SAN FRANCISCO – Despite their frequent contact with the health care system, patients with psoriasis and psoriatic arthritis often receive no treatment for major cardiovascular risk factors, according to two large multicenter studies.
“We identified a gap in quality of care in terms of the primary prevention of cardiovascular risk factors in psoriatic arthritis and psoriasis. The next step will be to develop strategies to increase awareness and implement treatment recommendations among primary care physicians, dermatologists, and rheumatologists,” Dr. Lihi Eder of the University of Toronto said in an interview at the annual meeting of the American College of Rheumatology.
Psoriatic and cardiovascular diseases share an inflammatory etiology and often co-occur. In past studies, patients with psoriasis and psoriatic arthritis were about 50% more likely than average to have dyslipidemia and ischemic heart disease, and about 80%-90% more likely than usual to have hypertension and diabetes, Dr. Eder said.
Dr. Lihi Eder
She and her associates studied dyslipidemia and hypertension among 1,327 patients with psoriatic arthritis and 927 patients with psoriasis at eight sites in Canada, the United States, and Israel as part of the International Psoriasis & Arthritis Research Team (IPART). Based on medical and laboratory reports and self-reported data, the investigators assessed these comorbidities and whether treatment adhered to cholesterol and hypertension guidelines from the American College of Cardiology and the American Heart Association (Circulation. 2014 Jul 1;129:S1-45), and the Eighth Joint National Committee (JAMA. 2014 Feb 5;311[5]:507-20), respectively.
More than 80% of patients in the cohort had at least one modifiable cardiovascular risk factor, Dr. Eder said. While 6% had ischemic heart disease, 45% had hypertension, 71% had dyslipidemia, 13% had diabetes, 54% had central obesity, and 17% were current smokers. Furthermore, close to half of patients who had been diagnosed with hypertension had uncontrolled high blood pressure, and 57% were not receiving antihypertensive medications. Likewise, 58% of patients with dyslipidemia met criteria for statins, but only a third of these patients were receiving them.
Undertreatment was associated with having psoriatic arthritis or severe psoriasis and with having a high school or lower level of education, Dr. Eder added. “You have to remember that this study was conducted among specialists – these are supposed to be experts in the field,” she said. “If the treatment adherence is relatively low in these centers, then I would expect that for patients who are being followed in centers that do not specialize in psoriatic disease, adherence would be even lower.”
Dr. Kashif A. Jafri
The second study detected significantly higher rates of cardiovascular risk factors among patients with psoriatic diseases, compared with controls from the Health Improvement Network, a medical records database that covers more than 9 million individuals in the United Kingdom. Patients with psoriatic arthritis or severe psoriasis were significantly more likely than were controls to develop hypertension, hyperlipidemia, obesity, or diabetes, with odds ratios ranging from 1.22 to 1.78, reported Dr. Kashif A. Jafri, who led the study while he was an internal medicine resident at the University of Pennsylvania in Philadelphia.
But despite their disproportionate risk, patients were treated at about the same rate as controls, Dr. Jafri said. About 15% of individuals with hypertension received no treatment, 30%-40% with hyperlipidemia went untreated, and nearly 60% with diabetes received no documented therapy. “The absence of a significant difference in receipt of appropriate therapy among the groups reflects a need for more careful attention to the management of cardiovascular risk factors in patients with inflammatory diseases,” Dr. Jafri emphasized. Because these risk factors can be successfully treated, it is “critical” to educate primary care providers about the need to do so, he said.
Rheumatologists also should periodically discuss cardiovascular risk factors with their patients as part of routine care, Dr. Jafri advised. “Although there are obviously time constraints during each office visit, this is a topic that dramatically influences the morbidity and mortality of our patient population, and rheumatologists have the unique ability to address this issue in the context of their long-term relationships with their patients,” he said.
Dr. Jafri is now a fellow in rheumatology at the University of California, San Francisco. His was supported by an Ephraim P. Engleman Endowed Resident Research Preceptorship Award from the Rheumatology Research Foundation. IPART is sponsored by the Krembil Foundation and the Canadian Institutes of Health Research. Dr. Jafri and Dr. Eder had no disclosures.