Background: Psoriasis is a common chronic immune mediated skin disease. Recent research indicates that the chronic inflammatory nature may lead to adverse health outcomes and patients carries an increased risk of developing co-morbidities including cardiovascular disease.

Objective: The aim was to examine the relationship between psoriasis and cardiovascular risk, as well as its demographic relationships.

Methods: A retrospective cross-sectional study, based on the records of 158 psoriatic patients between 1st of  January and 31st December 2014, in dermatology clinic of SKMC Abu Dhabi, UAE

Results: Our study indicated that 14% of patients with chronic plaque psoriasis had hypertension, 43% had high low-density lipoproteins (LDL), 27% had cholesterol higher than the reference range, 21% had triglycerides higher than the reference range and 80% were overweight or obese. A significant relationship was observed between some of the demographic variables and cardiovascular risk factors. Older age was significantly associated with increased risk of hypertension, diabetes, increased risk of high LDL, high cholesterol and with increased risk of high triglycerides.

Conclusion: There is a relationship between psoriasis and increased risk of cardiovascular disease. Further research is required to study the exact association of cardiovascular risks in those affected with chronic plaque psoriasis.

Psoriasis, a common chronic immune mediated disease that affects life quality and overall wellbeingand may lead to adverse health outcomes [1,2]. Several studies showed that psoriatic patientshave increased risk of comorbidities including hypertension, obesity, lipid abnormalities and insulin resistance. Research indicated a 50% increased risk of mortality that may result in approximately 5 years of life lost in patients with more severe disease [3]. Relationship between psoriasis and myocardial infarction, vascular inflammation and atherosclerosis has been found as well [4,5].

The aim was to examine the relationship between psoriasis and cardiovascular risk factors – diabetes mellitus (DM), hypertension (HTN), obesity, hyperlipidemia, and also some demographic characteristics among psoriatic patients with cardiovascular risk factors.

The study was conducted in the Dermatology Department of Sheikh Khalifa Medical City (SKMC), Abu Dhabi, United Arab Emirates (UAE).It was a retrospective study using records of 158 patients with chronic plaque psoriasis only or psoriasis associated with psoriatic arthritis (ICD9 code 696.1, 696.0) between January 2014 to December 2014. Data were obtained from the electronic medical records (Malaffi ®/Cerner® system).Of the total registered cohort of 261 subjects, 103 individuals were excluded. Exclusion criteria were: patient age below 16 or above 65years old, as well as patients with incorrect coding. 158 patients with psoriasis met the inclusion criteria. Of the 158 subjects, 82 were females (52%) Average age was 39.7 years (SD = 12.1). The diagnosis of hypertension, diabetes, obesity, hyperlipidemia or the abnormal levels of low-density lipoprotein (LDL), cholesterol and triglycerides were precisely documented into an excel spreadsheet. Additional data included age, sex, body mass index BMI and eventual systemic therapy. The SKMC IRB granted exempt approval for this study: Ethics Approval Reference No: REC-20.09.2015[RS-385]

Descriptive statistical analyses were performed for the study sample in terms of demographic variables and cardiovascular risk factors: diabetes, hypertension, high LDL, high cholesterol, high triglycerides, and body mass index (BMI). Continuous variables were expressed as mean ± SD, median (interquartile range, IQR). Number and percentage were used for categorical variables. Pairwise associations between cardiovascular risk factors measured using odds ratio (OR), with 95% confidence intervals were calculated (Figures 1,2). 

Figure 1: Descriptive Statistics: Percentage of Patients with Cardiovascular Risk Factors and 95% Confidence Interval.

Figure 2: Odds Ratio (OR) Measuring Pairwise Association between Cardiovascular Risks Factors, with 95% Confidence Interval.

Figure 3: Percentage of Patients with Hypertension by Marital Status, with 95% Confidence Interval.

Figure 4: Percentage of Patients with High Triglycerides by Marital Status, with 95% Confidence Interval.

The relationship between demographic variables: age, gender and marital status and cardiovascular risk factors was examined. The Chi-square test was used for categorical data (gender and marital status) and the Mann-Whitney U test or Kruskal-Wallis was used for continuous data (age) (Figures 3,4). Separate multivariate logistic regression models were utilized to predict the effect of age, gender and marital status on the risk of cardiovascular risk factors. Statistical significance was considered at p<0.05.

All statistical analyses were performed using SPSS 21.0 [Release 21.0.0.0, IBM, USA].    

A total of 158 psoriasis patients were included.  Our study population was typical for a psoriasis population with 48% of subjects being male (mean age 37 (32-48) years) and 52% female (mean age 39.7 ± 12.1) (Table I).  76% were ethnically Emirati and 24% of other ethnicities and 74% were married. Regarding cardiovascular risk factors 13% had diabetes, 14% were hypertensive, 43% had a high low density lipoprotein level (LDL), 33% had a raisedcholesterol level, 29% had a raised triglyceride level, 35% were overweight and 45% were obese - BMI: Normal (18.5-24.99 kg/m2), Overweight (25-29.99 kg/m2) and Obese (>30 kg/m²) (Table 1). No significant differences were found in cardiovascular risk factors between the genders (Table 2,3) whilst hypertension was significantly more likely in the married population and a raised triglyceride level more likely in the single population (Table 4,5). Our study analyzed the relationship between certain cardiovascular factors (obesity, diabetes, hypertension, dyslipidemia) with psoriasis and the relationship of selected demographic data with the cardiovascular risk factors among psoriatic patients in UAE. Previous studies demonstrated that psoriatic patients have higher risk of cardiovascular diseases and this risk increases with disease severity [6]. This association was confirmed by studies that demonstrated overlapping proinflammatory cytokines in both psoriasis and cardiovascular disease [7].

Hypertension was found in 14% of study population compared to 13% in UAE population8.  Increased blood pressure is associated to the increased level of angiotensin-converting enzyme (ACE), endothelin-1 (ET-1), and rennin [8-12]. Adipose tissues release angiotensinogen which is converted to angiotensin II that stimulates T-cell proliferation [13]. Weight reduction may lower blood pressure as it will reduce the angiotensin II [14]. Hypertension occurs more frequently in patients with psoriasis [15-18]. However, recent literature does not fully support this association 15. In our study, older age was significantly associated with increased hypertension risk [p = 0.006] (Tables 2 and 5). This is consistent with previous studies which concluded that psoriasis patients had an increased risk of hypertension after the age of 40 [19]. In our study, a significant relationship between marital status and hypertension was found. The prevalence of hypertension was higher among married patients [p = 0.017]. Our study showed that 43% of the patients had high LDL, 27% high cholesterol, 21% high triglycerides comparedrespectively to 38.6%, 42% and 29% among adult Emiratis [20]. Significantly higher prevalence of abnormal triglycerides levels in single patients [34% vs. 17%; p = 0.025] and over 8-fold higher risk of abnormal triglycerides levels than married ones (p <0.001). Older age was significantly associated with increased risk of higher LDL [p = 0.025], higher cholesterol [p = 0.005] and risk of higher triglycerides [p = 0.002].The relationship of dyslipidemia to psoriasis is explained by the chronic elevation of proinflammatory cytokineswhich affect the lipid metabolism. Other dyslipidemia causes in psoriasis patients include patient’s lifestyle and treatment side effect [21].

Our resultsare consistent with previous studies that psoriasis patients have higher concentrations of lipid levels [15-23]. Obesity or overweight was found in majority of our patients (80%). The UAE population is the one with world highest obesity level and obesity might be considered as an epidemic. No significant relation was found with age. Adipose tissue, an active endocrine tissue that releases pro-inflammatory cytokines [25,26]. The increased risk of obesity may be secondary to the release of inflammatory cytokines [27]. Obesity with high levels of C-reactive protein and raised erythrocyte sedimentation rate in the absence of inflammatory conditions may exacerbate skin lesions in patients with psoriasis [28]. Psoriasis patients were found to have higher levels of leptin and lower level of adiponectin [29]. Cohort studies suggest that obesity is a risk factor for psoriasis development [30,31]. Large databases of psoriatic patients found that BMI increased in patients after psoriasis diagnosis which might indicate that obesity is secondary to psoriasis.32Some cross-sectional studies found that increased BMI correlates with more severe psoriasis [32,33]. Moreover other studies mentioned that weight loss may improve psoriasis and treatment response [34-36]. Diabetes was found in 13% of our patients compared to 8% in UAE general population 8.The chronic inflammatory nature of psoriasis with the inflammatory mediators will result in epidermal hyperplasia, antagonized insulin signalling and mediate insulin resistance [29-37]. Previous study confirm the coexistence of diabetes in patients with severe psoriasis in 7.1% and with mild psoriasis in 4.4% compared to the control group (3.3%) [33]. Polish study showed slightly higher levels of insulin in psoriasis patients compared to the control group, but at the limit of statistical significance [38].

In our study, age was significantly different in diabetic patients vs. non-diabetics [median, IQR:  53 (37.8-59) years for diabetics vs. 36 (31-45.5) for non-diabetics; p = 0.001]. Older age was significantly associated with increased risk of diabetes [p = 0.001] and this was concurrent with previous studies which found significantly increased odds ratio for developing diabetes among psoriatic patients between 35 and 55 years of age [15-39]. Our results showed significant pairwise associations between a variety of cardiovascular risk factors including diabetes andhypertension [p<0.001], high cholesterol [p = 0.017], high triglycerides [p = 0.034]; hypertension and high cholesterol [p = 0.041], high triglycerides [p = 0.019]; high LDL and high triglycerides [p<0.001] and high cholesterol and high triglycerides [p<0.001]. The study highlights the importance of psoriasis and cardiovascular risk factors relationship. Early routine screening is vital. A previous study found, half of the dermatologists who were aware of the high cardiovascular risk didn’t educate their patients [40]. Some studies showed that biologics targeting TNF-alpha may reduce cardiovascular risk factors but no recommended therapies based on that [41,42]. Routine United States-based recommendations for all patients (not only psoriasis) include: 1) a blood pressure check in patients 21 or older, (2) fasting glucose every 3 years in patients above 45 or younger in patients with diabetes risk factors (3) cholesterol screening every 5 years starting at age 20 1. In Abu Dhabi, weqayaprogram was established in 2008 for cardiovascular risk factors screening among UAE individuals [43].

As patients with psoriasis have an increased risk of cardiovascular disease, physicians may put more strict levels for blood pressure and cholesterol [44]. Detecting any abnormalities earlier may reduce the cardiovascular risk. Future studies are needed to know the impact of treatment on the comorbidities. To the best of our knowledge this is the first study examining the cardiovascular risk factors among psoriatic patients in UAE. 

Our study was a retrospective cross sectional study which doesn’t allow the directionality of the association to be established.

1. Gelfand JM, Yeung H. Metabolic syndrome in patients with psoriatic disease. J Rheumatol Suppl. 2012; 89: 24-28.
2. Menter A, Griffiths CE, Tebbey PW, Horn EJ, Sterry W. Exploring the association between cardiovascular and other disease-related risk factors in the psoriasis population: the need for increased understanding across the medical community. J Eur Acad Dermatol Venereol. 2010; 24: 1371-1377.
3. Abuabara K, Azfar RS, Shin DB, Neimann AL, Troxel AB, Gelfand JM. Cause-specific mortality in patients with severe psoriasis: a population-based cohort study in the U.K. Br J Dermatol. 2010; 163: 586-592.
4. Mehta NN, Yu Y, Saboury B,  Foroughi N, Krishnamoorthy P, Raper A, et al. Systemic and vascular inflammation in patients with moderate to severe psoriasis as measured by [18F]-fluorodeoxyglucose positron emission tomography-computed tomography (FDG-PET/CT): a pilot study. Arch Dermatol. 2011; 147: 1031-1039.
5. Ahlehoff O, Gislason GH, Lindhardsen J, Olesen JB, Charlot M, Skov L, et al. Prognosis following first-time myocardial infarction in patients with psoriasis: a Danish nationwide cohort study. J Intern Med. 2011.
6. Kimball AB, Szapary P, Mrowietz U, Reich K, Langley RG, You Y, et al. Underdiagnosis and undertreatment of cardiovascular risk factors in patients with moderate to severe psoriasis. Am acad dermatol. 2011.
7. Wakee M, Thio HB, Prens EP, Gsijbrands EJ, Neumann HAM. Unfavorable cardiovascular risk profiles in untreated and treated psoriasis patients. Elsevier, Atherosclerosis. 2007; 190: 1-9.
8. World Health Organization. Non communicable diseases (NCD) country profiles. 2018.
9. Salihbegovic E, Hadzigrahic N, Suljagic E, Kurtalic N, Sadic S, Zejcirovic A, et al. Psoriasis and high blood pressure. Med Arh. 2015; 69: 13-15
10. Ena P, Madeddu P, GloriosoN, Cerimele D, Rappelli A. High prevalence of cardiovascular diseases and enhanced activity of the renin-angiotensin system in psoriatic patients. Acta Car- diol. 1985; 40: 199-205.
11. Das UN. Is angiotensin-II an endogenous pro-inflammatory molecule? Med Sci Monit. 2005; 11: 155-162.
12. Taler SJ, Textor SC, Canzanello VJ, Schwartz L. Cyclosporin-in- duced hypertension: incidence, pathogenesis and management. Drug Saf. 1999; 20: 437-449.
13. Nataraj C, Oliverio MI, Mannon RB, Mannon PJ, Audoly LP, Amuchastegu CS, et al. Angiotensin II regulates cellular immune responses through a calcineurin-dependent pathway. J Clin Invest. 1999; 104: 1693-1701.
14. Engeli S, Bohnke J, Gorzelniak K, Janke J, Schling P, Bader M, et al. Weight loss and the renin-angiotensin-aldosterone sys- tem. Hypertension. 2005; 45: 356-362.
15. Gottlieb AB, Dann F. Comorbidities in Patients with Psoriasis. The Ame J Med. 2009; 122: 1150-1150.
16. Sommer DM, Jenisch S, Suchan M, Christophers E, Weichenthal M. Increased prevalence of the metabolic syndrome in patients with moderate to severe psoriasis. Arch Dermatol Res. 2006; 298: 321-328.
17. Henseler T, Christophers E. Disease concomitance in psoriasis. J Am Acad Dermatol. 1995; 32: 982-986.
18. Lindegard B. Diseases associated with psoriasis in a general population of 159,200 middle-aged, urban, native Swedes. Dermatol. 1986; 172: 298-304.
19. Kaye JA, Li L, Jick SS. Incidence of risk factors for myocardial infarction and other vascular diseases in patients with psoriasis. Br J Dermatol. 2008; 159: 895-902.
20. Mahmoud I, Sulaiman N. Dyslipidaemia prevalence and associated risk factors in the United Arab Emirates: a population-based study. BMJ Open. 2019; 9.
21. Dauden E, Castaneda S, Suarez C, Garcia-Campayo J, Blasco AJ, Aguilar MD, et al. Integrated approach to comorbidity in patients with psoriasis. Working group on Psoriasis-associated comorbidities. ActasDermosifiliogr. 2012; 103: 1-64.
22. Akhyani M, Ehsani AH, Robati RM, Robati AM. The lipid profile in psoriasis: a controlled study. J Eur Acad Dermatol Venereol. 2007; 21: 1330-1332.
23. Mallbris L, Ritchlin CT, Stahle M. Metabolic disorders in patients with psoriasis and psoriatic arthritis. Curr Rheumatol Rep. 2006; 8: 355-363.
24. Rajan PB. The growing problem of obesity in the UAE. Academicus Inter Scientific J 2018; 9: 106-113.
25. Voiculescu VM, Lupu M, Papagheorghe L, Giurcaneanu C, Micu E. Psoriasis and metabolic syndrome – scientific evidence and therapeutic implications. J Med Life. 2014; 7: 468-471.
26. Rayhurn P, Beattie JH. Physiological role of adipose tissue: white adipose tissue as an endocrine and secretory organ. Proc Nutr Soc 2001; 60: 329-339.
27. Murray ML, Bergstresser PR, Adams-Huet B, Cohen JB. Relationship of psoriasis severity to obesity using same-gender siblings as controls for obesity. 2009; 34: 140-144.
28. Visser M, Bouter LM, McQuillan GM, Wener MH, Harris TB. Elevated C-reactive protein levels in overweight and obese adults. JAMA 1999; 282: 2131-2135.
29. Davidovici BB, Sattar N, Prinz JC, Puig L, Emery P, Barker JN, et al. Psoriasis and systemic inflammatory diseases: potential mechanistic links between skin disease and co-morbid conditions. J Invest Dermatol. 2010; 130: 1785-1796.
30. Naldi L, Chatenoud L, Linder D, Fortina AB, Peserico A, Virgili AR, et al. Cigarette smoking, body mass index, and stressful life events as risk factors for psoriasis: results from an Italian case-control study. J Invest Dermatol. 2005; 125: 61-67.
31. Setty AR, Curhan G, Choi HK. Obesity, waist circumference, weight change, and the risk of psoriasis in women: Nurses’ Health Study II. Arch Intern Med. 2007; 167: 1670-1675.
32. Herron MD, Hinckley M, Hoffman MS, Papenfuss J, Hansen CB, Callis KP, et al. Impact of obesity and smoking on psoriasis presentation and management. Arch Dermatol. 2005; 141: 1527-1534.
33. Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB, Gelfand JM. Prevalence of cardiovascular risk factors in patients with psoriasis. J Am Acad Dermatol. 2006; 55: 829-835.
34. Gottlieb AB, Dann F. Comorbidities in patients with psoriasis. Am J Med 2009; 122: 1150-1159.
35. Hamminga EA, van der Lely AJ, Neumann HA, Thio HB. Chronic inflammation in psoriasis and obesity: implications for therapy. Med Hypotheses 2006; 67: 768-773.
36. Gisondi P, Del Giglio M, Di Francesco V, Zamboni M, Girolomoni G. Weight loss improves the response of obese patients with moderate-to-severe chronic plaque psoriasis to low-dose cyclosporine therapy: a randomized, controlled, investigator-blinded clinical trial. Am J Clin Nutr 2008; 88: 1242-1247.
37. Azfar RS, Gelfand JM. Psoriasis and metabolic disease: epidemiology and pathophysiology. Current opinion rheumatol. 2008; 20: 416-422.
38. Janusz I, Lewandowski K, Lukamowicz J, Lukamowicz J, Swi?tkowska E, Narbutt J, et al. Insulin resistance and adiponectin levels in psoriasis patients [Polish]. PostepDermAlergol. 2010; 27: 451-455.
39. Owczarczyk-Saczonek AB, Nowicki RJ. Prevalence of cardiovascular disease risk factors, and metabolic syndrome and its components in patients with psoriasis aged 30 to 49 years. PostepDermAlergol. 2015; 32: 290-295.
40. Lee M, Kim H, Cho E, Park E, Kim K, and Kim K. A study of awareness and screening behavior of cardiovascular risk factors in patients with Psoriasis and dermatologists. Ann Dermatol. 2015; 27: 59-65.
41. Hugh J, Van Voorhees AS, Nijhawan RI, Bagel J, Lebwohl M, Blauvelt A, et al. From the Medical Board of the National Psoriasis Foundation: The risk of cardiovascular disease in individuals with psoriasis and the potential impact of current therapies. J Am Acad Dermatol. 2014; 70: 168-177.
42. Ryan C, Korman NJ, Gelfand JM, Lim HW, Elmets CA, Fedman SR, et al. Research gaps in psoriasis: opportunities for future studies. J Am Acad Dermatol. 2014; 70: 146-167.
43. Weqaya program by HAAD. 2016. 
44. Mehta NN, Yu Y, Pinnelas R, Krishnamoorthy P, Shin DB, Troxel AB, et al. Attributable risk estimate of severe psoriasis on major cardiovascular events. Am J Med. 2011; 124: 1-6.