Matteo Casale

Cardiovascular Risk and Psoriasis A Role in Clinical Cardiology

Psoriasis is a chronic inflammatory disease. Classic manifestations are erythematous patches of skin with periods of exacerbation and remission. The inflammatory process is evidenced by the increase in several markers such as cell adhesion molecules, cytokines, chemokines, and other molecules of the acute phase such as fibrinogen, C-reactive protein (CRP), and serum amyloid A protein. C-reactive protein levels correlate with an increase in potential cardiovascular (CV) risk predictors based on evidence obtained in experimental animals, which have demonstrated a role of toll-like receptor (TLR) type 2 and 4 in the development and progression of atherosclerosis. C-reactive protein promotes endothelial dysfunction by reducing endothelial nitric oxide synthetase expression and activity, reducing prostacyclin release from endothelial cells, increasing plasminogen activator inhibitor 1 expression and activity, endothelin 1 and interleukin 1 release, and by promoting cellular adhesion between endothelial cells and monocytes with increase in the size of atherosclerotic plaques; moreover a novel marker of endothelial dysfunction, endocan, was recently proposed to stratify CV risk in patients with psoriasis, since serum endocan levels correlated with the Psoriasis Area and Severity Index (PASI), CRP, and carotid intima–media thickness. It follows that psoriasis alone, or in combination with other risk factors, may play a role in the development and progression of CV disease but its exact contribution is not clear. Therefore, we performed a search of the literature, selecting the publications that we thought to be of interest. We carried out a systematic search in PubMed and Embase using the keywords ‘‘psoriasis,’’ ‘‘autoimmune disease,’’ ‘‘cardiovascular disease,’’ ‘‘diabetes,’’ ‘‘hypertension,’’ ‘‘high blood pressure,’’ ‘‘dyslipidaemia,’’ ‘‘metabolic syndrome,’’ and ‘‘obesity.’’ We found 231 articles of interest but we selected only 19 as the most representative. Several authors have highlighted the association between coronary heart disease (CHD) and psoriasis. However, there is no single definition of the parameters of severity of the psoriasis or a homogeneity of patient selection in different studies. In 1978, McDonald and Calabresi studied 323 hospitalized patients with psoriasis and showed an association with arterial and venous vascular diseases. Further studies have revealed a correlation between this disease and atherosclerosis, focusing on CHD. The main limitation of these studies was that they could not conclusively define a significant correlation between the 2 conditions mainly because they did not sufficiently take into account the presence of confounding factors, such as the presence of CV risk factors. This correlation, however, was established by Gelfand et al in 2006. Their objective was to ‘‘determine within a population-based cohort if psoriasis is an independent risk factor for acute myocardial infarction (AMI).’’ They studied 130 976 patients with psoriasis of whom 3827 had a severe form (ie, on systemic therapy). Patients were matched with 556 995 controls and followed for a mean of 5.4 years. There was an increased risk of AMI in patients with moderate and severe psoriasis. The authors concluded that psoriasis may be considered as an independent risk factor for AMI. A subsequent study in 2008 examined 2 large US databases and showed an increase in CV risk in patients with mild psoriasis. In 2009, Prodanovich et al in an observational study of 3236 patients with psoriasis reported a higher prevalence of traditional CV risk factors (diabetes mellitus, hypertension, dyslipidemia, and smoking) compared with controls. This association was known from previous studies but the new element was the association of psoriasis with an increased prevalence not only of myocardial ischemia but also of cerebrovascular and peripheral arterial disease. The conclusion was that psoriasis is associated with atherosclerosis. A study published in 2012 compared the severity of psoriasis (PASI score) with coronary flow reserve (CFR). In patients with reduced CFR (<2.5) psoriasis was more severe (higher PASI score). According to the authors in young

Left Atrial Morphology, Size and Function in Patients With Transthyretin Cardiac Amyloidosis and Primary Hypertrophic Cardiomyopathy – Comparative Strain Imaging Study –

BACKGROUND We sought to assess left atrial (LA) morphology and function in patients with transthyretin cardiac amyloidosis (TTR-CA) and hypertrophic cardiomyopathy (HCM). Primarily, longitudinal deformation (reservoir) and pump function were the focus of vector-velocity strain echocardiography imaging. METHODSANDRESULTS The study group comprised 32 patients (mean age 57.7±15.4 years, 16 in each group), and 15 healthy controls. Diagnosis of TTR-CA was based on echocardiography and either gadolinium-enhanced (LGE) cardiac magnetic resonance (cMRI) or radionuclide imaging. At baseline, there were no differences in age, body surface area, blood pressure and risk factors among the groups. Left ventricular (LV) mass was greater in patients than in controls, and slight LA dilatation was found in the TTR-CA group. LA reservoir was 14.1±4.7% in TTR-CA, 20.0±5.6% in HCM, and 34.0±11.8% in controls (<0.001). In addition, LA pump function chiefly was impaired in the former group, irrespective of LA chamber size and LV ejection fraction. LGE in the atrial wall was seen in 9/10 TTR-CA versus 0/8 HCM patients undergoing cMRI (P<0.001). LA reservoir ≤19% and pump function ≤-1.1% best discriminated TTR-CA from HCM patients in the receiver-operating characteristic analysis. CONCLUSIONS LA reservoir and pump function were significantly impaired in both TTR-CA and HCM patients compared with controls, but mainly in the former group, irrespective of LA volume and LV ejection fraction, likely caused by a more altered LA wall structure. (Circ J 2016; 80: 1830-1837).

Psoriasis and Cardiovascular Risk: Correlation Between Psoriasis and Cardiovascular Functional Indices:

Evidence suggests that psoriasis together with other cardiovascular (CV) risk factors is associated with increased vascular morbidity, but it is not clear whether psoriasis is an independent risk factor. Consecutive patients (n = 33; 35.6 ± 5.7 years; 13 females) with mild psoriasis (Psoriasis Area and Severity Index <10) without comorbidities and 33 healthy participants (36.3 ± 5.9 years; 15 females) were enrolled. Both groups underwent echocardiography, speckle tracking (2-dimensional strain echocardiography [2D-SE]), and pulse wave velocity (PWV) testing. Clinical and conventional echocardiographic characteristics were comparable between both groups. Global longitudinal strain (GLS) was significantly lower (P = .002) in the psoriasis group (22.39% ± 2.28%) than in controls (24.15% ± 2.17%). The PWV was significantly lower (P = .004) in controls (8.06 ± 1.68 m/s) than in the psoriasis group (9.23 ± 1.53 m/s). Significant correlations between GLS and disease duration (r = −.66, P < .0001) and between GLS and patient age at diagnosis (r = .48, P = .0043) were found. Psoriasis may be an independent CV risk factor, causing cardiac and vascular impairment. Both 2D-SE and PWV may be useful tools for the screening of CV risk in these patients.

Vitamin D Dietary Supplementation: Relationship with Chronic Heart Failure

It is estimated that over 1 billion people worldwide have a deficiency of vitamin D, also known as hypovitaminosis D, which the World Health Organization has defined as a public health problem. Beyond its historical homeostasis regulatory function of calcium and phosphorus, in relation to the preservation of the skeletal system, several studies show today a close connection between hypovitaminosis D and the genesis of rheumatic, autoimmune, neoplastic, and cardiovascular diseases. With exclusive reference to cardiovascular aspects, multiple heart diseases such as hypertension, myocardial ischemia, and heart failures might have deficiency in vitamin D as an important causative factor. Because of the influence of concomitant pathologies caused by antibiotic-resistant agents, the function of this vitamin should be critically evaluated. However, the role of vitamin D remains to be established; only a few studies have tested the effects of its supplementation in patients with chronic heart failure diseases, and reported results are unclear. It is important to implement studies in this field in order to assess the real benefits induced by vitamin D supplementation in cardiovascular patients and, in particular, in patients with heart failure. Should the research confirm actual clinical improvement after treatment with vitamin D, such a supplementation might represent a new low-cost therapeutic approach to improving quality of life.

Takotsubo Cardiomyopathy: A Benign Condition or a Bad Omen?:

Takotsubo cardiomyopathy (TC), also known as “stress cardiomyopathy” or “broken heart syndrome,” is a transient disorder, typically following an acute emotional or physical stress, mimicking an acute coronary syndrome (ACS). Patients with TC complain of chest pain and show electrocardiogram dynamic changes such as ST-segment elevation or negative T waves with a mild increase in cardiac biomarkers and absence of significant coronary artery involvement. Left ventricular (LV) wall motion abnormalities in TC are typically akinesia or hypokinesia of apical segments (apical balloon-like dilation pattern) associated with hyperkinesia of the basal segments. Echocardiography plays a key role in the diagnosis, allowing direct visualization of the typical apical ballooning pattern, and it is considered specific. New technologies, such as speckle tracking echocardiography, are useful. Despite the fact that these findings are unlikely in ACS, coronary angiography is needed to rule out myocardial infarction.