When I think of cardiovascular risk factors, the usual ones initially come to mind. Things like genetics, unhealthy lifestyle, smoking, obesity, minimal exercise, a low-quality diet, uncontrolled hypertension, and depression.¹ For the patient with psoriasis and psoriatic arthritis, the risk of developing cardiovascular disease is increased due to excess systemic inflammation, something which is central both to psoriatic and cardiovascular disease.² Additional, less common risk factors for the development of cardiovascular disease among our patients with psoriasis and psoriatic arthritis include insulin resistance, dyslipidemia, angiogenesis, oxidative stress, and endothelial dysfunction.³

The presence of systemic inflammation in conjunction with the metabolic syndrome— which includes issues such as obesity, hypertension, dyslipidemia, and diabetes— puts our patients at high risk of developing cardiovascular issues. Patients with psoriasis and PsA often have difficulty controlling their hypertension and require multiple medications to help. New-onset diabetes is also common, which again adds additional medications to the mix.

Although PsA patients tend in general to have lower levels of inflammatory biomarkers such as C-reactive protein (CRP) and erythrocyte sedimentation rates (ESR) than individuals with other rheumatic diseases, any elevations in these levels tend to indicate greater disease activity. In fact, persistent CRP elevations have been associated with an increased risk of cardiovascular events and mortality, while higher levels of ESR are associated with a greater burden of atherosclerosis and clinical cardiovascular events.¹

Rodney is one of my recent patients whose disease management required our practice to be on its toes to prevent dangerous and damaging health outcomes. He entered our practice in 2010 at the age of 58 after a referral from orthopedics due to the presence of uncontrolled, whole body plaque psoriasis. He had been diagnosed by his primary care physician with a host of other conditions, including type 2 diabetes mellitus, gout, hypertension, and hypercholesterolemia, but PsA didn’t enter the picture until our practice became involved. His medical history included a short trial of methotrexate approximately 7 years ago, but because of his high level of liver enzymes, we knew that wasn’t going to be an option anymore. According to Rodney, he had seen a rheumatologist “about 10 years ago,” but was told at the time that he did not have arthritis, so he chalked up his joint pain to the natural aging process. Additional prior medical history included hyperlipidemia, daily tobacco use, bipolar disorder, degenerative lumbar disc disease, and parental cardiovascular disease.

“Yet while his PsA was clearly under better control, we knew about the dangers of cardiovascular disease lurking below the surface due to his Rodney’s history.”

At his initial visit to our practice, Rodney presented with severe pain in his bilateral ankles that kept him awake for most of every night. He also had severe pain in the small joints of both hands. He had stopped driving several months ago due to the pain he was suffering. In addition to these issues, Rodney also had severe plaque psoriasis covering most of his body. Plain film x-rays showed degenerative arthritis of his knees and hands. While waiting for his insurance to approve a trial of infliximab, we started Rodney on the smallest possible dose of methotrexate (2.5 mg daily) as well as a topical NSAID cream.

I first met Rodney a year later after he had been on infliximab 5 mg/kg every 6 weeks for approximately 6 months. There was significant clearing of his psoriasis, with only small patches on his arms and legs. His knees, hands, and ankles showed only intermittent minor swelling and tenderness. There was also moderate improvement of pain in Rodney’s proximal and distal interphalangeal joints in his hands. Yet while his PsA was clearly under better control, we knew about the dangers of cardiovascular disease lurking below the surface due to his Rodney’s history. Patients with psoriasis and PsA are at a significantly greater risk of a major adverse cardiovascular event following myocardial infarction, and often see the pain and swelling associated with their disease increase as well. Some new studies have shown a 43% increased risk of cardiovascular disease and 68% increased risk of myocardial infarction in patients with severe psoriatic disease and high levels of systemic inflammation.² For these and other reasons, we were always careful about talking to Rodney about his cardiovascular risk factors at his regular follow-up appointments and encouraged him to embrace a more healthy lifestyle.

Despite our efforts, in 2016, Rodney suffered a heart attack and was diagnosed with a non-ST segment elevation of myocardial infarction. Fortunately, he recovered within a few weeks and was able to resume his infliximab infusions.

His disease remained under control for the next several years, with no additional serious cardiovascular events. Degenerative pain in his right knee led to a knee replacement in early 2019. We administered his scheduled infliximab injection a week before his surgery. Surgical complications required hospitalization, at which time Rodney became septic. He was diagnosed with Methicillin-resistant Staphylococcus aureus in his right knee, which fortunately resolved with appropriate antibiotic treatment.

A year later, Rodney was back in our office with the latest bit of bad news. He told us that he had been suffering from periodic chest pain in the spring and had been having difficulty breathing, especially at night. A referral to cardiology for a nuclear stress test demonstrated abnormal results. He then underwent a cardiac catheterization for placement of a drug-eluting stent in the proximal left anterior descending artery. In December 2019, Rodney was again hospitalized after a mild heart attack, though he was discharged a day later after adjustments were made to his medication regimen.

In the last few months, there have been further complications. Rodney began complaining of angina with increased fatigue and shortness of breath over the summer, and a coronary angioplasty was performed on the left anterior descending artery due to stenosis. He is currently receiving injections for his pain, and we have had to pause his infliximab for a few months until his condition stabilizes.

Managing Rodney’s constellation of health issues is undoubtedly going to continue to be a challenge. PsA should be recognized as a systemic inflammatory disease, with our treatment strategies based on the goal of reducing the effects of the inflammation. We desperately need improvement in the ability to screen our patients for potential cardiovascular disease, particularly those whose diagnosis has been delayed and have greater pathological changes. These are the patients, like Rodney, most likely to have ups and downs to their health that require us to remain on our toes at every visit.

References:

1. Puig L. Cardiometabolic Comorbidities in Psoriasis and Psoriatic Arthritis. Int J Mol Sci. 2017;19(1):58.

2. Sobchak C, Eder L. Cardiometabolic Disorders in Psoriatic Disease. Curr Rheumatol Rep. 2017;19(10):63.

3. Yim KM, Armstrong AW. Updates on cardiovascular comorbidities associated with psoriatic diseases: epidemiology and mechanisms. Rheumatol Int. 2017;37(1):97-105.

AUTHOR PROFILE: Teri Puhalsky, BSN, RN, CRNI is a registered nurse at Medstar Orthopedic Institute in Alexandria, VA, and a member at large on the Rheumatology Nurses Society Board of Directors.

Participants will receive 2.75 hours of continuing nursing contact hours, including 2.0 pharmacotherapeutic contact hours, by completing the education in our course: Rheumatology Nurse Practice: Managing the Common Comorbidities of Psoriatic Arthritis