Doctors have long known that heart disease is more common in people who have inflammatory conditions such as rheumatoid arthritis (RA) and psoriasis. But they weren’t sure if this applied to psoriatic arthritis (PsA), which is more complex and not nearly as well studied. Then, in 2016, Canadian researchers published a meta-analysis of studies evaluating cardiovascular disease risk and PsA in the journal Arthritis Care & Research. The results suggested that people with PsA were 43 percent more likely to have or develop heart disease compared with the general population. PsA patients also had a 22 percent increased risk of cerebrovascular disease – conditions such as stroke that affect blood flow to the brain.
Alexis Ogdie-Beatty, MD, an assistant professor at the Hospital of the University of Pennsylvania in Philadelphia and director of the Penn Psoriatic Arthritis Clinic, says although there were some biases in the studies, “everyone concurs there is substantial cardiovascular risk [in PsA].”
People with psoriasis and PsA actually have what amounts to a doubled cardiovascular risk, says John M. Davis III, MD, a researcher in the Cardio-Rheumatology Clinic at Mayo Clinic in Minnesota. They’re more likely to have traditional risk factors for heart disease, such as obesity and diabetes. And they experience the risk factor of ongoing, body-wide inflammation, which is known to damage blood vessels as well as the skin, joints and other organs.
Dr. Davis explains that in heart disease, inflammation affects the endothelium, the innermost layer of blood vessels. This can lead to atherosclerosis – the buildup of fats, cholesterol and cellular debris within blood vessel walls. Known as plaques, these fatty deposits narrow arteries, raising blood pressure and reducing the flow of blood to the heart and other organs. Some plaques can break down, causing a clot that may trigger a heart attack or stroke.
Are You at Risk?
A way to check for early atherosclerosis is to measure the thickness of the two inner layers of the carotid arteries — the major blood vessels leading to the brain. A study published in 2016 in the International Journal of Angiology found that PsA patients had increased arterial thickening even after other known cardiovascular risk factors were excluded. According to Dr. Ogdie-Beatty, current cardiovascular risk assessments, which use medical history and lifestyle information to predict a person’s chance of having a heart attack, were developed for the general population and aren’t very useful in PsA because they don’t factor in the effects of inflammation. Until a better way to assess risk is found, Dr. Ogdie- Beatty says all PsA patients should be screened for factors that put them at risk of heart disease, such as diabetes, high cholesterol and high blood pressure. She notes that many patients with psoriatic disease are underdiagnosed and untreated for traditional cardiovascular risk factors by their primary care doctors.
Protecting Your Heart
Having psoriatic arthritis doesn’t mean you will develop heart disease. Most risk factors — obesity, diabetes, inactivity, high cholesterol, high blood pressure and smoking — can be modified or managed. Achieving and maintaining a healthy weight is especially important because obesity is associated with many other cardiovascular risk factors, including high blood pressure and diabetes. Fat cells also release inflammatory proteins called cytokines that cause the kind of chronic low-grade inflammation that contributes to atherosclerosis.
Elinor Mody, MD, an assistant professor at Harvard Medical School and director of the Women’s Orthopedic and Joint Disease Program at Brigham and Women’s Hospital, both in Boston, says obesity is such a powerful inflammation-promoter that psoriasis symptoms sometimes clear with weight loss alone. Dr. Mody also stresses the importance of physical activity, which is essential for heart and joint health as well as weight loss.
If you smoke, try to quit. In addition to promoting inflammation, smoking likely reduces treatment response in patients with PsA, according to Dafna Gladman, MD, a professor of rheumatology at the University of Toronto, Canada. Also, watch your medications. Some drugs, especially nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen, are known to raise the risk of heart attack, stroke and heart failure in the general population – even when taken for a short time. Dr. Ogdie-Beatty is very cautious prescribing them for patients with existing heart disease. She says doctors and patients need to understand the cardiovascular risks in PsA, and patients should feel empowered to ask questions about treatment options, including medications.
Linda Rath for the Arthritis Foundation