Ischemic cardiovascular involvement in psoriasis: a systematic review

Psoriasis and associated risk factors: a cross-sectional analysis of the Brazilian Longitudinal Study of Adult Health

OBJECTIVE

This study investigated the association of psoriasis with cardiovascular risk factors and psychological aspects among participants of the Brazilian Longitudinal Study of Adult Health.

METHODS

This is a cross-sectional study from the baseline data of the Brazilian Longitudinal Study of Adult Health cohort, collected between 2008 and 2010 in six state capitals of Brazil (i.e., Belo Horizonte, Porto Alegre, Rio de Janeiro, Salvador, São Paulo, and Vitória). Participants were active and retired civil servants from college and research institutions, aged between 35 and 74 years. Exclusion criteria included the intention to quit working at the institution, pregnancy, severe cognitive impairment, and, if retired, residence outside of a study center's corresponding area. Psoriasis case identification was based on a previous medical diagnosis of psoriasis. Cardiovascular risk profile, psychological aspects, and sociodemographic variables were investigated.

RESULTS

Data from 15,105 participants were analyzed (mean age of 52.3 years, 51.3% women). The prevalence of psoriasis was 1.6% (n=236). Psoriasis was associated with higher education (OR 1.94 [CI 1.07-3.52]), health insurance plan (OR 1.56 [CI 1.08-2.25]), central obesity (OR 1.63 [CI 1.10-2.40]), smoking status (former OR 1.40 [CI 1.03-1.88]; current OR 1.61 [CI 1.08-2.40]), and very bad self-perception of health (OR 7.22 [CI 2.41-21.64]), remaining significant even after multivariate adjustment. Self-reported Black participants were less likely to have psoriasis (OR 0.45 [CI 0.26-0.75]).

CONCLUSION

In a sample of healthy workers, psoriasis was associated with central obesity, smoking, and a very bad self-perception of health, which may contribute to future cardiovascular disease.

Extracellular Nucleophosmin Is Increased in Psoriasis and Correlates With the Determinants of Cardiovascular Diseases

We previously showed that genotoxic stress induced an active extracellular release of nucleophosmin (NPM) in human cardiac mesenchymal progenitor cells, and that serum deprivation provokes NPM secretion from human endothelial cells, eliciting inflammation via nuclear factor kappa B (NF-kB) transcriptional activation. In this study, we wanted to determine whether NPM was similarly modulated in the skin and plasma of psoriatic patients (Pso). We found that NPM was induced in 6 skin biopsies compared to 6 normal skin biopsies and was markedly increased in lesional (LS) vs. non-lesional skin (NLS) biopsies. Moreover, NPM was also increased at the transcriptional levels in LS vs. NLS. Both the innate stimuli, such as lipopolysaccharides and Poly inositol–cytosine and adaptive stimuli, that is, cytokine mix, were able to induce the extracellular release of NPM in immortalized keratinocytes and human skin fibroblasts in the absence of cytotoxicity. Interestingly, NPM interacts with Toll-like receptor (TLR)4 in these cells and activates an NF-kB-dependent inflammatory pathway upregulating interleukin IL-6 and COX-2 gene expression. Finally, circulating NPM was increased in the plasma of 29 Pso compared to 29 healthy controls, and positively correlates with psoriasis area severity index (PASI) and with determinants of cardiovascular diseases (CVDs), such as pulse wave velocity, systolic pressure, and left ventricular mass. Furthermore, NPM positively correlates with miR-200c circulating levels, which we previously showed to increase in Pso and correlate with CVD progression. Our data show that circulating miR-200c is physically associated with extracellular NPM, which most probably is responsible for its extracellular release and protection upon cytokine mix via a TLR4-mechanism. In conclusion, NPM is increased in psoriasis both in the skin and plasma and might be considered a novel biologic target to counteract chronic inflammation associated with CVD risk.

Cardiovascular Involvement in Psoriasis, Diagnosing Subclinical Atherosclerosis, Effects of Biological and Non-Biological Therapy: A Literature Review

Psoriasis is a long-lasting, noncontagious chronic inflammatory disease of skin and joints. Previous epidemiological studies have demonstrated that psoriatic patients have a shorter life expectancy, mainly due to cardiovascular (CV) events with a higher prevalence of cardiovascular risk factors like dyslipidemia, diabetes mellitus, insulin resistance, obesity, and hypertension. Besides these risk factors, psoriasis likely plays an independent role in increasing CV events probably due to the chronic inflammatory state. This literature review aims to summarize the mechanism of atherosclerosis formation, CV risk factors, tools to diagnose subclinical atherosclerosis, and the effects of various therapies in psoriatic patients to prevent cardiovascular-related deaths in psoriasis. This review was performed by searching the relevant articles in PubMed and Google Scholar databases without including any exclusion criteria and time limitations. Our review documented that psoriatic patients are at increased risk of CV events due to chronic inflammatory profile and the associated CV risk factors. Also, anti-inflammatory therapies may prevent early subclinical atherosclerotic vascular changes reducing cardiovascular events. However, the available studies lack to establish the exact targets for CV risk factors, to assess the clinical importance of screening for subclinical vascular changes and the impact of anti-inflammatory therapies on CV risk profile in psoriatic patients. This heightened awareness about the CV involvement in psoriasis should encourage conducting large, well planned comprehensive studies to address these issues that can reduce cardiovascular morbidity and mortality.

Diabetes and Psoriasis: Different Sides of the Same Prism

Diabetes and psoriasis are prevalent conditions with a spectrum of serious adverse outcomes. Both diseases are common comorbidities for each other, and diabetes is considered as a risk factor for psoriasis and vice versa. However, it is our contention that these diseases are not merely comorbidities of each other but rather share common underlying pathophysiologies (ie, genes and epigenetic changes, inflammation, abnormal environment, and insulin resistance) that drive disease. As such, they can be viewed as facets of the same prism. Genes can cause or permit susceptibility to damage from abnormal external and internal environmental factors, inflammation, and insulin resistance which can also drive epigenetic changes. These co-existing mechanisms act in a vicious cycle over time to potentiate cell and tissue damage to ultimately drive disease. Viewing diabetes and psoriasis through the same prism suggests potential for therapies that could be used to treat both conditions. Although additional controlled trials and research are warranted, we believe that our understanding of the overlapping pathophysiologies continues to grow, so too will our therapeutic options.

The Oxidative Stress-Induced miR-200c Is Upregulated in Psoriasis and Correlates with Disease Severity and Determinants of Cardiovascular Risk

Psoriasis is a chronic inflammatory skin disease associated with reactive oxygen species (ROS) increase and a higher risk of cardiovascular (CV) events. We previously showed that the miR-200 family (miR-200s) is induced by ROS, miR-200c being the most upregulated member responsible for apoptosis, senescence, ROS increase, and nitric oxide decrease, finally causing endothelial dysfunction. Moreover, circulating miR-200c increases in familial hypercholesterolemic children and in plaques and plasma of atherosclerotic patients, two pathologies associated with increased ROS. Given miR-200s' role in endothelial dysfunction, ROS, and inflammation, we hypothesized that miR-200s were modulated in lesional skin (LS) and plasma of psoriatic patients (Pso) and that their levels correlated with some CV risk determinants at a subclinical level. All Pso had severe psoriasis, i.e., Psoriasis Area and Severity Index (PASI) > 10, and one of the following: at least two systemic psoriasis treatments, age at onset < 40 years, and disease duration > 10 years. RNA was extracted from plasma (Pso, N = 29; Ctrl, N = 29) and from nonlesional skin (NLS) and LS of 6 Pso and 6 healthy subject skin (HS) biopsies. miR-200 levels were assayed by quantitative RT-PCR. We found that all miR-200s were increased in LS vs. NLS and miR-200c was the most expressed and upregulated in LS vs. HS. In addition, circulating miR-200c and miR-200a were upregulated in Pso vs. Ctrl. Further, miR-200c positively correlated with PASI, disease duration, left ventricular (LV) mass, LV relative wall thickness (RWT), and E/e', a marker of diastolic dysfunction. Multiple regression analysis indicates a direct association between miR-200c and both RWT and LV mass. Circulating miR-200a correlated positively only with LV mass and arterial pressure augmentation index, a measure of stiffness, although the correlations were nearly significant (P = 0.06). In conclusion, miR-200c is upregulated in LS and plasma of Pso, suggesting its role in ROS increase and inflammation associated with CV risk in psoriasis.

Poor agreement in questionnaire-based diagnostic criteria for adult atopic dermatitis is a challenge when examining cardiovascular comorbidity

BACKGROUND

The association between atopic dermatitis (AD) and cardio-metabolic risk factors is not yet established. Furthermore, no validated questionnaire-based method of identifying adults with AD is currently available.

OBJECTIVES

To assess the cardio-metabolic risk in adults with a history of AD using 3 different questionnaire-based diagnostic criteria.

METHODS

We utilized data from a general population study including questionnaire data and objective measurements of 9656 Danish adults. To identify adults with a history of AD, we used a question regarding physician-diagnosed AD and 2 versions of the UK Working Party Diagnostic Criteria. Associations between AD status and cardio-metabolic endpoints were estimated using survey weighted logistic and linear regression analysis.

RESULTS

We identified 462 (4.8%) adults with self-reported physician-diagnosed AD, whereas 903 (9.4%) and 226 (2.3%) had AD according to the UK Working Party Criteria when at least 2 and 3of 4 minor criteria were fulfilled. The populations were not comparable in terms of occurrence of cardio-metabolic risk factors. For example, the prevalence of obesity was lower in participants with physician-diagnosed AD but overall higher in UK 2/4 and UK 3/4.

CONCLUSION

Due to the heterogeneity in the captured study populations in terms of the studied outcomes and absence of a gold standard, no conclusions regarding the cardio-metabolic risk in adults with AD in a general population could be made. This study serves as an example of the challenges that are often encountered in questionnaire-based epidemiologic studies and highlights the need of better definitions for this patient group.

The risk of cardiovascular events in psoriasis patients treated with tumor necrosis factor-α inhibitors versus phototherapy: An observational cohort study

BACKGROUND

Psoriasis is a risk factor for cardiovascular events.

OBJECTIVE

To assess the risk of major cardiovascular events and the effect of cumulative treatment exposure on cardiovascular event risk in patients with psoriasis treated with tumor necrosis factor-α inhibitors (TNFis) versus phototherapy.

METHODS

Adult patients with psoriasis were selected from a large US administrative claims database (from the first quarter of 2000 through the third quarter of 2014) and classified in 2 mutually exclusive cohorts based on whether they were treated with TNFis or phototherapy. Cardiovascular event risk was compared between cohorts using multivariate Cox proportional hazards models. Cumulative exposure was defined based on treatment persistence.

RESULTS

A total of 11,410 TNFi and 12,433 phototherapy patients (psoralen plus ultraviolet A light phototherapy, n = 1117; ultraviolet B light phototherapy, n = 11,316) were included in this study. TNFi patients had a lower risk of cardiovascular events compared to phototherapy patients (adjusted hazard ratio 0.77, P < .05). The risk reduction associated with 6 months of cumulative exposure was 11.2% larger for patients treated with TNFis compared to phototherapy (P < .05).

LIMITATIONS

Information on psoriasis severity and mortality was limited/not available.

CONCLUSIONS

Patients with psoriasis who were treated with TNFis exhibited a lower cardiovascular event risk than patients treated with phototherapy. Cumulative exposure to TNFis was associated with an incremental cardiovascular risk reduction compared to phototherapy.

Effects of polysaccharide from Physalis alkekengi var. francheti on liver injury and intestinal microflora in type-2 diabetic mice

CONTEXT

Diabetic liver injury is a serious diabetic complication. The alterations of intestinal microbiota play an important role in induction and promotion of liver injury progression. Physalis alkekengi L. var. francheti (Mast.) Makino (Solanaceae) has been used as a water decoction for treating diabetes.

OBJECTIVE

To study the effects of a polysaccharide (PPSB) from Physalis alkekengi var. francheti on liver injury and intestinal microflora in type-2 diabetic mice.

MATERIALS AND METHODS

Streptozotocin (160 mg/kg) was injected i.p. for 3 days to build model. The diabetic mice were randomly divided into four groups together with control group (10 mice in each group). The doses of PPSB were 50 and 100 mg/kg, respectively. After 5 weeks administration, level of blood glucose, ALT and AST were measured. Alterations of intestinal microflora, and protein expression of TGF-β1, TNF-α and DCN were detected.

RESULTS

Level of blood glucose decreased from (25.38 ± 2.21) mmol/L to (18.01 ± 2.53) mmol/L, ALT and AST decreased to (24.67 ± 4.86) U/L and (30.84 ± 7.50) U/L in PPSB-H group. Lactobacillus, Clostridium butyricum, and Bacteroides increased remarkably with increasing concentration of PPSB, but Enterobacter was inhibited. The relative expression of TGF-β1 and TNF-α decreased to (0.70 ± 0.17) and (0.39 ± 0.06), and the expression of DCN increased to (0.65 ± 0.13).

DISCUSSION AND CONCLUSIONS

Probiotics have been promoted by PPSB, and protein expressions have been modulated in the progression of liver injury. PPSB could be used as a natural agent for treating diabetic liver injury and intestinal microflora imbalance.

Prevalence of Metabolic Syndrome in Psoriasis and Levels of Interleukin-6 and Tumor Necrosis Factor-α in Psoriasis Patients with Metabolic Syndrome: Indian Tertiary Care Hospital Study

Background:

Psoriasis is a chronic inflammatory multisystem disease, found to be associated with metabolic syndrome (MS) and increased levels of cytokines. To evaluate the prevalence of MS in psoriasis and to determine the levels of interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) in psoriasis patients with MS.

Methods:

Observational study on 334 psoriasis patients and 230 controls. MS was diagnosed by the presence of three or more criteria of original, revised, and modified National Cholesterol Education Program's Adult Treatment Panel III (NCEP ATP III).

Results:

MS was significantly more common in psoriasis patients than in controls (multivariate odds ratio [95% confidence interval] of original NCEP ATP III = 5.73 [2.99–10.99], revised NCEP ATP III = 4.44 [2.43–8.10], and modified NCEP ATP III = 6.00 [3.43–10.52]). Higher prevalence of abdominal obesity (66.2% vs. 47%, P < 0.001), hypertriglyceridemia (40.4% vs. 29.6%, P = 0.009), systolic blood pressure (BP) ≥130 mmHg (25.1% vs. 7.4%, P < 0.001), diastolic BP ≥85 mmHg (30.2% vs. 12.2%, P < 0.001), and fasting plasma glucose ≥100 mg/dl (17.4% vs. 9.1%, P = 0.005) among psoriasis patients as compared to controls. Mean (standard deviation) values of IL-6 and TNF-α were 76.7 (73.9) pg/ml and 234.3 (273.9) in subgroup of psoriasis patients with MS (n = 42), significantly higher than the normal population (P < 0.0001).

Conclusion:

MS is more common in psoriasis. IL-6 and TNF-α is significantly higher in psoriasis patients with MS, signifying their role in pathogenesis of psoriasis and MS.

Reducing patient copayment levels for topical and systemic treatments in plaque psoriasis as a case for evidence-based, sustainable pharmaceutical policy change in Greece

AIM

Psoriasis is a chronic inflammatory skin disease that requires treatment to manage co-morbidities and improve patient quality-of-life. This study estimated the budget impact to National Organization for Health Care Services Provision (EOPYY) of changing reimbursement of psoriasis treatment with topical and systemic, non-biologic, agents (75%) to bring it on par with that of biologic agents (100%) in Greece.

METHODS

The Business Intelligence database of EOPYY was used to identify and provide analytics on patients with plaque psoriasis. Permission for use of anonymized data was obtained by the administration of EOPYY. EOPYY is responsible for funding healthcare and pharmaceutical care services for ∼95% of the permanent population in the country. Pre-defined ICD-10 codes were applied to identify patients with plaque psoriasis and at least one reimbursed prescription between 1 June 2014 and 31 May 2015. Age, gender, medications, and cost were recorded for these patients.

RESULTS

Of the 45,581 unique patients identified through completely anonymized data on the e-prescription system, 72% were on treatment with topicals only and accounted for 5% of EOPYY psoriasis expenditure. Another 9% of patients were on methotrexate or a per os (POS, orally administered) systemic agent and accounted for 2.35% of total expenditure. Approximately 12% of total patients were on treatment with a biologic-containing regimen and accounted for almost 90% of psoriasis expenditure. Patients on biologics were younger than patients on topical and systemic treatments. The burden to EOPYY of adjusting reimbursement levels for topical and systemic, non-biologic, treatments to 100% of their cost was estimated at €2.05 per patient per month for topical treatments (monotherapy) and an additional €9.5 per patient per month for treatment with methotrexate, POS systemic agents, and their combinations with topical agents. This additional cost is expected to be offset by averting 200 earlier than clinically necessary switches from topical and systemic, non-biologic, treatments to expensive biologics a year.

CONCLUSION

In circumstances of severe funding constraints for social health insurance in Greece, bringing patient copayment levels for psoriasis treatment on par with each other may aid proper clinical management of the condition, whilst achieving adequate treatment outcomes at optimal cost.

Cardiovascular Disease Outcomes Associated with Three Major Inflammatory Dermatologic Diseases: A Propensity-Matched Case Control Study

Introduction

Inflammation is an established component of cardiovascular disease (CVD) and an underlying factor of several dermatologic conditions including rosacea, atopic dermatitis, and psoriasis. Identifying potential associations between these dermatologic and cardiovascular diseases can better inform holistic healthcare approaches. The objective of this study was to determine whether rosacea, psoriasis or atopic dermatitis are independent risk factors for CVD 1 year following diagnosis.

Methods

Using a large commercial claims database of 21,801,147 lives, we employed a propensity-matched logistic regression to evaluate the association between diagnoses of rosacea, psoriasis, or atopic dermatitis and a 1-year risk of being diagnosed with cardiovascular disease. Control patients were matched based on health-care utilization, age and overall health status as defined by a modified Deyo–Charlson comorbidity index.

Results

The analysis included 2105 rosacea, 622 atopic dermatitis, 1536 psoriasis, and 4263 control patients. Compared to propensity-matched controls, the adjusted odds of cardiovascular disease were not higher in patients with rosacea (odds ratio: 0.894, p = 0.2713), atopic dermatitis (OR 1.032, p = 0.8489), or psoriasis (OR 1.087, p = 0.4210). In univariate analysis, the unadjusted odds of cardiovascular disease was higher in patients with psoriasis (OR 1.223, p = 0.0347).

Conclusions

Limitations of this study include the short follow-up period and inclusion of only commercially insured patients limit the generalizability of these findings. In this large study of patients with rosacea, atopic dermatitis, and psoriasis, we did not detect an increased 1-year risk of cardiovascular disease after adjusting for confounders.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-016-0144-3) contains supplementary material, which is available to authorized users.

NecroX-5 exerts anti-inflammatory and anti-fibrotic effects via modulation of the TNFα/Dcn/TGFβ1/Smad2 pathway in hypoxia/reoxygenation-treated rat hearts

Inflammatory and fibrotic responses are accelerated during the reperfusion period, and excessive fibrosis and inflammation contribute to cardiac malfunction. NecroX compounds have been shown to protect the liver and heart from ischemia-reperfusion injury. The aim of this study was to further define the role and mechanism of action of NecroX-5 in regulating infl ammation and fi brosis responses in a model of hypoxia/reoxygenation (HR). We utilized HR-treated rat hearts and lipopolysaccharide (LPS)-treated H9C2 culture cells in the presence or absence of NecroX-5 (10 µmol/L) treatment as experimental models. Addition of NecroX-5 signifi cantly increased decorin (Dcn) expression levels in HR-treated hearts. In contrast, expression of transforming growth factor beta 1 (TGFβ1) and Smad2 phosphorylation (pSmad2) was strongly attenuated in NecroX-5-treated hearts. In addition, signifi cantly increased production of tumor necrosis factor alpha (TNFα), TGFβ1, and pSmad2, and markedly decreased Dcn expression levels, were observed in LPS-stimulated H9C2 cells. Interestingly, NecroX-5 supplementation effectively attenuated the increased expression levels of TNFα, TGFβ1, and pSmad2, as well as the decreased expression of Dcn. Thus, our data demonstrate potential antiinflammatory and anti-fibrotic effects of NecroX-5 against cardiac HR injuries via modulation of the TNFα/Dcn/TGFβ1/Smad2 pathway.

Psoriasis, non-alcoholic fatty liver disease, and cardiovascular disease: Three different diseases on a unique background

Psoriasis is a chronic inflammatory immune-mediated skin disease, frequently associated with systemic comorbidities. According to recent data, patients with psoriasis show a greater prevalence of metabolic syndrome, which confers a higher cardiovascular risk. The link between these pathological conditions appears to be a chronic low-grade inflammatory status. The aim of this review is to focus on the multiple epidemiological and physio-pathogenetic aspects linking non-alcoholic fatty liver disease, psoriasis, and cardiovascular disease.

Deranged iron status in psoriasis: the impact of low body mass

BACKGROUND

Iron deficiency (ID) frequently complicates inflammatory-mediated chronic disorders, irrespective of anaemia. Psoriasis is a chronic, immune-mediated skin disease with systemic pro-inflammatory activation; thus, these patients may be prone to develop ID. ID adversely affects immune cells function, which can further contribute to disease progression. This study investigates iron status in psoriasis.

METHODS

Serum concentrations of ferritin, transferrin saturation (Tsat), soluble transferrin receptor (sTfR), and hepcidin were assessed as the biomarkers of iron status in 39 patients with psoriasis (17 men, age: 47 ± 10 years) and 44 healthy subjects (30 men, age: 53 ± 6 years).

RESULTS

Compared with healthy controls, patients with psoriasis demonstrated similar haematologic status but deranged iron status as evidenced by decreased Tsat and elevated sTfR (negative tissue iron balance) and low levels of hepcidin (depleted iron stores) (all P < 0.05 vs. controls). In patients, the levels of interleukin-6 (level of pro-inflammatory activation) significantly correlated with hepcidin (R = 0.54), but not with ferritin, Tsat, and sTfR. Biomarkers reflecting ID were not associated with the severity of the disease (assessed with the Psoriasis Area and Severity Index) but significantly correlated low body mass index (BMI). Patients with BMI < 24 kg/m(2) compared with those with BMI ≥ 24 kg/m(2) demonstrated lower levels of ferritin (40 ± 30 vs. 186 ± 128 ng/mL, P < 0.001) and hepcidin (4.9 ± 2.3 vs. 10.7 ± 6.7 ng/mL, P = 0.03).

CONCLUSION

Psoriasis is associated with deranged iron status characterized by depleted iron stores with concomitant unmet cellular iron requirements. The magnitude of these abnormalities is particularly strong in patients with low body mass index. Whether iron deficiency may become a therapeutic target in psoriasis needs to be investigated.

Association between adult atopic dermatitis, cardiovascular disease, and increased heart attacks in three population-based studies

BACKGROUND

Adults with eczema are more likely to smoke cigarettes, consume alcohol, and have sedentary lifestyle. We sought to determine whether adult eczema is associated with increased cardiovascular and cerebrovascular disease.

METHODS

Data from the 2005-2006 National Health and Nutrition Examination Survey (NHANES) (n = 4970) and 2010 (n = 27 157) and 2012 (n = 34 525) National Health Interview Survey (NHIS). History of coronary artery disease (CAD), angina, heart attack, stroke, and peripheral vascular disease (PVD) were determined.

RESULTS

In NHANES, flexural eczema in the past year was associated with significantly higher odds of CAD (P ≤ 0.04), heart attack (P ≤ 0.01), and congestive heart failure (P ≤ 0.02), but not with stroke (P ≥ 0.37), in survey-weighted multivariate logistic regression models that controlled for socio-demographics, comorbid asthma, and hay fever. Similarly, in NHIS 2010 and 2012, 1-year history of eczema was associated with significantly higher odds of CAD (P ≤ 0.02), angina (P ≤ 0.02), heart attack (P ≤ 0.047), other heart disease (P < 0.0001), stroke (P ≤ 0.02), and PVD (<0.0001) in multivariate models.

CONCLUSIONS

Adults with atopic dermatitis may have increased cardiovascular disease, heart attack, and stroke.