Date Published: February 8, 2019
Publisher: Public Library of Science
Author(s): Alvaro Gonzalez-Cantero, Jorge Gonzalez-Cantero, Ana Isabel Sanchez-Moya, Cristina Perez-Hortet, Salvador Arias-Santiago, Cristina Schoendorff-Ortega, Jorge Luis Gonzalez-Calvin, Rudolf Kirchmair.
Psoriasis is associated with an increased risk of cardiovascular disease (CVD) at younger ages that is not identifiable by traditional risk factors. Screening for subclinical atherosclerosis with ultrasound has only been investigated in carotid arteries. Femoral artery ultrasound has never been considered for this purpose. The link between psoriasis and accelerated atherosclerosis has not yet been established.
To study the usefulness of femoral artery ultrasound for the detection of subclinical atherosclerosis in psoriasis. We also investigated its possible relationship with changes in insulin resistance.
We conducted a cross-sectional study in 140 participants, 70 patients with moderate-to-severe psoriasis and 70 healthy controls, matched 1:1 for age, sex, and BMI. Femoral and carotid atherosclerotic plaques were evaluated by ultrasonography. Insulin resistance was assessed by the homeostasis model assessment method (HOMA-IR).
Femoral atherosclerotic plaque prevalence was significantly higher in patients with psoriasis (44.64%) than in controls (19.07%) (p<0.005), but no significant difference was found in carotid plaque prevalence (p<0.3). Femoral plaques were significantly more prevalent than carotid plaques (21.42%) among patients with psoriasis (p<0.001). In the regression analysis, insulin resistance was the most influential determinant of atherosclerosis in psoriasis and C-reactive protein the most significant predictor of insulin resistance. Ultrasound screening for femoral atherosclerotic plaques improves the detection of subclinical atherosclerosis in patients with psoriasis, whereas the study of carotid arteries is not sufficiently accurate. Insulin resistance appears to play a greater role in the development of atherosclerosis in these patients in comparison to other classical CVD risk factors.
Psoriasis is a complex chronic, inflammatory, immune-mediated disease of the skin and joints associated with multiple comorbidities [1, 2]. The life expectancy of patients with psoriasis is reduced by 4 to 5 years due to cardiovascular disease (CVD), and there is an increased risk of myocardial infarction at a younger age [3, 4]. It is well established that classical screening methods such as the Framingham Risk Score do not reliably evaluate the risk of coronary artery disease in patients with psoriasis [4, 5]. Early detection of subclinical coronary atherosclerosis and the adoption of primary preventive measures could minimize the risk of coronary artery disease in these patients. Rigorous screening for atherosclerosis has therefore been proposed for patients with psoriasis, emphasizing the need for a noninvasive, simple, and widely available technique for this purpose . High-resolution ultrasonic arterial scanning provides information on arterial atherosclerotic plaques and meets the aforementioned criteria . Carotid intima-media thickness (IMT) was initially used as a biomarker of atherosclerosis  but is now known to be a very weak predictor of cardiovascular risk. The IMT is not always related to atherosclerosis and does not add significant predictive capacity to traditional risk scores, and it is no longer recommended in American College of Cardiology/ American Heart Association guidelines [8–10]. A few studies used ultrasound to assess the presence of carotid plaques and reported contradictory results on their prevalence in patients with psoriasis [11–13]. Autopsy studies have observed that the presence of femoral plaque but not carotid plaque is a significant predictor of coronary atherosclerosis and coronary mortality [14, 15], and studies in healthy adults found femoral plaques to be more prevalent than carotid plaques and more strongly associated with traditional CVD risk factors and coronary calcium [16–18].
The study was approved by the ehtics committe of Complejo Hospitalario de Toledo. All participants signed written informed consent. We conducted a cross-sectional study in 140 Caucasian participants: 70 patients with moderate to severe chronic plaque psoriasis (psoriasis area and severity index (PASI) and body surface area (BSA) values > 10), and 70 healthy control subjects matched 1:1 for age, gender, and BMI. Patients were consecutively recruited from May through September 2017 at the Department of Dermatology of our hospital in Toledo, Spain. The diagnosis of psoriasis was based on clinical findings. The other study inclusion criterion for patients was no systemic anti-psoriasis treatment for at least 3 months before the study. Exclusion criteria were: the presence of diabetes mellitus, chronic kidney disease, chronic liver disease, malignancy, chronic inflammatory disease, or arthritis, or a history of cardiovascular or cerebrovascular disease. The control group was recruited from among individuals with non- inflammatory dermatological diseases other than psoriasis (nevi, seborrheic keratosis, actinic keratosis, or verruca) and from among hospital paramedical and administrative personnel. Inclusion criteria for the controls were: age>18 years and the signing of informed consent to study participation. Exclusion criteria were the same as described above for patients plus the presence of psoriasis or a family history of this disease. Patients and controls were consecutively enrolled during the same time period, resided in the same geographic area, and signed their informed consent before study enrollment.
Table 1 exhibits the anthropometrical and clinical data of participants. No significant differences were found between psoriasis patients and controls in age, sex, BMI, waist circumference, arterial hypertension, dyslipidemia, daily physical activity, or tobacco consumption.
The main finding of this study is that screening for femoral plaques improves the detection of subclinical atherosclerosis in patients with psoriasis, whereas the study of carotid arteries is not sufficiently accurate. Insulin resistance was a more influential determinant of subclinical atherosclerosis in these patients in comparison to other classical CVD risk factors, and age was also a significant predictor. The prevalence of femoral but not carotid atherosclerotic plaques was significantly higher in patients with psoriasis than in age-, sex-, and BMI-matched controls, and the patients had a two-fold higher prevalence of femoral versus carotid plaques.