TOPIC SERIES: CVD PREVENTION IN RHEUMATIC DISEASE

Data from an observational, cross-sectional study of patients with psoriatic arthritis (PsA) suggest that preventive consultations with cardiologists are underutilized, and that a proportion of patients with diagnosed carotid plaques did not receive evidence-based therapy to mitigate cardiovascular (CV) risk. These findings were recently published in Arthritis Research & Therapy.

The development of optimal screening recommendations for patients with inflammatory disease who may be at increased risk of developing CV comorbidities is a topic of emerging research. Carotid duplex ultrasound (CDU), a noninvasive imaging technique capable of identifying subclinical carotid plaque, is one of the diagnostic tests available to clinicians caring for patients with PsA.  


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While CDU has been more extensively studied for CV risk stratification in the general population, definitive management guidelines have not been created specifically for patients with PsA and asymptomatic pathologic carotid plaques because clinical outcomes resulting from CDU screening had not been previously established.

 

To further gauge the efficacy of CDU for screening patients with PsA for preclinical CV disease, Michael Lucke, MD, of the Department of Rheumatology, Allegheny Health Network, Pittsburgh, Pennsylvania, and colleagues analyzed clinical data from patients enrolled in the Cardiometabolic Outcome Measures in Psoriatic Arthritis Study (COMPASS) database.

High Yield Data Summary

  • High rates of carotid plaque formation were found in a database of patients with PsA undergoing ultrasound screening

Patients enrolled in COMPASS were identified from a single tertiary rheumatology clinic and met Classification of Psoriatic Arthritis Study Group criteria for a diagnosis of PsA. Once entered into the COMPASS database, patients were independently managed by their respective attending rheumatologists. Prompts for referral for preventive cardiology consultation were generated automatically via the electronic healthcare record platform.

A total of 87 patients were enrolled into the COMPASS database. Baseline patient data included demographic information, presence of traditional CV risk factors, PsA disease activity and duration, and pharmacotherapy.  Study participants then underwent annual assessments, including measurements of body mass index, total cholesterol, serum triglycerides, cholesterol panels, erythrocyte sedimentation rate, and C-reactive protein. 

Registered vascular sonographers trained in performing CDU were given protocols for circumferential plaque screening of the bilateral internal carotid, external carotid, and common carotid arteries. The Mannheim carotid intima-media thickness consensus criteria were used to define presence of carotid plaque.

Researchers found carotid plaques were present in 39% of patients with PsA. Older age (P < .001), history of hypertension (P < .003), and elevated triglyceride levels (P <.014) were found to be associated with carotid plaque presence. Age and triglyceride levels remained independent predictors of carotid plaque development in PsA after multivariate logistic regression analyses.

Notably, only 10% of patients who were found to have carotid plaques and whose healthcare providers automatically received a prompt for specialist referral completed at least 1 preventive cardiology visit. Rates of utilization of preventive cardiology services between patients with and without carotid plaques were not significantly different (P = .73). 

Use of lipid-lowering therapy with statins and antiplatelet medication was also noted to be low (21% and 27%, respectively). PsA disease duration and activity were not associated with carotid plaque development in this study cohort.

“In addition to traditional risk factors, demonstration of carotid plaque can improve risk stratification but will only be impactful if incorporated into treatment plans by primary care physicians, rheumatologists, and/or cardiologists,” the authors stated. “Lack of familiarity with CDU screening and the risk represented by carotid plaque may have also led to an underappreciation of CV risk.”

Further research identifying possible barriers to adequate assessment of CV risk in patients with PsA is still needed.

Summary & Clinical Applicability

Low rates of completed cardiology preventive consultations were found in a database of patients with PsA who underwent CDU screening and were found to have carotid plaques. These low rates of referral occurred despite the implementation of automatic electronic medical record alerts.

“This additional  optional electronic alert [prompting specialty CV screening] may have been perceived as too time consuming or not of high value in patient care by physicians, and may not be of high utility to improve outcomes as a general treatmentstrategy,” the authors hypothesized.

Limitations & Disclosures

  • Low absolute number of carotid plaques found resulted in limited statistical power to determine effects of preventive cardiology referral on CV risk factors
  • Generalizability of this data set may be limited to patients who present to tertiary care centers and who may have higher PsA disease activity
  • The cross-sectional design of the study did not allow for data incorporation from any cardiac interventions performed at outside institutions
  • Data for other possible CV confounders, including body mass index, were not available for all patients

Esther S. H. Kim, MD, has disclosed the following relevant financial relationships: Served as a consultant for Phillips Ultrasound; received research funding from General Electric.

M. Elaine Husni, MD, has disclosed the following relevant financial relationships: Served as a consultant for Abbvie, Amgen, Bristol Myers Squibb, Eli Lilly, Novartis, and UCB; received research funding from the National Psoriasis Foundation and Arthritis National Research Foundation.

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Reference

Lucke M, Messner W, Kim ES, Husni ME. The impact of identifying carotid plaque on addressing cardiovascular risk in psoriatic arthritis. Arthritis Res Ther. 2016;18:178-185.

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