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Psoriasis: an opportunity to identify cardiovascular risk

SIR, In their review of cardiovascular risk factors and their treatment in patients with psoriasis Federman et al. discuss therapeutic interventions which should be considered when dermatologists review patients with psoriasis. We believe that in addition to the ‘conventional’ risk factors identified in the review certain other cardiovascular risk factors are especially important in patients with psoriasis. Moderate alcohol consumption has been shown in several epidemiological studies to be cardioprotective; excess alcohol consumption, however, increases cardiovascular risk and mortality. Poikolainen et al. reported excessive alcohol consumption to be the leading cause of excess mortality in patients hospitalized for treatment of psoriasis. Excessive alcohol consumption has been widely documented in patients with psoriasis. Alcohol consumption should therefore be included in any synthesis of cardiovascular risk in patients with psoriasis. Although mentioned, the authors do not consider homocysteine in formulating a risk profile for patients. Elevated levels of homocysteine have been shown to be an independent risk factor for the development of cardiovascular disease. The magnitude of the risk is similar to that of smoking and hyperlipidaemia. In a case–control study, patients had a 7Æ1 times relative risk greater than controls of having significantly raised levels of homocysteine. The authors refer to a study by Prodanovich et al. which found that methotrexate in combination with folate supplementation lowered cardiovascular risk, and hence we contend that homocysteine levels should be measured in patients who have adverse cardiovascular risk profiles. Although intervention does not lower risk it should be assessed. There is also evidence to support a role for chronic inflammation in psoriasis, as cardiovascular risk factors and inflammatory markers such as fibrinogen have been shown to be raised in patients with psoriasis. Atherothrombotic markers such as fibronection and platelets may also be raised in psoriasis. Patients with psoriasis also display evidence of hyperinsulinaemia and insulin resistance. Insulin levels correlated with disease severity. Insulin resistance itself is a risk factor for atherosclerosis. This further endorses the view that patients with psoriasis display a risk factor profile beyond those conventional risk factors encoded by the Framingham Risk Score such as age, sex, total cholesterol, high-density lipoprotein cholesterol, smoking history and systolic blood pressure. Treatment of psoriasis may lower cardiovascular risk but certain treatments may adversely affect cardiovascular risk. Ciclosporin may cause hypertension and renal impairment, acitretin may elevate triglycerides and tumour necrosis factor inhibitors may worsen heart failure. It must also be borne in mind that not all patients with psoriasis have risk factors for cardiovascular disease. It would appear safe to conclude that those with most severe disease have the greatest risk. We agree with Federman et al. that risk factor evaluation and intervention are very important in psoriasis. We would suggest that additional factors such as excess alcohol consumption, homocysteine levels, markers of inflammation, insulin and the influence of treatment on risk factors be included in a disease-specific assessment of cardiovascular risk in psoriasis.