The American Journal of Medicine
Volume 123, Issue 4 , Pages 350-357, April 2010

Coronary Heart Disease and Stroke Risk in Patients with Psoriasis: Retrospective Analysis

  • Alexa Boer Kimball, MD, MPH

      Affiliations

    • Harvard Medical School, Boston, Massachusetts
    • Corresponding Author InformationReprint requests should be addressed to Alexa Boer Kimball, MD, MPH, Vice Chair, Department of Dermatology, Massachusetts General Hospital, Associate Professor, Harvard Medical School, Director, Clinical Unit for Research Trials in Skin (CURTIS), 50 Staniford Street, #246, Boston, MA 02114
    • ,
  • Annie Guerin, MSc

      Affiliations

    • Analysis Group, Boston, Mass
    • ,
  • Dominick Latremouille-Viau, MA

      Affiliations

    • Analysis Group, Boston, Mass
    • ,
  • Andrew P. Yu, PhD

      Affiliations

    • Analysis Group, Boston, Mass
    • ,
  • Shiraz Gupta, PharmD, MPH

      Affiliations

    • Abbott Laboratories, Abbott Park, Ill
    • ,
  • Yanjun Bao, PhD

      Affiliations

    • Abbott Laboratories, Abbott Park, Ill
    • ,
  • Parvez Mulani, PhD

      Affiliations

    • Abbott Laboratories, Abbott Park, Ill

Article Outline

Abstract 

Background

Past studies suggest an association between psoriasis and the risk of developing coronary heart disease. The objectives of this study were to estimate the 10-year risks of coronary heart disease and stroke in patients with moderate to severe psoriasis, to compare risks between patients and the general population, and to determine whether risk profiles are affected by disease severity.

Methods

Data were pooled from patients with moderate to severe psoriasis (Psoriasis Area and Severity Index [PASI] score≥10) who were enrolled in Phase II (M02-528) or Phase III trials (Comparative Study of HUMIRA vs Methotrexate vs Placebo In PsOriasis PatieNts[CHAMPION], Randomized Controlled EValuation of Adalimumab Every Other Week Dosing in Moderate to Severe Psoriasis TriAL[REVEAL]) evaluating adalimumab. Risks of coronary heart disease and stroke were estimated using the Framingham risk score algorithm and a stroke risk function based on the Framingham Heart Study cohorts. To compare risks between patients with psoriasis and the general population, average population risks were imputed on the basis of age and gender. Wilcoxon rank-sum tests evaluated risk differences between patients with psoriasis and the general population and between patients with moderate psoriasis and patients with severe psoriasis.

Results

A total of 1591 patients were identified, including 1082 patients with PASI scores≥10 and ≤ 20 and 509 patients with PASI scores>20. Patients with PASI scores from 10 to 20 and PASI scores>20 had similar 10-year risks of coronary heart disease (12.3% and 12.2%; P=.49) and stroke (8.3% and 8.7%; P=.28). Compared with the general population, 10-year risks of patients with psoriasis were 28% greater for coronary heart disease (P<.001) and 11.8% greater for stroke (P=.02).

Conclusion

Patients with moderate to severe psoriasis had increased risks of coronary heart disease and stroke compared with the general population.

Keywords: Coronary heart disease, Psoriasis, Stroke

 

Psoriasis is a chronic inflammatory and systemic skin disorder that affects 1% to 3% of the population,1 with a greater prevalence in white populations than in other racial groups. The most common physical symptom of psoriasis is the appearance of thick, dry, red skin lesions known as plaques, covered with silvery scales. Plaques frequently occur on the scalp, face, elbows, knees, palms, and soles of the feet. The level of disease severity varies; mild cases of psoriasis are frequently disturbing and uncomfortable, but moderate and severe cases are generally painful, disfiguring, and disabling.

Clinical Significance

 


•Patients with moderate to severe psoriasis have significantly greater risks of developing coronary heart disease and stroke compared with the general population.

•Because patients with psoriasis might be underdiagnosed and undertreated, providing counseling about their increased risk for coronary heart disease is critical to proper management of these patients.

Psoriasis impairs patients' physical and psychologic well-being, leading to reduced health-related quality of life and work productivity.2 The disease also is associated with significant medical costs and indirect costs related to lost work. A recent study estimated that incremental annual total costs of psoriasis are $1500 more than costs for patients without psoriasis.3

In addition to its economic burden, psoriasis is associated with a substantial comorbidity burden, including an elevated risk for cardiovascular disease.4, 5 The prevalence of all heart diseases in patients with psoriasis in the United States has been estimated at 14.3%, compared with 11.3% for the entire US population.6 This association may be attributed to the presence of major cardiovascular risk factors (eg, obesity, hypertension, hyperlipidemia, and diabetes mellitus)1, 7 or a direct effect of psoriasis on cardiovascular disease based on genetic predisposition.8, 9 However, patients with psoriasis have greater prevalence rates of myocardial infarction even after adjusting for risk factors, suggesting that psoriasis is an additional independent risk factor for cardiovascular diseases.10 For example, Cohen et al7 found that ischemic heart disease was observed in 14.2% of patients with psoriasis compared with 7.1% of psoriasis-free controls (P<.001). Multivariate models adjusting for age, gender, and smoking status of patients demonstrated that psoriasis was associated with ischemic heart disease (odds ratio [OR]=1.1; 95% confidence interval [CI], 1.0-1.2). Disease severity also might influence risk, because patients with severe psoriasis have increased risk of metabolic disorders or cardiovascular diseases compared with patients with mild psoriasis and the general population.1, 11, 12, 13, 14, 15

Although the prevalence of comorbidities and cardiovascular events has been described in patients with psoriasis versus control populations, future risk is less well studied. The objectives of this analysis are to estimate and compare the 10-year risks of coronary heart disease and stroke in patients with moderate to severe psoriasis versus the general population and to assess whether psoriasis severity affects coronary heart disease and stroke risks.

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Material and Methods 

Data Sources 

Data were obtained from 3 randomized controlled trials: a Phase II trial, M02-528,16, 17 and 2 Phase III trials, Comparative Study of HUMIRA vs Methotrexate vs Placebo In PsOriasis PatieNts (CHAMPION)18 and Randomized Controlled EValuation of Adalimumab Every Other Week Dosing in Moderate to Severe Psoriasis TriAL (REVEAL).19 All patients were aged 18 years or more; were recruited from the United States, Canada, and Europe; and had moderate to severe psoriasis. Severity was defined using body surface area, Psoriasis Area and Severity Index (PASI), and Physician's Global Assessment of disease activity. Specifically, M02-528 included patients with a body surface area ≥ 5%, CHAMPION included patients with a body surface area ≥ 10% and PASI ≥ 10, and REVEAL included patients with a body surface area ≥ 10%, PASI ≥ 12, and a Physician's Global Assessment of at least moderate disease.

Sample Selection 

Data from 1591 patients with 10 ≤ PASI ≤ 20 or PASI > 20 from the 3 trials were pooled (n = 111 [M02-528], n = 268 [CHAMPION], and n = 1212 [REVEAL]). Two subpopulations were used to compare the predicted 10-year risks of coronary heart disease and stroke with their imputed risk scores based on the age- and gender-adjusted risks of the average US population. The subpopulation used to estimate coronary heart disease risk included patients with psoriasis aged 30 to 74 years, whereas the subpopulation used to estimate stroke risk included patients aged 55 to 84 years; the age ranges were based on the age restrictions for risk estimation used in the Framingham Heart Study algorithm.20, 21

Studied Outcomes 

Ten-Year Risk of Coronary Heart Disease in Patients with Moderate to Severe Psoriasis 

The 10-year risk of coronary heart disease was estimated using a predictive model based on the Framingham risk score algorithm developed by Wilson et al.21 This algorithm, derived from Framingham Heart Study estimations, is used extensively to assess the probability of having a coronary heart disease event (myocardial infarction or coronary death) during the next 10 years on the basis of risk-factor profiles. The model includes age, diabetes status, smoking status, blood pressure, total cholesterol, and high-density lipoprotein (HDL) cholesterol as risk predictors. To achieve greater predictive power, gender-specific functions are applied. Because information on HDL cholesterol was not collected in the trial data, age-adjusted mean ratios of total cholesterol to HDL cholesterol were used to estimate patients' HDL cholesterol concentrations on the basis of their race, gender, and body mass index (BMI).22

Ten-Year Risk of Stroke in Patients with Moderate to Severe Psoriasis 

The 10-year risk of stroke was estimated using the prediction point-system method of D'Agostino et al,23 developed on the basis of Framingham Heart Study estimations. The algorithm uses a gender-specific model that controls for age, diabetes status, smoking status, blood pressure, antihypertensive therapy, prior cardiovascular disease, atrial fibrillation, and left ventricular hypertrophy. Because diagnosis of atrial fibrillation was not collected in the data sample, patients were considered to have atrial fibrillation if they had a history of medication use for treating atrial fibrillation either before or during the study period.

Ten-Year Risks of Coronary Heart Disease and Stroke in the General Population 

Because the trial data did not include patients without psoriasis, the 10-year risk of coronary heart disease and stroke for the age- and gender-matched general population was imputed on the basis of published reports of average risks of coronary heart disease21 and stroke23 derived from the Framingham Heart Study population.

Coronary Heart Disease and Stroke Risk Severity Categories 

The 10-year risks for coronary heart disease and stroke were categorized into 3 levels per the classification of Nair et al:24 low (predicted 10-year risk<10%), intermediate (predicted risk 10%-20%), and high (predicted risk>20%).

Statistical Analyses 

Patient characteristics, such as age, gender, race, and coronary heart disease and stroke risk factors, were reported for the studied population and for subgroups stratified by psoriasis severity (moderate vs severe). Two-sample nonparametric Wilcoxon rank-sum tests were used to test for statistically significant differences in the 10-year coronary heart disease and stroke risks between patients with psoriasis and the general population and between patients with moderate psoriasis and patients with severe psoriasis.

Sensitivity Analyses 

Two sensitivity analyses were performed to address limitations of the Framingham risk score algorithms that could lead to an underestimation of risk.

Patients with psoriasis have a greater prevalence of obesity compared with the general population,25 and obesity also is associated with an increased risk of cardiovascular diseases, particularly coronary heart disease.26, 27 The Framingham risk score algorithm for coronary heart disease accounts for hypertension, diabetes, and other metabolic factors that are highly correlated with obesity. Nonetheless, to fully capture the effect of obesity on coronary heart disease risk, a sensitivity analysis was performed to report the 10-year coronary heart disease risks for patients with obesity (BMI≥30) and patients with normal weight (BMI<30) separately.28

The Framingham risk score algorithm also might underestimate the coronary heart disease risk in patients receiving lipid-lowering therapy, because the algorithm uses patients' cholesterol concentrations without adjusting for therapy use. Because patients with elevated cardiovascular disease risk would be expected to be taking lipid-lowering therapy,29 a sensitivity analysis was performed to account for the possible treatment effect by restricting the study sample to patients without previous lipid therapy.

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Results 

Study Population 

A total of 1591 patients with psoriasis were pooled from 3 clinical trials, including 1082 (68%) with 10 ≤ PASI ≤ 20 and 509 (32%) with PASI>20. Cardiovascular differences were similar between the groups, except for small but significant differences in mean cholesterol concentration and mean systolic blood pressure (Table 1).

Table 1. Baseline Study Population Characteristics
CharacteristicsPsoriasis SeverityP Valued
All (n=1591)10 ≤ PASI ≤ 20 (n=1082)PASI>20(n=509)10 ≤ PASI ≤ 20 vs PASI>20
Demographics
Mean age (SD), y44.1(13.1)44.5(13.0)43.2(13.2).05
Female, n (%)531(33.4)382(35.3)149(29.3).02
Caucasian, n (%)1452(91.3)1011(93.4)441(86.6)<.001
Risk factors
Mean total cholesterol (SD), mg/dL202.7(41.3)204.4(41.7)199.3(40.2).02
Mean HDL cholesterol (SD), mg/dL40.1(9.3)40.4(9.2)39.3(9.3).01
Mean systolic blood pressure (SD), mm Hg126.8(15.2)126.2(15.3)128.1(15.0).02
Mean diastolic blood pressure (SD), mm Hg79.1(9.5)79.0(9.6)79.4(9.3).67
Optimal blood pressure, n (%)a363(22.8)261(24.1)102(20.0).07
Normal blood pressure, n (%)a477(30.0)315(29.1)162(31.8).27
High blood pressure, n (%)a352(22.1)247(22.8)105(20.6).32
Hypertension stage I, n (%)a320(20.1)207(19.1)113(22.2).15
Hypertension stages II-IV, n (%)a79(5.0)52(4.8)27(5.3).67
Prior cardiovascular diseases, n (%)b48(3.0)33(3.0)15(2.9).91
Atrial fibrillation, n (%)c7(0.4)7(0.6)0(0.0).07
Left ventricular hypertrophy, n (%)52(3.3)29(2.7)23(4.5).05
Diabetes, n (%)153(9.6)98(9.1)55(10.8).27
Smoker, n (%)1049(65.9)720(66.5)329(64.6).45

PASI=Psoriasis Area and Severity Index; SD=standard deviation; HDL=high-density lipoprotein.

aOptimal blood pressure, normal blood pressure, high blood pressure, and hypertension I–IV were defined using the fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure categories.28

bIncludes myocardial infarction and coronary artery diseases.

cHistory of atrial fibrillation was determined on the basis of medication use.

dP values of Wilcoxon rank-sum test or chi-square test were reported.

Ten-Year Risks for Coronary Heart Disease and Stroke in Patients with Moderate to Severe Psoriasis versus the General Population 

A total of 1330 patients aged 30 to 74 years were included in the sample population for calculating coronary heart disease risk; 346 patients aged 55 to 84 years were included in the stroke sample (Table 2). Compared with the general population, patients with psoriasis had a 28% greater 10-year risk of coronary heart disease (12.3% vs 9.6%, P<.001) and a 12% greater 10-year risk of stroke (8.4% vs 7.5%, P=.02) (Table 2).

Table 2. Comparison of 10-Year Coronary Heart Disease Risk and Stroke Risk: Predicted Risk Values for Patients with Psoriasis versus Imputed Risk Values Based on Average US Population
VariableNPredicted Risks of Patients with Psoriasis (%)Age-/Gender-Adjusted Population Risksa (%)Patients with Psoriasis vs Age-/Gender-Adjusted General Population
[A][B][A] – [B]
Mean (SD)Mean (SD)DifferencebP Valuec
Risk of coronary heart diseased133012.3(9.4)9.6(6.6)2.7<.001
Risk of strokee3468.4(7.9)7.5(3.7)0.9.02

SD=standard deviation.

aAccording to gender and age, patients with psoriasis were attributed the average risks of the general US population.

bPositive difference indicates that patients with psoriasis are at higher risk than the general US population.

cP values of Wilcoxon rank-sum test were reported.

dRisks of coronary heart disease were reported for patients aged 30 to 74 years.

eRisks of stroke were reported for patients aged 55 to 85 years.

The sensitivity analysis based on BMI demonstrated that regardless of whether BMI was<30 or≥30, the 10-year risk of coronary heart disease was significantly greater for patients with psoriasis versus the general population with the same distribution of age and gender. Compared with the general population, patients with moderate to severe psoriasis and BMI<30 had a 21.5% greater 10-year risk of coronary heart disease (11.3% vs 9.3%, P=.003), and patients with BMI≥30 had a 33.3% greater 10-year risk (13.2% vs 9.9%, P<.001) (Table 3).

Table 3. Comparison of 10-Year Coronary Heart Disease Risk: Predicted Risk Values for Patients with Psoriasis versus Imputed Risk Values Based on Average US Population by Body Mass Index
Risk of Coronary Heart DiseaseaNPredicted Risks of Patients with Psoriasis (%)Age-/Gender-Adjusted Population Risksb (%)P Valuec
Mean (SD)Mean (SD)
All133012.2(9.4)9.6(6.6)<.001
BMI<3067611.3(9.3)9.3(6.6).003
BMI≥3065413.2(9.3)9.9(6.5)<.001

SD=standard deviation; BMI=body mass index.

aRisks of coronary heart disease were reported for patients aged 30 to 74 years.

bAccording to gender and age, patients with psoriasis were attributed the average risks of the general US population.

cP values of Wilcoxon rank-sum test were reported.

The second sensitivity analysis, in which patients taking lipid therapy were excluded from the study sample, demonstrated that the difference in the coronary heart disease risk between the population with psoriasis without lipid-lowering therapy and the general population was still highly significant. Specifically, the estimated 10-year risk difference for coronary heart disease between patients with psoriasis and the general population decreased from 2.7 percentage points in the full-sample analysis to 2.4 percentage points in the sensitivity analysis. For the stroke estimation, the change in the risk difference between patients with psoriasis and the general population was larger; the difference decreased from 0.9 to 0.3 percentage points after excluding patients taking lipid-lowering therapy (Table 4).

Table 4. Comparison of 10-Year Coronary Heart Disease Risk and Stroke Risk: Predicted Risk Values for Patients with Psoriasis without Lipid Therapy versus Imputed Risk Values Based on Average US Population
VariableNPredicted Risks of Patients with Psoriasis (%)Age-/Gender-Adjusted Population Risksa (%)Patients with Psoriasis vs Age-/Gender-Adjusted General Population
[A][B][A] – [B]
Mean (SD)Mean (SD)DifferencebP Valuec
Risk of coronary heart diseased110211.2(8.8)8.8(6.2)2.4<.001
Risk of strokee2307.6(7.9)7.3(3.7)0.3<.001

SD=standard deviation.

aAccording to gender and age, patients with psoriasis were attributed the average risks of the general US population.

bA positive difference indicates that patients with psoriasis are at higher risk than the general US population.

cP Values of Wilcoxon rank-sum test were reported.

dRisks of coronary heart disease were reported for patients aged 30 to 74 years.

eRisks of stroke were reported for patients aged 55 to 85 years.

Comparison Between Patient Populations According to Severity 

The average 10-year coronary heart disease and stroke risks did not differ between patients with moderate psoriasis and patients with severe psoriasis (12.3% vs 12.2%, P=.49 for coronary heart disease; 8.3% vs 8.7%, P=.28 for stroke) (Table 5). Regardless of psoriasis disease severity, patients were distributed equally among low, intermediate, and high-risk categories for coronary heart disease and stroke (Table 5).

Table 5. Ten-Year Coronary Heart Disease Risk and Stroke Risk by Psoriasis Severity
Variable10≤PASI≤20aPASI>20b10≤PASI≤20 vs PASI>20
[A][B][A]-[B]
N(%)N(%)P Valuec
Mean (SD) risk of coronary heart disease, %d12.3(9.4)12.2(9.3).49
Low risk of coronary heart disease463(50.9)207(49.3).66
Intermediate risk of coronary heart disease297(32.6)143(34.0).58
High risk of coronary heart disease150(16.5)70(16.7).92
Mean (SD) risk of stroke, %e8.3(7.9)8.7(7.9).28
Low risk of stroke185(75.5)70(69.3).23
Intermediate risk of stroke40(16.3)20(19.8).44
High risk of stroke20(8.2)11(10.9).42

PASI=Psoriasis Area and Severity Index; SD=standard deviation.

aNCORONARY HEART DISEASE=910, NSTROKE=245.

bNCORONARY HEART DISEASE=420, NSTROKE=101.

cP values of chi-square and Wilcoxon rank-sum test were reported.

dRisks of coronary heart disease were reported for patients aged 30 to 74 years.

eRisks of stroke were reported for patients aged 55 to 85 years.

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Discussion 

The results of this study demonstrate that patients with moderate to severe psoriasis have significantly greater 10-year risks for coronary heart disease and stroke than the general population. However, coronary heart disease and stroke risks in patients with psoriasis did not differ statistically with increasing severity above the threshold of a PASI≥10.

Consistent with our findings, the study by Gelfand et al10 reported an increased rate of myocardial infarction in patients with severe psoriasis compared with a psoriasis-free population. The increased risk of coronary heart disease and stroke in the population with psoriasis versus the general population might partially be due to greater prevalence of obesity.5, 30, 31 In the current study, approximately 50% of the study population had a BMI≥30, whereas the prevalence of obesity in the US general population in 2005 and 2006 was approximately 30%.32 Although the Framingham risk score algorithms control for important factors linked to obesity (eg, hypertension, diabetes, cholesterol concentrations), they do not directly control for BMI. However, the sensitivity analysis controlled for BMI and demonstrated that the difference in the coronary heart disease risks for the population with psoriasis and the general population persisted independently of BMI status. Similarly, in the publication by Gelfand et al,10 obesity was not identified as an independent risk factor for myocardial infarction.

The second finding of this study suggests no significant difference in the 10-year risks of coronary heart disease and stroke based on psoriasis severity once the threshold of a PASI≥10 is met. This finding does not rule out the possibility that there is a difference in patients with a PASI<10 compared with those with more severe psoriasis.

A PASI≥10 is widely accepted as a threshold that represents substantial inflammatory burden for which systemic therapy is a reasonable consideration. Mallbris et al33 reported that inpatients with severe psoriasis, but not outpatients with psoriasis, showed an increased risk of cardiovascular-related death. The severity of the hospitalized patients likely met or exceeded a PASI of 10, whereas the outpatients seem to have had substantially milder disease. Further research is needed to determine whether there is a relevant threshold of severity below a PASI of 10. The results of this study cannot be generalized for the entire patient population with psoriasis because the analysis was based on data from patients with moderate to severe psoriasis, as defined by a PASI score≥10, and patients with mild psoriasis might have a lower risk of coronary heart disease compared with patients with moderate to severe psoriasis.

Although this study used data collected from patients enrolled in psoriasis clinical trials, the coronary heart disease risks were estimated on the basis of Framingham risk score modeling instead of observed risks, and thus should be interpreted with caution. The estimates presented might underestimate the true risks, because the Framingham risk score models do not take into account the possibility that psoriasis could be an independent risk factor. Inflammation can contribute to increased risk of vascular disease through effects not considered by the Framingham risk score algorithms. Recent studies have suggested a link between psoriasis and vascular disease caused by patients' immunobiologic responses. It has been shown that immune activity plays a key role in developing atherosclerosis and that patients with psoriasis are characterized by immune system abnormalities.10, 11 Furthermore, other autoimmune diseases, such as rheumatoid arthritis, are independent risk factors for myocardial infarction and coronary artery disease.34, 35 This limitation of the Framingham risk score algorithms could result in underestimation of the 10-year coronary heart disease and stroke risks for patients with more severe psoriasis. In addition, psoriasis is an independent risk factor for myocardial infarction after controlling for other well-established risks.10 Further, the Framingham risk score algorithm does not consider other novel cardiovascular risk factors, such as homocysteine concentrations, which have been shown to increase with psoriasis severity.36

The sensitivity analysis that tested for the effect of lipid-lowering therapy demonstrated that such therapy did not greatly influence the coronary heart disease risk; this could be due to the small percentage of patients receiving lipid-lowering therapy (∼15% of the study sample). The impact of lipid therapy on the stroke estimation was larger, possibly because the stroke algorithm does not account for cholesterol concentration, even though cholesterol and treatment for its reduction seem to be important risk factors. The risk differences estimated in the sensitivity analysis imply that the study's risk estimations are conservative.

Another potential source of underestimation is the lack of low-density lipoprotein and HDL cholesterol values in the data sample. The value for HDL cholesterol was imputed using age-adjusted mean ratios of total cholesterol to HDL cholesterol of adults in the United States based on race, gender, and BMI. Patients with psoriasis, however, are known to have a greater prevalence of hyperlipidemia compared with the average population.1 Thus, imputing the HDL cholesterol value on the basis of the average population underestimates the rate of hyperlipidemia and renders our risk estimates more conservative. Actual risks could be further increased if psoriasis confers additional risks independently of the risk factors considered in this algorithm.

Lastly, the Framingham risk score algorithms underestimate risks in high-risk populations. McEwan et al37 and Coleman et al38 showed that the Framingham risk equation underestimates coronary heart disease risk in populations with type 2 diabetes, because there were few patients with diabetes in the original Framingham cohort. The present study might have underestimated risks for patients with psoriasis, because approximately 10% of patients had comorbid diabetes.

The consequences of increased risks are real for patients with coronary heart disease and stroke with psoriasis. In 2004, coronary heart disease caused 1 of every 5 deaths in the United States. Approximately 38% of individuals who experience a coronary attack in a given year will die as a consequence.39 Individuals who survive the acute stage of a myocardial infarction have a 1.5- to 15-fold greater chance of illness and death versus the general population. Among survivors, the risk of another myocardial infarction, sudden death, angina pectoris, heart failure, and stroke is substantial.40 Among those who survive a first myocardial infarction at age 40 years, 18% of men and 23% of women die within 1 year and 33% of men and 43% of women die within 5 years. In 2008, estimated coronary heart disease direct and indirect costs were $156.4 billion in the United States.39

Although the mortality rate associated with stroke is lower, consequences of stroke are serious. Stroke is the third greatest cause of death, after heart diseases and cancer.41 Among individuals aged 45 to 64 years, 8% to 12% of those who experience an ischemic stroke and 37% to 38% of those who experience a hemorrhagic stroke die within 30 days.42 Stroke is a leading cause of serious, long-term disability.43 Among patients with a first stroke at age 40 years, 21% of men and 24% of women die within 1 year. Among patients with a first stroke between 40 and 69 years of age, 13% of men and 22% of women experience a recurrent stroke within 5 years. Recovery depends on stroke severity. Between 50% and 70% of stroke survivors regain functional independence, but 15% to 30% are permanently disabled, and 20% require institutional care 3 months after stroke onset.44 In 2008, estimated stroke direct and indirect costs were $65.5 billion in the United States.39

To date, there is not enough evidence to recommend additional screening or care for patients with moderate to severe psoriasis beyond what would be recommended for a population with similar risk factors. However, patients with psoriasis might be underdiagnosed and undertreated45 and at a minimum should have their age- and gender-based preventive screenings up to date.46 Counseling patients with psoriasis about their increased risk for coronary heart disease also is critical to proper management of these patients.

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Conclusions 

Our pooled analysis of 3 trials demonstrates that patients with moderate to severe psoriasis have significantly greater risks of developing coronary heart disease and stroke than the general population. No significant differences in the 10-year coronary heart disease and stroke risks were observed across psoriasis disease severity in this group of patients with moderate to severe disease. It remains to be seen whether effective treatment for psoriasis that reduces systemic inflammation and improves patients' overall health-related quality of life also leads to a reduction in coronary heart disease and stroke risks.8, 47 However, any reduction in cardiovascular disease events could significantly reduce direct and indirect costs of this comorbidity, which in 2008 amounted to a total of $156.4 billion for coronary heart disease and $65.5 billion for stroke.39

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Acknowledgment 

Editorial support was provided by Arbor Communications, Inc.

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 Funding: Abbott Laboratories sponsored the clinical trials (M02-528, CHAMPION, REVEAL) and supported this retrospective analysis.

 Conflict of Interest: Consultancies: A.B. Kimball (Abbott Laboratories, Amgen, Biogen, Centocor, Genentech); Employment: Y. Bao (Abbott Laboratories), S. Gupta (Abbott Laboratories), P. Mulani (Abbott Laboratories), A. Guerin (Analysis Group, under contract with Abbott Laboratories), D. Latremouille-Viau (Analysis Group, under contract with Abbott Laboratories), A. Yu (Analysis Group, under contract with Abbott Laboratories).

 Authorship: All authors had access to the data and played a role in writing this manuscript.

PII: S0002-9343(09)01013-4

doi:10.1016/j.amjmed.2009.08.022

The American Journal of Medicine
Volume 123, Issue 4 , Pages 350-357, April 2010

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