Carotid artery ultrasound parameters, including carotid intima-media thickness (cIMT) and total plaque area (TPA), when considered in addition to Framingham Risk Score (FRS), may improve cardiovascular (CV) risk stratification in patients with psoriatic arthritis (PsA), according to study results published in Rheumatic & Musculoskeletal Diseases.
Previous studies have shown that patients with PsA are at increased risk for CV disease (CVD). The objective of the current study was to determine the performance of carotid ultrasound parameters alone, or in combination with FRS, for CV risk stratification in patients with PsA with and without coronary artery disease.
The study included 91 patients with PsA (mean age, 50 years; 56 men) without overt CVD who visited the outpatient clinic of the Prince of Wales Hospital, Hong Kong. Patients who received carotid ultrasound and coronary computed tomography angiography (CCTA) were included in the study.
Researchers identified carotid plaques in 35 patients (38.5%), with a median TPA of 11.89 mm2; coronary plaques were identified in 54 patients (59.3%), with evidence of obstructive coronary artery disease in 9 patients (9.9%). According to FRS, 20% of patients with coronary artery disease and 33% of those with obstructive coronary artery disease were correctly identified as having high CV risk. A total of 32% of patients (n=25/78) with low to intermediate CV risk, according to FRS, were reclassified as having high CV risk, based on the presence of carotid plaque. Of these 25 patients, 16 (64%) had coronary artery disease and 2 (12.5%) had significant stenosis.
Mean cIMT was significantly higher for study participants with vs without coronary artery disease (0.69 vs 0.63 mm, respectively; P =.017), but the prevalence of carotid plaque was similar in both groups. There was a trend suggesting a larger TPA for those with vs without coronary artery disease (P =.059). Increased cIMT was associated with an increased risk for coronary artery disease; the aOR for every 0.01 mm increase in mean cIMT was 1.06 (95% CI, 1.01-1.11; P =.013). The mean cIMT was significantly higher for the 9 patients with obstructive coronary artery disease compared with those without significant stenosis (0.76 vs 0.65 mm, respectively; P =.011). Mean cIMT (aOR, 1.07; 95% CI, 1.00-1.15; P =.042), max cIMT (aOR, 1.06; 95% CI, 1.00-1.11; P =.036), and TPA (aOR, 1.55; 95% CI, 1.013-2.359; P =.043) were all associated with increased risk for obstructive coronary artery disease. Mean cIMT and TPA were also significantly higher for patients with 3-vessel disease.
The optimal cutoff for FRS in distinguishing coronary artery disease was 5.2% (area under the curve [AUC], 0.76, P <.001; sensitivity, 81%; specificity, 62%) and mean cIMT of 0.62 mm (AUC, 0.67, P =.007; sensitivity, 76%; specificity, 60%). The combination model that included FRS less than 5% and mean cIMT less than 0.62 mm showed an AUC of 0.71 (P =.001), with a sensitivity of 67% and specificity of 76%. The optimal cutoffs for distinguishing obstructive coronary artery disease were FRS of 10.7% (AUC, 0.76; P =.012; sensitivity, 78%; specificity, 65%) and mean cIMT of 0.73 mm (AUC, 0.80; P =.004; sensitivity, 78%; specificity, 78%). The combination model that included FRS less than 10% and cIMT less than 0.73 mm had an AUC of 0.71 (P =.045), with a sensitivity of 56% and specificity of 85%.
The study had several limitations, including the enrollment of patients with mild to moderate disease activity and only a small number of patients with significant stenosis or 3-vessel disease; modalities other than high-resolution ultrasound may be more sensitive in detecting carotid plaques; and no data was available on other potential end points using the stress test or coronary angiogram.
“While the presence of carotid plaque alone was insufficient to discriminate patients with PsA with or without [coronary artery disease], a combination of FRS and cIMT may be considered for CV risk stratification in these patients,” the researchers concluded.
Cheng IT, Wong KT, Li EK, et al. Comparison of carotid artery ultrasound and Framingham risk score for discriminating coronary artery disease in patients with psoriatic arthritis. RMD Open. doi:10.1136/rmdopen-2020-001364