Heart failure linked to disease activity, inflammation in patients with psoriatic disease
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Systemic inflammation burden and disease activity are independent risk factors for heart failure among patients with psoriatic disease, according to data published in Arthritis Care & Research.
“Heart failure occurs when the heart does not pump blood properly, which leads to difficulties in performing daily activities and may result in premature death,” Lihi Eder, MD, PhD, of Women’s College Hospital and the University of Toronto, told Healio Rheumatology. “Patients with psoriatic disease are at high risk to develop this condition, yet it is unclear what are the mechanisms linking these two diseases.”
To determine the incidence of, and risk factors for, heart failure among patients with psoriatic disease, Eder and colleagues conducted a cohort analysis of individuals followed at the University of Toronto Psoriatic Disease clinic from 1978 to 2018. All patients in the cohort are assessed according to a standard protocol every 6 to 12 months.
For their study, the researchers included 1,994 patients from the cohort who had at least 1 year of follow-up and no history of heart failure prior to their first clinic visit. The primary outcome was the time to first heart failure event. For the secondary outcome, these heart failure events were classified as either ischemic or non‐ischemic. The researchers used Cox proportional hazards regression to assess the association between cardiovascular risk factors, measures of disease activity and heart failure events. They also described electrocardiographic and echocardiographic findings associated with heart failure.
According to the researchers, there were 64 heart failure events — 38 ischemic and 26 non‐ischemic — among the included patients. The incident rate for first heart failure event was 2.85 per 1,000 patient years, compared with 1.93 per patient years as reported in a recent study of residents in the same province, the researchers wrote. In all events, the most common electrocardiographic findings were atrial fibrillation, with 22%, and bundle branch blocks, at 29%. Echocardiogram demonstrated a 37% reduced ejection fraction and 63% preserved ejection fraction.
Independent risk factors for all heart failure events, according to the multivariable analysis, were ischemic heart disease, adjusted mean tender joint count, adjusted mean swollen joint count, adjusted mean erythrocyte sedimentation rate, adjusted mean C‐reactive protein, and physical function (all P < .05). Meanwhile, minimal disease activity status was protective for all heart failure (P < .05).
“Our study found that heart failure in patients with psoriatic disease is associated not only with the known cardiac risk factors, such as hypertension and diabetes, but also with the burden of inflammation related to the skin and joint disease,” Eder said. “People with more active arthritis and psoriasis as well as those with higher levels of inflammatory blood markers, were at higher risk of heart failure. This study highlights the importance of controlling inflammation in patients with psoriasis and psoriatic arthritis to potentially reduce the risk of future heart failure.”
Perspective
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J. Nicholas Manwaring, MSN, APRN, FNP-C
This study helps to support the notion that systemic inflammation has a significant effect on cardiovascular damage, independent of other cardiovascular risk factors, specifically non-ischemic heart failure. This is of particular value because it supports a treat-to-target approach for psoriatic arthritis treatment.
Patients with psoriatic arthritis often also suffer from other comorbidities that contribute to cardiovascular disease risk, including obesity, diabetes, hypertension, hyperlipidemia and smoking. Knowing that psoriatic arthritis by itself can lead to heart failure is critical in establishing a comprehensive approach to treatment that not only focuses on healthy lifestyle changes — weight loss, diet, exercise, smoking cessation — and management of other comorbid conditions, but also accentuates the importance of treating active inflammation not just to improve the patients’ quality of life but to reduce their overall lifetime morbidity and mortality.
This information can prove to be a valuable tool in discussing the benefit of DMARDs with patients who may be apprehensive to start a medication, such as a biologic, that carries some inherent risks due to its potential effects on the immune system. To understand that the benefit outweighs the risks of such medications over time may help some patients feel more comfortable accepting biologic DMARDs who would otherwise be resistant to such treatment.
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