The relationship between systemic inflammation and increased left ventricular mass is partly mediated by noncalcified coronary artery disease burden in psoriasis

Objective

Increased left ventricular (LV) mass is an important precursor to heart failure. Inflammation plays an important role in increasing LV mass. However, the contribution of subclinical coronary artery disease (CAD) to the inflammation-LV mass relationship is unknown. In subjects with psoriasis, a chronic inflammatory skin disease, we evaluated if systemic inflammation assessed by plasma glycoprotein A (GlycA) associated with LV mass measured on coronary CT angiography (CCTA). Additionally, we analyzed whether this relationship was mediated by early CAD assessed as noncalcified coronary burden (NCB).

Methods

We performed an observational longitudinal study of 213 subjects with psoriasis free of known cardiovascular disease, 189 of whom were followed over one year. All participants had GlycA measurements by nuclear magnetic resonance spectroscopy and LV mass and NCB quantified by CCTA.

Results

The cohort had a mean age of 50.3 (±12.9) years and 59% were male. There was moderate psoriasis severity and low cardiovascular risk. LV mass increased by GlycA tertiles [1st tertile:24.6 g/m^2.7(3.8), 2nd tertile:25.5 g/m^2.7(3.8), 3rd tertile:27.7 g/m^2.7(5.5), p<0.001]. Both GlycA (β=0.24, p = 0.001) and NCB (β=0.50, p<0.001) associated with LV mass in models adjusted for age, sex, hypertension, hypertension therapy, lipid therapy, biologic therapy for psoriasis, waist:hip ratio, psoriasis disease duration and severity. In multivariable-adjusted mediation analyses, NCB accounted for 32% of the GlycA-LV mass relationship. Finally, over one year, change in NCB independently associated with change in LV mass (β=0.25, p = 0.002).

Conclusions

Both systemic inflammation and coronary artery NCB were associated with LV mass beyond cardiovascular risk factors in psoriasis. Furthermore, a substantial proportion of the inflammatory-LV mass relationship was mediated by NCB. These findings underscore the possible contribution of early coronary artery disease to the relationship between systemic inflammation and LV mass.

Fostamatinib for the Treatment of Hospitalized Adults With Coronavirus Disease 2019: A Randomized Trial

BACKGROUND

Coronavirus disease 2019 (COVID-19) requiring hospitalization is characterized by robust antibody production, dysregulated immune response, and immunothrombosis. Fostamatinib is a novel spleen tyrosine kinase inhibitor that we hypothesize will ameliorate Fc activation and attenuate harmful effects of the anti-COVID-19 immune response.

METHODS

We conducted a double-blind, randomized, placebo-controlled trial in hospitalized adults requiring oxygen with COVID-19 where patients receiving standard of care were randomized to receive fostamatinib or placebo. The primary outcome was serious adverse events by day 29.

RESULTS

A total of 59 patients underwent randomization (30 to fostamatinib and 29 to placebo). Serious adverse events occurred in 10.5% of patients in the fostamatinib group compared with 22% in placebo (P = .2). Three deaths occurred by day 29, all receiving placebo. The mean change in ordinal score at day 15 was greater in the fostamatinib group (-3.6 ± 0.3 vs -2.6 ± 0.4, P = .035) and the median length in the intensive care unit was 3 days in the fostamatinib group vs 7 days in placebo (P = .07). Differences in clinical improvement were most evident in patients with severe or critical disease (median days on oxygen, 10 vs 28, P = .027). There were trends toward more rapid reductions in C-reactive protein, D-dimer, fibrinogen, and ferritin levels in the fostamatinib group.

CONCLUSION

For COVID-19 requiring hospitalization, the addition of fostamatinib to standard of care was safe and patients were observed to have improved clinical outcomes compared with placebo. These results warrant further validation in larger confirmatory trials.

CLINICAL TRIALS REGISTRATION

Clinicaltrials.gov, NCT04579393.

Association Among Noncalcified Coronary Burden, Fractional Flow Reserve, and Myocardial Injury in Psoriasis

Background

Myocardial infarction and premature death have been observed in patients with psoriasis. Although inflammation‐driven accelerated atherosclerosis has been proposed as a mechanism, the relationship between subclinical noncalcified coronary burden (NCB), functional coronary flow impairment, and myocardial injury is unclear.

Methods and Results

In an ongoing longitudinal cohort study, 202 consecutive patients with psoriasis (168 at 1 year) underwent coronary computed tomography angiography to identify coronary plaque, quantify NCB, and calculate coronary fractional flow reserve by computed tomography. Serum high‐sensitivity troponin‐T (hs‐cTn‐T) was measured using a fifth‐generation assay. Overall, patients were middle‐aged, predominantly male, and low cardiovascular risk. A higher than median NCB associated with a positive hs‐cTn‐T (fully adjusted model [odds ratio (OR), 1.72; 95% CI, 1.10–2.69, P=0.018]) at baseline. Additionally, patients with a higher than median baseline NCB had higher odds of positive hs‐cTn‐T at 1 year in fully adjusted analyses (adjusted OR, 2.36; 95% CI, 1.47–3.79, P<0.001). Higher NCB was associated with a higher frequency of fractional flow reserve by computed tomography ≤0.80 (36.11% versus 25.11%, Pearson χ²=6.84, P=0.009, unadjusted OR, 2.09; 95% CI, 1.36–3.22, P<0.001) and higher frequency of a positive hs‐cTn‐T (54.36% versus 27.54%, Pearson χ²=32.23, P<0.001) in adjusted models (OR, 2.63; 95% CI, 1.56–4.42, P<0.001).

Conclusions

NCB was associated with hs‐cTn‐T at baseline as well as at 1 year. Furthermore, patients with high NCB had higher prevalence of fractional flow reserve by computed tomography ≤0.80 and a >2‐ fold higher odds of positive hs‐cTn‐T. These findings underscore the importance of early vascular disease in driving myocardial injury, and support conduct of myocardial perfusion studies to better understand these findings.

Treatment of Psoriasis With Biologic Therapy Is Associated With Improvement of Coronary Artery Plaque Lipid-Rich Necrotic Core: Results From a Prospective, Observational Study

BACKGROUND

Lipid-rich necrotic core (LRNC), a high-risk coronary plaque feature assessed by coronary computed tomography angiography, is associated with increased risk of future cardiovascular events in patients with subclinical, nonobstructive coronary artery disease. Psoriasis is a chronic inflammatory condition that is associated with increased prevalence of high-risk coronary plaque and risk of cardiovascular events. This study characterized LRNC in psoriasis and how LRNC modulates in response to biologic therapy.

METHODS

Consecutive biologic naïve psoriasis patients (n=209) underwent coronary computed tomography angiography at baseline and 1-year to assess changes in LRNC using a novel histopathologically validated software (vascuCAP Elucid Bioimaging, Boston, MA) before and after biologic therapy over 1 year.

RESULTS

Study participants were middle-aged, predominantly male with similar cardiometabolic and psoriasis status between treatment groups. In all participants at baseline, LRNC was associated with Framingham risk score (β [standardized β]=0.12 [95% CI, 0.00-0.15]; P=0.045), and psoriasis severity (β=0.13 [95% CI, 0.01-0.26]; P=0.029). At 1-year, participants receiving biologic therapy had a reduction in LRNC (mm²; 3.12 [1.99-4.66] versus 2.97 [1.84-4.35]; P=0.028), while those who did not receive biologic therapy over 1 year demonstrated no significant change with nominally higher LRNC (3.12 [1.82-4.60] versus 3.34 [2.04-4.74]; P=0.06). The change in LRNC was significant compared with that of the nonbiologic treated group (ΔLRNC, -0.22 mm² versus 0.14 mm², P=0.004) and remained significant after adjusting for cardiovascular risk factors and psoriasis severity (β=-0.09 [95% CI, -0.01 to -0.18]; P=0.033).

CONCLUSIONS

LRNC was associated with psoriasis severity and cardiovascular risk factors in psoriasis. Additionally, there was favorable modification of LRNC in those on biologic therapy. This study provides evidence of potential reduction in LRNC with treatment of systemic inflammation. Larger, longer follow-up prospective studies should be conducted to understand how changes in LRNC may translate into a reduction in future cardiovascular events in psoriasis.

Association of Biologic Therapy With Coronary Inflammation in Patients With Psoriasis as Assessed by Perivascular Fat Attenuation Index

Importance

Psoriasis is a chronic inflammatory skin disease associated with increased coronary plaque burden and cardiovascular events. Biologic therapy for psoriasis has been found to be favorably associated with luminal coronary plaque, but it is unclear whether these associations are attributable to direct anti-inflammatory effects on the coronary arteries.

Objective

To investigate the association of biologic therapy with coronary inflammation in patients with psoriasis using the perivascular fat attenuation index (FAI), a novel imaging biomarker that assesses coronary inflammation by mapping spatial changes of perivascular fat composition via coronary computed tomography angiography (CCTA).

Design, Setting, and Participants

This prospective cohort study performed from January 1, 2013, through March 31, 2019, analyzed changes in FAI in patients with moderate to severe psoriasis who underwent CCTA at baseline and at 1 year and were not receiving biologic psoriasis therapy at baseline.

Exposures

Biologic therapy for psoriasis.

Main Outcomes and Measures

Perivascular FAI mapping was performed based on an established method by a reader blinded to patient demographics, visit, and treatment status.

Results

Of the 134 patients (mean [SD] age, 51.1 [12.1] years; 84 [62.5%] male), most had low cardiovascular risk by traditional risk scores (median 10-year Framingham Risk Score, 3% [interquartile range, 1%-7%]) and moderate to severe skin disease. Of these patients, 82 received biologic psoriasis therapy (anti-tumor necrosis factor α, anti-interleukin [IL] 12/23, or anti-IL-17) for 1 year, and 52 did not receive any biologic therapy and were given topical or light therapy (control group). At baseline, 46 patients (27 in the treated group and 19 in the untreated group) had a focal coronary atherosclerotic plaque. Biologic therapy was associated with a significant decrease in FAI at 1 year (median FAI -71.22 HU [interquartile range (IQR), -75.85 to -68.11 HU] at baseline vs -76.09 HU [IQR, -80.08 to -70.37 HU] at 1 year; P < .001) concurrent with skin disease improvement (median PASI, 7.7 [IQR, 3.2-12.5] at baseline vs 3.2 [IQR, 1.8-5.7] at 1 year; P < .001), whereas no change in FAI was noted in those not receiving biologic therapy (median FAI, -71.98 [IQR, -77.36 to -65.64] at baseline vs -72.66 [IQR, -78.21 to -67.44] at 1 year; P = .39). The associations with FAI were independent of the presence of coronary plaque and were consistent among patients receiving different biologic agents, including anti-tumor necrosis factor α (median FAI, -71.25 [IQR, -75.86 to -66.89] at baseline vs -75.49 [IQR, -79.12 to -68.58] at 1 year; P < .001) and anti-IL-12/23 or anti-IL-17 therapy (median FAI, -71.18 [IQR, -75.85 to -68.80] at baseline vs -76.92 [IQR, -81.16 to -71.67] at 1 year; P < .001).

Conclusions and Relevance

In this study, biologic therapy for moderate to severe psoriasis was associated with reduced coronary inflammation assessed by perivascular FAI. This finding suggests that perivascular FAI measured by CCTA may be used to track response to interventions for coronary artery disease.

Application of machine learning to determine top predictors of noncalcified coronary burden in psoriasis: An observational cohort study

BACKGROUND

Psoriasis is associated with elevated risk of heart attack and increased accumulation of subclinical noncalcified coronary burden by coronary computed tomography angiography (CCTA). Machine learning algorithms have been shown to effectively analyze well-characterized data sets.

OBJECTIVE

In this study, we used machine learning algorithms to determine the top predictors of noncalcified coronary burden by CCTA in psoriasis.

METHODS

The analysis included 263 consecutive patients with 63 available variables from the Psoriasis Atherosclerosis Cardiometabolic Initiative. The random forest algorithm was used to determine the top predictors of noncalcified coronary burden by CCTA. We evaluated our results using linear regression models.

RESULTS

Using the random forest algorithm, we found that the top 10 predictors of noncalcified coronary burden were body mass index, visceral adiposity, total adiposity, apolipoprotein A1, high-density lipoprotein, erythrocyte sedimentation rate, subcutaneous adiposity, small low-density lipoprotein particle, cholesterol efflux capacity and the absolute granulocyte count. Linear regression of noncalcified coronary burden yielded results consistent with our machine learning output.

LIMITATION

We were unable to provide external validation and did not study cardiovascular events.

CONCLUSION

Machine learning methods identified the top predictors of noncalcified coronary burden in psoriasis. These factors were related to obesity, dyslipidemia, and inflammation, showing that these are important targets when treating comorbidities in psoriasis.

Managing emerging transnational public health security threats: lessons learned from the 2014 West African Ebola outbreak

Background

Pandemics pose significant security/stability risks to nations with fragile infrastructures. We evaluated characteristics of the 2014 West African Ebola outbreak to elucidate lessons learned for managing transnational public health security threats.

Methods

We used publically available data to compare demographic and outbreak-specific data for Guinea, Sierra Leone, and Liberia, including key indicator data by the World Health Organization. Pearson correlation statistics were calculated to compare country-level infrastructure characteristics with outbreak size and duration.

Results

Hospital bed density was inversely correlated with longer EVD outbreak duration (r = − 0.99). Country-specific funding amount allocations were more likely associated with number of incident cases than the population at-risk or infrastructure needs. Key indicators demonstrating challenges for Guinea included: number of unsafe burials, percent of EVD-positive samples, and days between symptom onset and case hospitalization. Sierra Leone’s primary key indicator was the number of districts with ≥1 security incident. Liberia controlled their outbreak before much of the key-indicator data were collected.

Conclusion

Many of the country-level factors, particularly the WHO key indicators were associated with controlling the epidemic. The infrastructure of countries affected by communicable diseases should be assessed by international political and public health leaders.

Prevalence and Mortality of Melanoma in Oklahoma Among Racial Groups, 2000-2008

INTRODUCTION

This study assessed the period prevalence (2000-2008) and mortality rates of melanoma, in Oklahoma, among different racial/ethnic strata.

METHODS

We analyzed incident cases of melanoma from 2000-2008 from the Oklahoma Central Cancer Registry and determined disease duration using Kaplan-Meier survival analysis to calculate period prevalence of melanoma in Oklahoma. Using a series of Chi-Square tests, we compared period prevalence and mortality rates among the racial groups and compared mortality between Oklahoma and the US.

RESULTS

White non-Hispanics in Oklahoma have the highest period prevalence (p<0.0001) among the racial strata. American Indian or Alaska Native (AI/AN) individuals have the second highest period prevalence in Oklahoma (p<0.0001). Furthermore, white non-Hispanics (p<0.0001) and AI/AN individuals (p=0.0003) in Oklahoma had higher mortality rates compared to the US.

CONCLUSIONS

There are disparities in the prevalence and mortality of melanoma among the AI/AN population in Oklahoma, and prevention and education programs should focus on this population.

Cancer among American Indians - Identifying Priority Areas in Oklahoma

BACKGROUND

We describe and compare cancer incidence and mortality among American Indians (AI/ANs) and whites in nine Indian Health Service (IHS) Service Units in Oklahoma.

METHODS

Using data from the Oklahoma Central Cancer Registry and the web-based OK2SHARE database, we obtained age-adjusted cancer incidence rates from 1997 to 2012 and cancer mortality rates from 1999 to 2009 for AI/ANs and whites in Oklahoma. We examined differences in primary site, percentage of late stage diagnoses, and trends over time.

RESULTS

AI/ANs consistently had higher cancer incidence and mortality compared to whites in Oklahoma. The magnitude of disparity for cancer incidence and mortality varied by IHS Service Unit and by gender. The top three cancer sites were the same for all Service Units. The percentage of late stage diagnosis also varied by region.

CONCLUSIONS

We identify priority areas where cancer disparity challenges exist among AI/ANs in Oklahoma.

Cancer incidence and staging among American Indians in Oklahoma

BACKGROUND

This study describes overall and site specific cancer incidence among AI/ANs compared to whites in Oklahoma and differences in cancer staging.

METHODS

Age-adjusted incidence rates obtained from the Oklahoma Central Cancer Registry are presented for all cancer sites combined and for the most common cancer sites among AI/ANs with comparisons to whites. Percentages of late stage cancers for breast, colorectal, and melanoma cancers are also presented.

RESULTS

AI/ANs had a significantly higher overall cancer incidence rate compared to whites (629.8/100,000 vs. 503.3/100,000), with a rate ratio of 1.25 (95% CI: 1.22, 1.28). There was a significant disparity in the percentage of late stage melanoma cancers between 2005 and 2009, with 14.0% late stage melanoma for whites and 20.0% for AI/ANs (p-value:0.03).

CONCLUSIONS

Overall, there were cancer disparities between AI/ANs and whites in Oklahoma. Incidence rates were higher among AI/ANs for all cancers and many site specific cancers.