your disease today, and all of these things that you should be thinking about when you live with psoriasis or psoriatic arthritis.

When the NPF started our current strategic plan, now almost 5 years ago, we very intentionally began wording the language of that plan by not focusing on the skin and joints. We had this recognition that the impact of psoriasis went much beyond the skin and joints and that these other health conditions that we're talking about here today play a really huge role in the health outcomes that our community has. That was what was behind the thinking of launching one of our new research mechanisms in this current strategic plan period focused on the prevention of psoriasis, prevention of psoriatic arthritis, and prevention of comorbidities.

Gelfand: Leah, I think the NPF's efforts have been so important for educating patients because they may not hear about this from their dermatologist, or they may not even have a dermatologist or be getting medical care. It's an important source of information for them.

I think one of the things that NPF has really been a leader in is funding work to look at new ways of preventing cardiovascular disease in psoriasis. We're involved in this project that Dr Garshick is a part of called the CP3 study: Prevention of Cardiovascular Disease and Mortality in Patients With Psoriasis or Psoriatic Arthritis.

At first, we're trying to understand how dermatologists, rheumatologists, and patients feel about this stuff. What we learned from the data — it was interviews and surveys — is that all the major stakeholders care about this and think this is really important, but the clinicians feel like they don't really have time to manage cardiovascular risk factors. The patients and clinicians feel like it's hard to coordinate the care back to primary care, preventive cardiology, or what have you.

That's the genesis of the idea behind a centralized care coordination model, this idea of having someone who, say, works at the National Psoriasis Foundation, where a dermatologist could talk to their patient and educate them about psoriasis and cardiovascular risk. As routine care, they can screen for diabetes with A1c measurement, do a blood test, check for lipids, and check blood pressure. If these things are abnormal, they can then refer patients to the care coordinator for a virtual visit with the care coordinator of the NPF.

Then, that person really has the ability to look at the blood work and the blood pressure to figure out what their risk for cardiovascular disease is and, when it's elevated, give them a guidelines-based plan from the American College of Cardiology/American Heart Association to bring back to their primary care provider or preventive cardiologist.

In the initial part of this work, we've seen that patients are very motivated to follow through. About 90% of patients will get their labs done, record their blood pressures, and follow up with the care coordinator when risk is elevated. The patients really appreciate this opportunity to have a place where they could go through this information, because it's so much to hear in one spot in a dermatology office.

I've been surprised by how many of our patients — even in my own practice where we're supposed to be a Center of Excellence — we miss a large amount of people with elevated cardiovascular risk. There are many patients out there who fall through the system a little bit.

Our pilot study is about one third of people who had elevated cardiovascular risk that really needed to see people like Michael but weren't aware of it. Those are at centers that are very intensively doing this type of work already. You can imagine how there's a large opportunity to identify people who could benefit from education on diet, exercise, and then appropriate medical therapy like statins, colchicine, blood pressure management, or smoking cessation. Those are ways we can help people quite a bit.

Michael, maybe just give us a flavor from your perspective. A patient comes in, referred to you; their cholesterol is elevated, and maybe the blood pressure's a little elevated. What do you tell that patient from a preventive cardiologist point of view? What are the routine things you'll do to further risk-stratify them?

Garshick: Whenever we get a patient who has X, Y, and Z elevated, you first want to know the degree of elevation and how to calculate the 10-year or even lifetime risk of a cardiovascular event. I think what's so nice about the CP3 trial is that you're not only providing good standard of care and offloading to other providers but also identifying what I consider the low-hanging fruit, which is what you were getting at — the cholesterol levels that are just so high, they're almost in genetic range, or the blood pressures that are so high I'm just shocked that no one has picked up on this earlier. This patient's been seeing providers for years and no one checked their blood pressure. That's what I think is amazing.

When those patients referred to me, we first need to know the degree of elevation. Of course, there are some cutoffs we use where you don't calculate a score; you just treat. For example, anybody who has type 2 diabetes, for the most part, should get a lipid-lowering therapy with a statin. It's a class I indication.

When we're trying to be more nuanced, we default back to the history, what the patient's wishes are, and ancillary testing. With a history, it's a family history of significant cardiovascular disease, and history for the patient of other comorbidities. If they can't give us an answer or the patient wants a more personalized approach, we start to default to imaging.

One of the most popular imaging tests we have is CT assessment of the coronary arteries, specifically looking at the calcium buildup, which builds up on the outside of the blood vessel. It's a biomarker of stuff going on the inside of the blood vessel that you can't see, and it's an excellent predictor of cardiovascular risk.

Gelfand: We do this often at Penn. Our preventive cardiologists do this often. I think for those who take care of many people with psoriasis, we recognize that patients with chronic disease are not always as eager to go on more medication. They've been dealing with their psoriasis for a long time. They're kind of frustrated. They often don't even want to be on medications for psoriasis.

We find that doing the coronary artery calcium score when things are uncertain or the patient is feeling like they are not sure if they really want to treat these risk factors, it's very eye opening for patients. Often, they have very high calcium scores that indicate substantial risk for cardiovascular disease. They probably have atherosclerosis going on that they can't feel yet.

You don't want to have the first time you're aware of atherosclerosis be when you're having chest pain and have to go to the emergency department with a cardiovascular event. We're trying to prevent those things. My understanding is that often insurance covers it or the out-of-pocket cost is fairly low. Many patients will opt for it, basically.

Garshick: The out-of-pocket cost is fairly reasonable for the most part. What I tell patients, because it's almost never covered by insurance, is that it's one of the more affordable tests that we have in healthcare. It's hard to give you a price because they vary across institutions and regions.

I will agree with that sentiment that many patients don't want to take the additional medication, or we've had a ton of patients who were very concerned about potential side effects of lipid-lowering therapy, such as muscle cramps, aches, and pains for a long time. I think the art of preventive cardiology is helping patients work through some of those concerns and find something that they'll stick with and take.

They need to also realize that in 2024, we have many options to lower cholesterol, reduce blood pressure, and help people lose weight. I think the paradigm has really shifted in terms of the preventive care that we can offer patients with psoriatic disease.

Gelfand: I think that's really what it means to have a Center of Excellence: being able to meet the patient where they are and using your expertise and extensive knowledge to find the right treatment for that patient. It's going to ultimately help them get a better outcome not only for their skin and joints, but ultimately in overall health.

Michael and Leah, it has been a pleasure talking to you about this really important topic of cardiovascular disease identification, risk factors and management of them, and more holistic management of people with psoriatic conditions.

Thanks so much for joining us. I hope people will find this to be a helpful program for them.

Medscape Dermatology © 2024 

Cite this: Joel M. Gelfand, Michael S. Garshick, Leah McCormick Howard. Cardiovascular Effects of Psoriasis: The Importance of Making the Connection - Medscape - May 30, 2024.