PracticeUpdate Dermatology May 2019

EXPERT OPINION 17

References 1. Gelfand JM, Neimann AL, Shin DB, et al. Risk of myocardial infarction in patients with psoriasis. JAMA 2006;296(14):1735-1741. 2. Sobchak C, Eder L. Cardiometabolic disorders in psoriatic disease. Curr Rheumatol Rep 2017;19(10):63. 3. Mehta NN, Yu Y, Saboury B, et al. Systemic and vascular inflammation in patients with moderate to severe psoriasis as measured by [18F]-fluorodeoxyglucose positron emission tomography-computed tomography (FDG- PET/CT): a pilot study. Arch Dermatol 2011;147(9):1031-1039. 4. Wu JJ, Sundaram M, Cloutier M, et al. The risk of cardiovascular events in psoriasis patients treated with tumor necrosis factor-α inhibitors versus phototherapy: an observational cohort study. J Am Acad Dermatol 2018;79(1):60-68. 5. Wu JJ, Guerin A, Sundaram M, et al. Cardiovascular event risk assessment in psoriasis patients treated with tumor necrosis factor-α inhibitors versus methotrexate. J Am Acad Dermatol 2017;76(1):81-90. 6. Bissonnette R, Harel F, Krueger JG, et al. TNF-α antagonist and vascular inflammation in patients with psoriasis vulgaris: a randomized placebo-controlled study. J Invest Dermatol 2017;137(8):1638-1645. 7. Gelfand JM, Shin DB, Joshi AA, et al. Effect of 2 psoriasis treatments on vascular inflammation and novel inflammatory cardiovascular biomarkers: a randomized placebo-controlled trial. Circ Cardiovasc Imaging 2018;11(6):e007394. 8. Gelfand JM, et al. The VIP-S trial: study to evaluate the effect of secukinumab compared to placebo on aortic vascular inflammation in subjects with moderate-to-severe plaque psoriasis. Annual AAD Meeting 2019; S034 (poster 11034); March 2, 2019; Washington, DC. 9. Elnabawi YA, Dey AK, Goyal A , et al. Coronary artery plaque characteristics and treatment with biologic therapy in severe psoriasis: results from a prospective observational study. Cardiovasc Res 2019 Feb 05;[EPub Ahead of Print]. 10. Bittencourt MS, Hulten E, Ghoshhajra B, et al. Prognostic value of nonobstructive and obstructive coronary artery disease detected by coronary computed tomography angiography to identify cardiovascular events. Circ Cardiovasc Imaging 2014;7(2):282–291. This commentary is based upon the article Coronary Artery Plaque Characteristics and Treatment With Biologic Therapy in Severe Psoriasis: Results From a Prospective Observational Study by Elnabawi YA et al. www.practiceupdate.com/c/79705 " Results of this study by Elnabawi et al suggest that researchers may have found a mechanism alternative to direct effect on vascular inflammation that links biologic therapy to decreased risk of cardiovascular events. "

concerning the impact of biologic therapy on coronary plaque burden and character- istics in psoriasis patients. Importantly, patients in the study by Elna- bawi et al had low cardiovascular risk per Framingham score. Also, patients had a rel- atively lowmedian PASI score of 8.6. These characteristics make it attractive to hypoth- esize that psoriasis patients with higher Framingham scores and/or PASI scores may have more significant improvement in coronary plaque burden and plaque characteristics when treated with biolog- ics than seen in the current study. This is underscored by the fact that patients in the Elnabawi study had a noncalcified coro- nary plaque burden that correlated with increasing PASI scores. Hopefully larger, better-designed studies in the future will include psoriasis patients with a wider vari- ety of disease severity and cardiovascular risk to further explore such hypotheses. In short, more work needs to be done, and we are only beginning to understand the true relationship between psoriasis and cardio- vascular disease. For the moment, however, the study by Elnabawi et al appears to have potentially uncovered an exciting piece of the puzzle concerning howbiologic therapymay positively impact cardiovascular disease risk in psoriasis patients.

for traditional cardiovascular risk factors. Additionally, reduction in coronary plaque burden was significantly greater with anti-IL17 therapy compared with anti-IL12/23 therapy and no biologic therapy. On the other hand, there was progression of coronary artery disease with conversion of fibrous burden to fibro-fatty burden of plaques in the nonbiologic-treated cohort. Although this is a relatively small study fol- lowing patients for a short period of time, it may be significant. Could decreasing noncalcified coronary plaque burden and coronary plaque characteristics be the key to preventing future myocardial infarctions and strokes in psoriasis patients who are known to be at risk for developing them? Recently, it has been shown that CCTA plaque features are important for defining accurate cardiovascular risk. 10 Although the progression rate of subclinical ather- osclerosis on CCTA in psoriasis patients is unknown, lipid-rich plaque and necrotic core, both of which decreased with bio- logic therapy in the study by Elnabawi et al, are known to be inflammation-driven. This inflammatory component would support the positive results that may truly be related to biologic therapy. The results of this study are exciting, but there are important lim- itations preventing definitive statements

VOL. 3 • NO. 2 • 2019