Psoriatic Arthritis and Your Heart

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% more likely to have or develop heart disease compared with the general population. PsA patients also had a 22% increased risk of cerebrovascular disease – conditions that affect blood flow to the brain.

Alexis Ogdie-Beatty, MD, an associate professor of medicine 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 PsA actually have what amounts to a doubled cardiovascular risk, says John M. Davis III, MD, a researcher in the Cardio-Rheumatology Clinic and clinical rheumatologist 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 unstable plaques can rupture, triggering a clot that may cause a heart attack or stroke.

“[Traditional] risk factors are important, but they don’t account for a big part of the risk, which comes from inflammation,” Dr. Davis says.

One way doctors check for 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. Researchers say this suggests PsA is an independent risk factor for heart disease, although they didn’t find much correlation between the severity of PsA and the degree of atherosclerosis.

That’s good news, of course, but it also means it’s harder to identify the people most likely to develop heart problems. 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.
 

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 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.

Obesity is such a powerful inflammation-promoter that psoriasis symptoms sometimes clear with weight loss alone, says 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.

“I talk to everybody about diet,” Dr. Mody says. She refers patients to a nutritionist if they’re having a hard time with a heart-healthy diet or it isn’t working for them. She also stresses the importance of physical activity, which is essential for heart and joint health as well as weight loss.

Does Treating PsA Reduce Cardiovascular Risk?

It makes sense that drugs that suppress skin and joint inflammation would suppress inflammation in blood vessels, too. But Dr. Ogdie-Beatty says there’s lack of good evidence to support that idea.

“Systemic inflammation can accelerate plaque development, so we think suppressing inflammation might decrease cardiovascular risk. Observational studies suggest that’s the case, and anti-TNFs [anti-tumor necrosis factor drugs] are possibly better than methotrexate for that. But we just don’t have a lot of good data. We do know that reducing weight and treating diabetes effectively are important and lead to better outcomes,” she says.

Some arthritis medications, 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 says it’s not clear NSAIDs have the same effect in people with inflammatory arthritis, but says she’s very cautious prescribing them for patients with existing heart disease.

She says both doctors and patients need to understand the cardiovascular risks in PsA, and patients should feel empowered to ask questions about treatments, including medications. Dr. Mody agrees, saying primary care physicians and cardiologists should treat PsA patients as higher-risk and work to modify any traditional cardiovascular risk factors they have.

What You Can Do

You can do a lot to reduce your risk of heart disease. Here’s how:

• If you smoke, stop. 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 in Canada.
• Get moving. Staying active improves pain and function and cuts the risk of heart disease nearly in half.
• Eat well. A heart-healthy diet helps control weight, blood sugar and cholesterol and can reduce inflammation.
• Watch your medications. Work with your doctor to find medications that control pain and inflammation without raising heart disease risk.

Reviewed 2/14/22