For years, physicians have been following widely accepted guidelines for preventing heart attack and stroke in the general population. These include controlling cholesterol, blood pressure and body weight through lifestyle changes and, when necessary, medication.
Doctors also use an established set of equations to measure a patient’s cardiovascular risk factoring in age, race and a variety of other variables.
However, when it comes to patients with psoriatic arthritis (PsA) — a group known to be at higher-than-average risk for cardiovascular disease — no comparable guidelines are yet in place.
Elaine Husni, M.D., a leading rheumatologist at Cleveland Clinic and a member of the National Psoriasis Foundation Medical Board, has been working to address that lack.
Senior author of a study focusing on cardiovascular disease risk in PsA patients, Husni and her colleagues screened a total of 87 PsA patients for the build-up of plaque—an accumulation of “bad” cholesterol and other fatty substances—in a large blood vessel called the carotid artery.
To visualize the plaque, the researchers used carotid duplex ultrasound (CDU), a highly effective screening technique. They found carotid plaque in 39 percent of the patients enrolled in the study.
The study’s findings were published in Arthritis Research & Therapy in August 2016. The study was funded by a $200,000 Psoriatic Arthritis Research Grant that received support from both the National Psoriasis Foundation and the Arthritis National Research Foundation in 2010.
“The presence of carotid plaque goes hand in hand with atherosclerosis — hardening and narrowing of the arteries — which is the most common cause of heart attack and stroke,” said Husni. “Patients who have carotid plaque are at very high cardiovascular risk.”
The good news is that once that risk is confirmed, patients and their doctors can work together to keep stroke and heart attack at bay.
Who should be screened?
Which PsA patients, exactly, are at highest risk? How can physicians identify them for special attention and care, whether in the form of prevention, intervention or referrals? “We aren’t recommending blanket screening,” Husni said, “but we need new protocols for identifying high-risk patients before they start having symptoms.”
Like other serious conditions, cardiovascular disease is far easier to treat before it happens, she explained.
Out of a wide range of variables, from smoking to high blood pressure, diabetes and obesity, two factors turn out to be the strongest predictors that a PsA patient has carotid plaque: being over 50 years old and having high triglycerides — a type of blood fat that, when elevated, increases the risk of heart disease and stroke.
Older age and high triglycerides, Husni contended, could be important risk factors that may alert physicians to screen for heart disease more carefully.
The research team referred patients in the study for preventive cardiology services. Surprisingly, only nine of them made use of these services.
“We can only speculate as to why so few took advantage of preventive cardiology,” Husni said. “They may not have taken their cardiovascular risk seriously enough. Their physicians, too, might have under-estimated their risk. A lack of familiarity with CDU screening and of the risk represented by carotid plaque could have affected the way they communicated with their patients, making preventive cardiology seem optional and non-urgent.”
PsA patients and their doctors have their hands full as they struggle to keep the painful symptoms of the disease under control, she continued. Still, with the high risk of heart attack and stroke among these patients, prevention should be front and center in the minds of patients and doctors alike.
What’s needed, Husni suggested, is a change in medical “culture.” When enough evidence reaches enough doctors, attitudes tend to shift.
After all, she said, colonoscopies and mammograms haven’t been around forever. It took research, advocacy and plenty of consensus-building to introduce these screening technologies into mainstream medicine. It also took years of educating patients.
On the research front, she said larger, prospective studies are needed that track patients for a period of years to see whether today’s data turn out to be meaningful. Such studies could confirm the usefulness of CDU as a tool that helps doctors identify the PsA patients who need urgent preventive cardiology care and distinguish them from those who don’t.
Mainly, she said she hopes that larger-scale research studies will highlight the unmet needs of patients with psoriatic arthritis and effect positive change in their care.
Husni envisions a future in which collaboration between rheumatologists and cardiologists is the norm, not the exception. “We need to be more aggressive in our efforts to control psoriatic arthritis to decrease life-threatening cardiac events, and that means greater collaboration with cardiologists.”
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