Impact of Psoriasis on Cardiovascular Disease

Introduction

Psoriasis (plaque psoriasis) is a common chronic inflammatory disease caused by an immune system disorder that negatively affects patients’ quality of life (1, 2). Psoriasis affects the skin, causing silver-colored plaques to form on its surface, and in severe cases, the joints may also be affected. Psoriasis affects 1–3% of the world's population (18).

Recent scientific studies have shown that psoriasis is a systemic inflammatory disease that is often accompanied by various other conditions. Although psoriasis has traditionally been considered a skin disease, in recent years it has increasingly been classified as a multisystem disorder that increases morbidity and mortality and worsens quality of life (18). A higher risk of developing severe vascular conditions, such as cardiovascular and cerebrovascular diseases, has been observed.

As with other chronic inflammatory diseases, including rheumatoid arthritis, inflammatory bowel diseases, and systemic lupus erythematosus, the inflammatory mechanisms involved in psoriasis are shared and contribute to atherosclerosis. Chronic skin inflammation can lead to vascular and systemic inflammation, atherosclerosis, and thrombosis. Cardiovascular risk factors such as hypertension, diabetes, obesity, dyslipidemia, atherosclerosis, and smoking are more common in patients with psoriasis (4–6).

Cardiovascular Disease Risk in Patients With Psoriasis

Studies conducted in the United Kingdom (UK) have shown an increased risk of myocardial infarction in individuals with psoriasis (3). This association has also been demonstrated in epidemiological studies conducted in the United States and Canada (8–11). A relationship between the risk of myocardial infarction and the severity of psoriasis has also been identified.

Another study conducted in the UK found that individuals with psoriasis have an increased risk of major cardiovascular events—not only myocardial infarction but also stroke and cardiovascular death (7). A study conducted in Denmark found that the risk of myocardial infarction is higher in individuals with severe psoriasis than in those with moderate psoriasis (12). Furthermore, studies conducted in the UK have shown that patients with severe psoriasis have a life expectancy shortened by approximately 6 years, often due to death from cardiovascular disease (13).

One study included 8,180 individuals with psoriasis and 163,600 individuals in the control group (32). The period between the development of psoriasis and the onset of metabolic disorders, including hypertension, diabetes, or dyslipidemia, was evaluated. In this study, psoriasis was considered a precursor of systemic inflammatory diseases if it developed before the metabolic diseases. Psoriasis diagnosed after the metabolic diseases was considered an enhancer of these diseases. It was found that the risk of developing severe vascular diseases was higher when psoriasis acted as an enhancer of metabolic diseases rather than as a precursor.

The presence of comorbidities in patients with psoriasis may also increase the risk of developing cardiovascular diseases. A study conducted in Taiwan found that the risk of ischemic heart disease and stroke was higher in patients with psoriasis who had sleep disorders than in patients with psoriasis without sleep disorders (14).

Psoriasis and Atherosclerosis

Patients with psoriasis have been found to have increased arterial stiffness compared with the control group, and a relationship between arterial stiffness and the duration of psoriasis has been identified (15, 16). In a study involving 32 patients with psoriasis, coronary artery calcification was found to be more frequent (59.4% vs. 28.1%) and more pronounced in patients with psoriasis.

Atherosclerosis can also develop as a result of chronic vascular inflammation. Positron emission tomography and computed tomography studies have demonstrated greater inflammation of large blood vessels in patients with psoriasis, and a relationship between psoriasis severity and the degree of vascular inflammation has been identified (17).

In psoriasis, the profile of cytokines involved in skin damage is very similar to that of cytokines involved in vascular damage during atherosclerosis, with increased levels of Th1 and Th17 lymphocytes observed in both conditions (33, 34). Coronary artery atherosclerosis is a significant risk factor for the development of ischemic heart disease. Similar to patients with psoriasis, patients with ischemic heart disease have increased peripheral blood levels of Th17-related cytokines, including IL-17, IL-6, and IL-8 (35).

It has been observed that improvement in the course of psoriasis reduces inflammation in major blood vessels. Although numerous studies have been conducted and similarities between systemic inflammation in psoriasis and the pathogenesis of atherosclerosis have been identified, the exact relationship has not yet been established.

Psoriasis and Arterial Hypertension

It has been established that the inflammatory process plays a significant role in the pathogenesis of hypertension (20). Particular attention is given to inflammatory cytokines such as tumor necrosis factor alpha (TNF-α). Elevated TNF-α levels in patients with hypertension have been associated with a poorer prognosis and may contribute to myocardial dysfunction and other complications caused by hypertension through multiple mechanisms, one of which is endothelial dysfunction (20).

TNF-α is also considered one of the main inflammatory mediators in the pathogenesis of psoriasis, and increased circulating levels of TNF-α have been found in patients with psoriasis (21). Psoriasis is associated not only with increased vascular stiffness, which can contribute to hypertension by increasing myocardial workload and vascular resistance, but also with endothelial dysfunction (20).

Studies have shown that individuals with psoriasis or psoriatic arthritis are more likely to be diagnosed with subclinical left ventricular dysfunction in the absence of clinically apparent cardiovascular disease or traditional risk factors (22). The development of hypertension may also be influenced by higher levels of angiotensin-converting enzyme, endothelin-1, and renin in patients with psoriasis (23).

Obesity and Psoriasis

A higher body mass index (BMI) is more common in individuals with severe psoriasis, and obesity is directly associated with cardiovascular mortality (24). It is known that the severity of psoriasis correlates with the degree of obesity (30). This may be related to both psychosocial factors and lower levels of physical activity.

Both psoriasis and obesity are associated with chronic inflammatory reactions that may influence the development of cardiovascular diseases or complicate their course. Many studies have shown that weight loss in patients with psoriasis or in overweight individuals leads to an improvement in skin condition (31). The molecular mechanism underlying the relationship between psoriasis and obesity is not precisely known.

Diabetes Mellitus

Diabetes mellitus is more common in individuals with severe psoriasis (25). A study conducted by Karadag et al. identified significant changes in endothelial function and increased insulin resistance in patients with psoriasis (27).

As mentioned above, individuals with psoriasis have increased levels of TNF-α, which stimulates hyperinsulinemia through a mechanism involving increased insulin resistance and promotes the secretion of adhesion molecules by endothelial cells, facilitating monocyte adhesion. Insulin resistance is increased by promoting the production of free fatty acids, reducing adiponectin synthesis, and decreasing insulin sensitivity (26).

Dyslipidemia

According to studies, patients with psoriasis have elevated levels of total cholesterol, triglycerides, and low-density lipoprotein cholesterol, as well as decreased levels of high-density lipoprotein cholesterol (28, 29). Individuals with psoriasis have a higher risk of developing hypercholesterolemia (36). These lipid changes in patients with psoriasis influence the development of cardiovascular diseases.

Smoking and Alcohol Consumption

Both smoking and alcohol consumption are risk factors for cardiovascular diseases. Various studies have found a higher prevalence of smoking and alcohol consumption among individuals with psoriasis (32). However, it remains unclear whether smoking and alcohol consumption increase the risk of psoriasis or whether they are simply consequences of psychological stress.

Conclusion

Growing evidence suggests that psoriasis is not only a skin or joint disease—it can also lead to cardiovascular and metabolic diseases. Patients with psoriasis have a higher risk of developing heart and vascular diseases and are more frequently diagnosed with hypertension, diabetes, dyslipidemia, obesity, and metabolic syndrome, and smoking is also more common among them.

Both family physicians and dermatologists should assess cardiovascular disease risk in patients with psoriasis. Dermatologists should identify concomitant diseases, ensure adequate treatment of psoriasis, and aim not only to alleviate its course but also to prevent complications associated with the disease.

When treating a patient with severe psoriasis, it is important to remember that psoriasis causes multisystem involvement and to inform the patient about the possible consequences of the disease.

Publication "Internistas," No. 6, 2018.

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