Psoriasis is a chronic inflammatory skin disease associated with increased cardiovascular morbidity and mortality. The Framingham risk score is a validated and composite measurement that predicts the absolute risk of developing major cardiovascular events at 5 and 10 years. The objective of this study was to estimate the Framingham cardiovascular risk score in patients with psoriasis. A cross-sectional study in 234 adult patients with psoriasis and 234 age- and gender-matched patients with skin diseases other than psoriasis was performed. The Framingham risk score includes age, gender, total cholesterol, high-density lipoprotein cholesterol, systolic blood pressure, smoking status, and diabetes mellitus. Framingham risk score was significantly higher in patients with psoriasis than in controls at 5 years (mean ± SD 5.3 ± 4.4 vs 3.4 ± 3.3, p <0.001) and at 10 years (11.2 ± 8.1 vs 7.3 ± 6.3, p <0.001). The risk was higher for patients >50 years of age. Patients with psoriasis were more frequently smokers and diabetics and had more commonly atherogenic dyslipidemia than controls (p <0.05). Presence of psoriasis was independently associated with a higher Framingham score (coefficient 1.6, 95% confidence interval [CI] 0.6 to 2.5, p = 0.001). There was no correlation between severity or duration of psoriasis and Framingham risk score (coefficient 0.009, 95% CI −0.02 to 0.04, p = 0.6; coefficient 0.02, 95% CI 0.007 to 0.04, p = 0.7, respectively). In conclusion, patients with psoriasis have an intermediate risk of developing major cardiovascular events and thus interventions aimed to correct modifiable cardiovascular risk factors are warranted.
Patients with chronic plaque psoriasis have an increased mortality, largely attributable to cardiovascular diseases. The Framingham risk score is a tool to predict the absolute risk of major coronary and cerebrovascular events at 5 and 10 years in adults 30 to 74 years of age by stratifying patients into 3 risk categories: low (<10% risk of an event in 10 years), intermediate (10% to 20%), and high (>20%). It is available in different application formats (e.g., point scoring systems, risk charts, Web-based calculators) and requires only information from patient history and easily available tests. Classic Framingham risk factors include age, gender, smoking status, hypertension, systolic blood pressure, total blood cholesterol, high-density lipoprotein (HDL) cholesterol, and diabetes mellitus. In contrast to the general population and patients with diabetes, rheumatoid arthritis, and systemic lupus erythematosus, there is no information about the estimation of Framingham risk in patients with psoriasis. The aim of this study was to estimate the Framingham risk score in patients with chronic plaque psoriasis.
Methods
This was a cross-sectional study of 234 adult patients with chronic plaque psoriasis and 234 controls who were recruited from patients consecutively attending the dermatology clinic of the University Hospital of Verona (Verona, Italy) over a period of 6 months (from June to December 2009). Controls consisted of patients with a dermatologic disorder other than psoriasis who were randomly selected in a 1:1 ratio to be matched for age and gender to psoriatic patients. Source population for patients and controls was the same. Inclusion criteria for patients and controls were absence of systemic treatments for skin diseases for ≥2 months before enrollment, age 30 to 74 years, and no previous major cardiovascular events. The latter 2 inclusion criteria were applied because the Framingham risk score was validated in patients 30 to 74 years of age and without previous major cardiovascular accidents. Framingham risk score using the modified classic Framingham equation for “hard” coronary (myocardial infarction) or cerebrovascular (stroke) events at 5 and 10 years was estimated in the study population. In particular, parameters collected for each subject were age, gender, systolic blood pressure, total and HDL cholesterol concentrations, smoking habit, and presence of diabetes mellitus. Participants were defined as having diabetes mellitus when they were taking hypoglycemic medications, had a fasting plasma glucose concentration ≥126 mg/dl, or if a physician had ever told them that they had diabetes. Other relevant data collected consisted of body mass index, hypertension, age at psoriasis onset, and severity of psoriasis. Body mass index was calculated as weight in kilograms divided by height squared in meters. Hypertension was diagnosed if participants were taking antihypertensive medications, reported being told by a physician that they had high blood pressure, or the average of 3 blood pressure readings was ≥140/90 mm Hg. Diagnosis of psoriasis was made clinically and disease severity was assessed using the Psoriasis Area and Severity Index (PASI) and body surface area (BSA) estimation. The PASI evaluates degree of erythema, thickness, and scaling of psoriatic plaques and estimates extent of involvement of each of these components in 4 separate body areas (head, trunk, upper and lower extremities). The study was approved by the institutional review board of the University Hospital of Verona, and all subjects gave informed consent.
Venous blood was drawn in the morning after an overnight fast. Serum total, HDL, and low-density lipoprotein cholesterol levels were determined by standard laboratory procedures (DAX 96, Bayer Diagnostics, Milan, Italy). Upper limits for total cholesterol, HDL, and low-density lipoprotein cholesterol level were <200, >40, and >150 mg/dl, respectively.
The risk score was calculated for each subject using the risk score of Wilson et al. In this algorithm, subjects receive a point score based on categorical values of age, total cholesterol, HDL cholesterol, blood pressure, smoking, and diabetes mellitus. The scoring sheet is available online ( http://www.nhlbi.nih.gov/about/framingham/riskabs.htm ).
All analyses were performed using STATA 10.0 (STATA Corp. LP, College Station, Texas) and GraphPad 4.0 (San Diego, California). Data are expressed as mean ± SD or percentages. Skewed variables were logarithmically transformed to improve normality for statistical purposes and then back-transformed to their natural units for presentation in tables and figures. Statistical analyses included unpaired t test (for continuous variables) and chi-square test with Yates correction for continuity (for categorical variables). Independence of the association of the Framingham score with presence of psoriasis was assessed by multivariate forward stepwise regression analysis. In the fully adjusted regression model age, gender, smoking habit, diabetes, systolic arterial pressure, total cholesterol, HDL cholesterol, psoriasis, psoriasis duration, and PASI score were also included as independent covariates. A p value <0.05 was considered statistically significant.
Results
Patients with psoriasis had mild to severe disease with a PASI score of 1.2 to 40 (mean 9.9 ± 7, median 8.7). BSA was 2% to 90% (mean 23.2 ± 31.3, median 8). Psoriasis duration was 0.5 to 65 years (mean 17.6 ± 13.6, median 15). Prevalences of dermatologic diagnoses in the control group were 71% with chronic eczema (irritant, allergic, nummular, atopic), 15% with lichenoid dermatoses, and 14% with chronic urticaria. Characteristics of the study populations are presented in Table 1 . All variables included in the Framingham score significantly differed between patients and controls. In particular, prevalence of diabetics and smokers was greater in patients than in controls as were mean systolic blood pressure, mean total cholesterol levels, and mean HDL cholesterol value. Accordingly, 5- and 10-year Framingham risk scores were higher in patients with psoriasis compared to controls (5.3 ± 4.4 vs 3.4 ± 3.2, p = 0.000; and 11.2 ± 8.1 vs 7.3 ± 6.3, p = 0.000). As expected, cardiovascular risk increased linearly with age and was higher compared to controls only for patients >50 years old at 5 and 10 years ( Figure 1 ). In the linear regression model, presence of psoriasis was independently associated to a higher Framingham score (coefficient 1.6, 95% confidence interval [CI] 0.6 to 2.5, p = 0.001), whereas there was no correlation between severity or duration of psoriasis and cardiovascular score (coefficient 0.009, 95% CI −0.02 to 0.04, p = 0.6; and coefficient 0.02, 95% CI 0.007 to 0.04, p = 0.7, respectively). This held true also when patients were stratified for PASI classes (≤4.9 vs 5 to 9.9 vs ≥10; Figure 2 ), BSA classes (<10% vs ≥10.1%), or psoriasis duration (data not shown).
| Variable | Patients With Psoriasis (n = 234) | Controls (n = 234) | p Value |
|---|---|---|---|
| Men/women | 134/100 | 134/100 | NS |
| Age (years) | 56.7 ± 12.0 | 56.2 ± 11.5 | NS |
| Body mass index (kg/m 2 ) | 26.4 ± 4.1 | 25.6 ± 1.8 | 0.02 |
| Diabetes mellitus | 42 (18%) | 23 (10%) | 0.01 |
| Smoking habit | 98 (41%) | 66 (28%) | 0.000 |
| Systolic blood pressure (mm Hg) | 131 ± 15 | 127 ± 13 | 0.006 |
| Total cholesterol (mg/dl) | 206 ± 34 | 195 ± 47 | 0.003 |
| High density lipoprotein cholesterol (mg/dl) | 55 ± 10 | 65 ± 14 | 0.000 |
| Framingham 5-year score | 5.3 ± 4.4 | 3.4 ± 3.2 | 0.000 |
| Framingham 10-year score | 11.2 ± 8.1 | 7.3 ± 6.3 | 0.000 |
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