JEADV
DOI: 10.1111/jdv.12516
ORIGINAL ARTICLE
Epicardial adipose tissue and coronary artery calcification in psoriasis patients T. Torres,1,2,* N. Bettencourt,3 D. Mendoncß a,4 C. Vasconcelos,2,5 V. Gama,3 B.M. Silva,2,6, M. Selores1 1
Department of Dermatology, Centro Hospitalar do Porto, Porto, Portugal dicas Abel Salazar, University of Porto, Porto, Unit for Multidisciplinary Investigation in Biomedicine, Instituto de Ci^ encias Biome Portugal 3 Department of Cardiology, Centro Hospitalar Gaia/Espinho, Porto, Portugal 4 dicas Abel Salazar, University of Porto, Porto, Portugal Department of Population Studies, Instituto Ci^encias Biome 5 Department of Clinical Immunology, Centro Hospitalar of Porto, Porto, Portugal 6 dicas Abel Salazar, University of Porto, Porto, Portugal Immunogenetics Laboratory, Instituto Ci^encias Biome *Correspondence: T. Torres. E-mail: [email protected] 2
Abstract Background Psoriasis is a chronic, immune-mediated disease associated with several cardio-metabolic comorbidities, accelerated atherosclerosis and cardiovascular disease (CVD). Other causes beyond systemic inflammation and traditional cardiovascular risk factors (CVRF) may be implicated in the increased risk of CVD observed in these patients. Epicardial adipose tissue (EAT), a type of visceral adipose tissue surrounding the heart and coronary vessels has been implicated in the development of coronary artery disease, by endocrine mechanisms, but particularly by local inflammation. Objective To compare EAT volumes in psoriasis patients and controls using multidetector computed tomography (MDCT) and to analyse if eventual differences were independent from abdominal visceral adiposity; to determine, within psoriasis patients, its relation with subclinical atherosclerosis and other markers of cardiometabolic risk. Methods One hundred patients with severe psoriasis, without CVD underwent MDCT, with EAT and abdominal visceral fat (AVF) assessment and coronary artery calcification (CAC) quantification and were compared with 202 control patients. Results EAT volume was increased in psoriasis patients compared to control subjects, independently from age, sex and AVF, being, on average, 15.2 4.41 mL higher (95% CI: 6.5–26.0, P = 0.001) than in controls. Moreover, psoriasis patients had a statistically significant higher risk of having subclinical atherosclerosis (OR 2.52, 95% CI: 1.23–5.16) than controls, after adjusting for traditional CVRF. Within psoriasis patients EAT volume was associated with subclinical atherosclerosis, independently of age, sex, psoriasis duration, classical CVRF and AVF. Conclusion This study showed that psoriasis was associated with increased EAT volume independently of visceral abdominal fat and with subclinical atherosclerosis. Within psoriasis patients EAT volume was independently associated with CAC. EAT may be another important contributor to the higher cardiovascular risk observed in psoriasis. Received: 20 December 2013; Accepted: 17 March 2014
Conflicts of interest None declared.
Fundings This study was supported in part by an unrestricted grant from the Portuguese Society of Dermatology and Venereology.
Introduction Psoriasis is a chronic inflammatory disease affecting 1–3% of the population.1 Nowadays, it is considered as a systemic inflammatory disorder2 associated with numerous medical comorbidities and with clinically significant increased risk of cardiovascular disease (CVD) and cardiovascular mortality.3–6 Psoriasis appears
JEADV 2015, 29, 270–277
to be an independent risk factor for subclinical atherosclerosis, probably due to disease’s inflammatory burden, as an increased prevalence of subclinical atherosclerosis has been reported in several studies using various surrogate markers of atherosclerosis.7–9 However, other causes beyond systemic inflammation and traditional cardiovascular risk factors (CVRF) may be implicated
© 2014 European Academy of Dermatology and Venereology
Epicardial adipose tissue and psoriasis
in CVD in psoriasis. Psoriasis patients are more likely to have abdominal visceral adiposity than healthy subjects of similar waist circumference10 which is strongly related to several cardiometabolic risk factors.11 Epicardial adipose tissue (EAT) is a type of visceral adipose tissue surrounding the heart and coronary vessels. It is externally limited by the pericardium and is mainly present in the atrioventricular and interventricular grooves, following the courses of the main coronary vessels12(Fig. 1). Its close relation to the coronary tree has been suggested to be potentially relevant for the development of coronary artery disease (CAD), by endocrine mechanisms, but particularly by local inflammation and paracrine mechanisms, as EAT has been shown to produce and secrete, several proatherogenic and proinflammatory hormones and cytokines, including TNFa, IL-6, adipocytokines and leptin.13–15 EAT has been independently associated with CAD16 and in the Multi-Ethnic Study of Atherosclerosis (MESA) it has been shown to be predictive of incident cardiovascular events independently of conventional risk factors and body mass index (BMI).17 There are various imaging modalities for measuring EAT, like magnetic resonance imaging (MRI), computed tomography (CT) and echocardiography, although MRI and CT are considered currently gold standard and additionally permit measuring abdominal visceral fat (AVF).18 The aim of this study was to compare EAT volumes in psoriasis patients and controls using multidetector computed tomography (MDCT) and to analyse if eventual differences were independent from AVF, a reliable marker of visceral
Figure 1 Multidetector computed tomography image of epicardial adipose tissue and left anterior descending coronary artery calcification.
JEADV 2015, 29, 270–277
271
adipose tissue accumulation, or other potential confounders, and to determine, within psoriasis patients, its relation with subclinical atherosclerosis using coronary artery calcification (CAC) quantification and other markers of cardiometabolic risk.
Methods Consecutive patients with severe plaque-type psoriasis [Psoriasis Area Severity Index (PASI) > 10 and/or systemic therapy], without psoriatic arthritis (no previous/current signs/symptoms of joint involvement) and no CVD, defined as the presence of coronary heart disease (CHD) (myocardial infarction, angina, angioplasty or coronary artery bypass grafting), cerebrovascular accident (stroke or transient ischemic attack) or peripheral vascular disease, were recruited from the Dermatology outpatient clinic. All patients underwent clinical evaluation (complete medical history and physical examination) and laboratory evaluation. The following information was systematically recorded: demographic characteristics, psoriasis disease duration, severity and current therapy, medical history of CVRF and therapy. Patients were considered to have diabetes, hypertension, hyperlipidaemia if they were receiving specific treatment or have been previously diagnosed or if they had fasting plasma glucose ≥126 mg/dL, blood pressure ≥ 140/≥90 mmHg and fasting lowdensity lipoprotein (LDL)-cholesterol ≥ 160 mg/dL or triglycerides ≥ 200 mg/dL respectively. Overweight and obesity was defined by a BMI≥25 or BMI≥30, respectively, smoking status as current smokers (current tobacco use or stop smoking within the last year), non-smokers and ex-smokers (smoking cessation for more than a year) and family history of premature CHD as history of CHD in male first degree relative
DOI: 10.1111/jdv.12516
ORIGINAL ARTICLE
Epicardial adipose tissue and coronary artery calcification in psoriasis patients T. Torres,1,2,* N. Bettencourt,3 D. Mendoncß a,4 C. Vasconcelos,2,5 V. Gama,3 B.M. Silva,2,6, M. Selores1 1
Department of Dermatology, Centro Hospitalar do Porto, Porto, Portugal dicas Abel Salazar, University of Porto, Porto, Unit for Multidisciplinary Investigation in Biomedicine, Instituto de Ci^ encias Biome Portugal 3 Department of Cardiology, Centro Hospitalar Gaia/Espinho, Porto, Portugal 4 dicas Abel Salazar, University of Porto, Porto, Portugal Department of Population Studies, Instituto Ci^encias Biome 5 Department of Clinical Immunology, Centro Hospitalar of Porto, Porto, Portugal 6 dicas Abel Salazar, University of Porto, Porto, Portugal Immunogenetics Laboratory, Instituto Ci^encias Biome *Correspondence: T. Torres. E-mail: [email protected] 2
Abstract Background Psoriasis is a chronic, immune-mediated disease associated with several cardio-metabolic comorbidities, accelerated atherosclerosis and cardiovascular disease (CVD). Other causes beyond systemic inflammation and traditional cardiovascular risk factors (CVRF) may be implicated in the increased risk of CVD observed in these patients. Epicardial adipose tissue (EAT), a type of visceral adipose tissue surrounding the heart and coronary vessels has been implicated in the development of coronary artery disease, by endocrine mechanisms, but particularly by local inflammation. Objective To compare EAT volumes in psoriasis patients and controls using multidetector computed tomography (MDCT) and to analyse if eventual differences were independent from abdominal visceral adiposity; to determine, within psoriasis patients, its relation with subclinical atherosclerosis and other markers of cardiometabolic risk. Methods One hundred patients with severe psoriasis, without CVD underwent MDCT, with EAT and abdominal visceral fat (AVF) assessment and coronary artery calcification (CAC) quantification and were compared with 202 control patients. Results EAT volume was increased in psoriasis patients compared to control subjects, independently from age, sex and AVF, being, on average, 15.2 4.41 mL higher (95% CI: 6.5–26.0, P = 0.001) than in controls. Moreover, psoriasis patients had a statistically significant higher risk of having subclinical atherosclerosis (OR 2.52, 95% CI: 1.23–5.16) than controls, after adjusting for traditional CVRF. Within psoriasis patients EAT volume was associated with subclinical atherosclerosis, independently of age, sex, psoriasis duration, classical CVRF and AVF. Conclusion This study showed that psoriasis was associated with increased EAT volume independently of visceral abdominal fat and with subclinical atherosclerosis. Within psoriasis patients EAT volume was independently associated with CAC. EAT may be another important contributor to the higher cardiovascular risk observed in psoriasis. Received: 20 December 2013; Accepted: 17 March 2014
Conflicts of interest None declared.
Fundings This study was supported in part by an unrestricted grant from the Portuguese Society of Dermatology and Venereology.
Introduction Psoriasis is a chronic inflammatory disease affecting 1–3% of the population.1 Nowadays, it is considered as a systemic inflammatory disorder2 associated with numerous medical comorbidities and with clinically significant increased risk of cardiovascular disease (CVD) and cardiovascular mortality.3–6 Psoriasis appears
JEADV 2015, 29, 270–277
to be an independent risk factor for subclinical atherosclerosis, probably due to disease’s inflammatory burden, as an increased prevalence of subclinical atherosclerosis has been reported in several studies using various surrogate markers of atherosclerosis.7–9 However, other causes beyond systemic inflammation and traditional cardiovascular risk factors (CVRF) may be implicated
© 2014 European Academy of Dermatology and Venereology
Epicardial adipose tissue and psoriasis
in CVD in psoriasis. Psoriasis patients are more likely to have abdominal visceral adiposity than healthy subjects of similar waist circumference10 which is strongly related to several cardiometabolic risk factors.11 Epicardial adipose tissue (EAT) is a type of visceral adipose tissue surrounding the heart and coronary vessels. It is externally limited by the pericardium and is mainly present in the atrioventricular and interventricular grooves, following the courses of the main coronary vessels12(Fig. 1). Its close relation to the coronary tree has been suggested to be potentially relevant for the development of coronary artery disease (CAD), by endocrine mechanisms, but particularly by local inflammation and paracrine mechanisms, as EAT has been shown to produce and secrete, several proatherogenic and proinflammatory hormones and cytokines, including TNFa, IL-6, adipocytokines and leptin.13–15 EAT has been independently associated with CAD16 and in the Multi-Ethnic Study of Atherosclerosis (MESA) it has been shown to be predictive of incident cardiovascular events independently of conventional risk factors and body mass index (BMI).17 There are various imaging modalities for measuring EAT, like magnetic resonance imaging (MRI), computed tomography (CT) and echocardiography, although MRI and CT are considered currently gold standard and additionally permit measuring abdominal visceral fat (AVF).18 The aim of this study was to compare EAT volumes in psoriasis patients and controls using multidetector computed tomography (MDCT) and to analyse if eventual differences were independent from AVF, a reliable marker of visceral
Figure 1 Multidetector computed tomography image of epicardial adipose tissue and left anterior descending coronary artery calcification.
JEADV 2015, 29, 270–277
271
adipose tissue accumulation, or other potential confounders, and to determine, within psoriasis patients, its relation with subclinical atherosclerosis using coronary artery calcification (CAC) quantification and other markers of cardiometabolic risk.
Methods Consecutive patients with severe plaque-type psoriasis [Psoriasis Area Severity Index (PASI) > 10 and/or systemic therapy], without psoriatic arthritis (no previous/current signs/symptoms of joint involvement) and no CVD, defined as the presence of coronary heart disease (CHD) (myocardial infarction, angina, angioplasty or coronary artery bypass grafting), cerebrovascular accident (stroke or transient ischemic attack) or peripheral vascular disease, were recruited from the Dermatology outpatient clinic. All patients underwent clinical evaluation (complete medical history and physical examination) and laboratory evaluation. The following information was systematically recorded: demographic characteristics, psoriasis disease duration, severity and current therapy, medical history of CVRF and therapy. Patients were considered to have diabetes, hypertension, hyperlipidaemia if they were receiving specific treatment or have been previously diagnosed or if they had fasting plasma glucose ≥126 mg/dL, blood pressure ≥ 140/≥90 mmHg and fasting lowdensity lipoprotein (LDL)-cholesterol ≥ 160 mg/dL or triglycerides ≥ 200 mg/dL respectively. Overweight and obesity was defined by a BMI≥25 or BMI≥30, respectively, smoking status as current smokers (current tobacco use or stop smoking within the last year), non-smokers and ex-smokers (smoking cessation for more than a year) and family history of premature CHD as history of CHD in male first degree relative
