How to manage cardiovascular and thrombotic risks in patients with psoriasis?

Managing Cardiovascular and Thrombotic Risks in Psoriasis

All patients with psoriasis require systematic cardiovascular risk assessment and aggressive management of traditional risk factors, with risk calculations multiplied by 1.5 for those with severe disease (>10% BSA) or requiring systemic therapy. 1

Understanding the Cardiovascular Risk in Psoriasis

Psoriasis functions as an independent risk factor for myocardial infarction, with the greatest risk observed in young patients with severe disease. 1 The pathophysiology involves increased antigen presentation, T-cell activation, and T-helper cell type 1 cytokines, resulting in systemic inflammation marked by elevated CRP levels. 1 This chronic inflammatory state creates common pathways with atherosclerosis, including lipid accumulation, inflammation, and thrombosis. 2, 3

The relative risk of myocardial infarction remains elevated even after controlling for traditional cardiovascular risk factors, and this risk persists but attenuates with age. 1 Patients with severe psoriasis demonstrate higher myocardial infarction risk than those with mild disease, consistent with the hypothesis that greater immune activity correlates with higher cardiovascular event rates. 1

Mandatory Screening Protocol

Standard Screening for All Psoriasis Patients

Cardiovascular risk assessment including screening for hypertension, diabetes, and hyperlipidemia according to national guidelines is required for all patients with psoriasis. 1

• Hypertension screening: Every 3-5 years for normal BP (<120/80 mmHg) in ages 18-39 without risk factors; yearly for age ≥40 years or those with BP 130-139/85-89 mmHg, overweight/obesity, or Black race. 1
• Diabetes screening: Every 3 years for adults aged 40-70 years with BMI ≥25 kg/m²; begin at age 45 years for those without risk factors. 1
• Cardiovascular risk assessment: Every 4-6 years for adults aged 20-79 years with standard risk factors; estimate 10-year risk for adults aged 40-79 years. 1

Enhanced Screening for Severe Disease

Early and more frequent screening for hypertension, diabetes, and hyperlipidemia should be implemented in psoriasis patients who are candidates for systemic or phototherapy or who have psoriasis involving ≥10% of BSA. 1

Risk Calculation Adjustment

Risk score models must be adapted for patients with psoriasis by introducing a 1.5 multiplication factor when the patient meets either criterion: disease severity of BSA ≥10% or candidate for systemic or phototherapy. 1 This adjustment accounts for the independent cardiovascular risk conferred by psoriasis beyond traditional risk factors. 1

Comprehensive Risk Factor Management

Lifestyle Modifications (First-Line for All Patients)

Modification of traditional risk factors through lifestyle changes is of particular importance in reducing risk in individuals with psoriasis. 1

• Smoking cessation: Mandatory maintenance of tobacco abstinence, as smoking significantly increases cardiovascular risk and worsens psoriasis activity. 1, 4, 5
• Weight management: Target BMI <25 kg/m² through combined dietary changes and physical activity, as obesity is both a risk factor for developing psoriasis and worsens cardiovascular outcomes. 4, 5, 6
• Mediterranean diet: Rich in legumes, dietary fiber, nuts, fruits, and vegetables with high flavonoid intake. 4
• Physical activity: Low to moderate-intensity aerobic activities, gradually increasing to 30 minutes of moderate-intensity activity most days of the week. 4

Pharmacological Management

Cardiovascular risk management for hypertension and dyslipidemia should be carried out according to national guidelines, with target blood pressure and lipid levels based on risk calculated for psoriasis (including the 1.5 multiplication factor). 1

Lipid Management

• High-intensity statin therapy: Target LDL-C goal of <1.4 mmol/L (55 mg/dL) with >50% reduction from baseline. 4
• Add ezetimibe: If target LDL-C levels are not achieved with maximum tolerated statin dose. 4
• Consider PCSK9 inhibitor: For patients who still don't reach targets on statin plus ezetimibe. 4

Blood Pressure Management

• Target blood pressure: 120-129/80 mmHg in patients with peripheral arterial and aortic disease. 4
• Antihypertensives: May be used as in the general population, with beta-blockers considered first-line for patients with aortic disease to reduce aortic wall stress. 4

Critical caveat: Beta-blockers can exacerbate pre-existing psoriasis or trigger new onset in susceptible individuals, particularly with long-term use. 5 This creates a clinical dilemma requiring careful monitoring and potential alternative antihypertensive selection.

Addressing Undertreatment

A substantial problem exists with undertreatment of coronary risk factors in psoriasis patients. 7 In patients with severe psoriasis, 27.7% with hypertension received no antihypertensive pharmacotherapy, only 55.8% with dyslipidemia received cholesterol-lowering medications, and only 42.1% and 23.7% of diabetic patients received ACE inhibitors/ARBs and cholesterol-lowering medications, respectively. 7

Increased focus on identifying cardiovascular risk factors and initiation of preventive cardiovascular pharmacotherapy in patients with psoriasis is warranted. 7

Role of Psoriasis Treatment in Cardiovascular Risk Reduction

Non-randomized observational studies report reductions in rates of vascular events and cardiovascular death among psoriasis patients being treated with weekly methotrexate in doses ranging from 10 to 20 mg. 1 Systemic treatments for psoriasis, including methotrexate and TNF-α inhibitors, may significantly decrease cardiovascular risk by reducing systemic inflammation. 1, 3

However, most systemic therapies also have adverse cardiovascular effects like dyslipidemia, hyperhomocysteinemia, and hypertension, requiring preventive measures during long-term treatments. 2

Monitoring and Follow-Up

• Lipid profile monitoring: Every 3-6 months until target levels are achieved, then annually. 4
• Blood pressure monitoring: Regular assessment to ensure targets are maintained. 4
• Screening for asymptomatic atherosclerosis: Consider screening in other vascular beds (carotid, coronary) given multiple risk factors. 4
• Regular cardiovascular risk assessment: Using validated risk calculators (with 1.5 multiplication factor) to guide intensity of therapy. 4

Provider Responsibility

Cardiovascular risk management should be performed by either a primary care physician or other healthcare provider experienced in cardiovascular risk management, or the dermatologist. 1 Close communication between dermatology and primary care is essential to ensure comprehensive management. 8