Should all patients with psoriasis receive statins? Analysis according to different strategies,

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Anais

Brasileiros

de

Dermatologia

www.anaisdedermatologia.org.br

INVESTIGATION

Should

all

patients

with

psoriasis

receive

statins?

Analysis

according

to

different

strategies

夽,夽夽

Walter

Masson

a,b,∗

_,

_Martín

_Lobo

b

_,

_Graciela

_Molinero

b

_,

_Emiliano

_Rossi

a

a_Cardiology_Service,_Hospital_Italiano_de_Buenos_Aires,_Buenos_Aires,_Argentina

b_Council_of_Epidemiology_and_{Cardiovascular}_Prevention,_Sociedad_Argentina_de_{Cardiología,}_Buenos_Aires,_Argentina

Received13December2018;accepted28March2019 Availableonline24October2019

KEYWORDS Hydroxymethylglutaryl-CoAreductase inhibitors; Lipids; Psoriasis Abstract

Background: Differentstrategieshavebeenproposedforthecardiovascularriskmanagement ofpatientswithpsoriasis.

Objective: To estimate the cardiovascular risk andevaluate two cardiovascular prevention strategiesinpatientswithpsoriasis,analyzingwhichproportionofpatientswouldbecandidates toreceivestatintherapy.

Methods: A retrospective cohortwas selected froma secondarydatabase. Allpatients >18 yearswithpsoriasiswithoutcardiovasculardiseaseorlipid-loweringtreatmentwereincluded. The atherosclerotic cardiovascular disease calculator (2018 American College of Cardiol-ogy/AmericanHeartAssociationguidelines)andtheSystematicCoronaryRiskEvaluationrisk calculator (2016 European SocietyofCardiology/European SocietyofAtherosclerosis guide-lines)werecalculated.TheSCOREriskvalue wasadjustedbyamultiplicationfactorof1.5. Therecommendationsfortheindicationofstatinssuggestedbybothguidelineswereanalyzed. Results: A totalof892patients(meanage59.9±16.5years,54.5%women) wereincluded. The median atherosclerotic cardiovascular disease calculator and SystematicCoronary Risk Evaluationvalueswere13.4%(IQR6.1---27.0%)and1.9%(IQR0.4---5.2),respectively.According totheatheroscleroticcardiovasculardiseasecalculator,20.1%,11.0%,32.9%,and36.4%ofthe populationwasclassiﬁedatlow,borderline,moderate,orhighrisk.ApplyingtheSystematic CoronaryRiskEvaluation,26.5%,42.9%,20.8%,and9.8%ofpatientswerestratiﬁedashaving low, moderate,high,or very highrisk,respectively. The proportion ofsubjectswith statin indicationwassimilarusingbothstrategies:60.1%and60.9%for the2018AmericanCollege ofCardiology/AmericanHeartAssociationand2016EuropeanSocietyofCardiology/European SocietyofAtherosclerosisguidelines,respectively.

夽 _How_to_cite_this_article:_Massom_W,_Lobo_M,_Molinero_G,_Rossi_E._Should_all_patients_with_psoriasis_receive_statins?_Analysis_according_to

differentstrategies.AnBrasDermatol.2019;94:691---7.

夽夽_Study_conducted_at_the_Hospital_Italiano_de_Buenos_Aires,_Buenos_Aires,_Argentina. ∗_{Corresponding}_author.

E-mail:[email protected](W.Masson).

https://doi.org/10.1016/j.abd.2019.03.001

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Studylimitations: Thiswasasecondarydatabasestudy.Dataontheseverityofpsoriasisand pharmacologicaltreatmentswerenotincludedintheanalysis.

Conclusion: Thispopulationwithpsoriasiswasmostlyclassiﬁedatmoderate---highriskandthe statintherapyindicationwassimilarwhenapplyingthetwostrategiesevaluated.

Introduction

Chronicinﬂammatorydisorders,includingpsoriasis,are cha-racterized by enhanced atherosclerosis and consequently higher cardiovascular morbidity and mortality rates com-paredwiththegeneralpopulation.1---4

Therefore, particular attention should be paid to con-ventional cardiovascular risk factor treatment, including dyslipidemia,inthesepatients.Statinsareeffectivein redu-cingdiseaseactivity,andinposthocanalysisofrandomized clinical trials, statins improved lipid levels and cardio-vascular outcomesin patients withand without psoriasis, supportingstatin usein patientswithpsoriasis.5 _However,

thereis nocertainindication fortheuse oflipid-lowering therapyonlyonthebasisofthepresenceofthedisease.

Thetraditionalriskscalesusedtoestimate cardiovascu-lar risk have great limitations; due to the fact that they were not developed speciﬁcally for psoriasis, they have a tendency to underestimate the risk.6,7 _The _decrease _in

theindicationofinterventionsincardiovascularprevention, suchasstatins,maybetheresultofthisdeﬁcient evalua-tion.

Twostrategieshavebeenproposedforthecardiovascular riskmanagementofthesepatients.Theﬁrst,recommended bytheEuropeanSocietyofCardiology(ESC),theEuropean SocietyofAtherosclerosis(EAS), andtheEuropean League AgainstRheumatism(EULAR),istoadjusttheriskcalculated byamultiplyingfactor(1.5×)andfollowthe recommenda-tionsforstatintherapyofthegeneralpopulation.8,9

Thesecondstrategyplacespsoriasisasaclinicalsituation thatincreasescardiovascularriskandconsequently,itfavors theindicationofstatinsatleastinsubjectswith interme-diaterisk. Inthiscase, noadjustmentfactorissuggested. ThisstrategyisrecommendedbythenewAmericanCollege ofCardiology/AmericanHeartAssociation(ACC/AHA) guide-linesforcholesterolmanagementintroducedattheendof 2018.10

Takingintoaccountthepreviouslymentioned consider-ations,theobjectivesofthisstudywereasfollows:(1)to estimatethecardiovascularriskmeasuredbytwodifferent scores in patients with psoriasis without previous cardio-vasculardisease(CVD);(2)toevaluatetwocardiovascular prevention strategies in patients withpsoriasis, analyzing whichproportionofpatientswouldbecandidatestoreceive statintherapy;(3)toestablishthereasonsthatjustifythis indication.

Methods

A retrospective cohort was selected from a secondary database (electronic medical records). The sample was

obtainedfroma privatehealthsystem constitutedbytwo universityhospitalsandanetworkof21associated periph-eralcentersdistributed inthecity of BuenosAiresand in theprovinceofBuenos Aires,Argentina.Allpatientsolder than 18yearswithadiagnosis of psoriasiswereincluded. Patientswithprevious CVD,chronic renalinsufﬁciency, or concomitantlipid-loweringtreatmentwereexcluded.

Theatheroscleroticcardiovasculardisease(ASCVD) cal-culatorusedbythe2018ACC/AHAguidelinesforcholesterol management10 _and _the _Systematic _Coronary _Risk

Evalua-tion (SCORE) estimate the ten-year risk of ASCVD fatal events,correspondingtolow-riskcountriesusedbythe2016 ESC/EASguidelinesonCVDpreventioninclinicalpractice,8

werecalculated.ThechoiceofSCORE,correspondingtolow riskcountries,wasarbitrary,basedonthefactthatmostof theArgentineimmigrantpopulationcomesfromthose coun-tries.TheriskvaluecalculatedbytheSCOREwasadjustedby amultiplicationfactorof1.5,followingthelatestEuropean recommendations.8,9_Following_the_{recommendations}_of_the

mentionedguidelines,indicationsforstatinswithalevelof recommendationIorIIawereselectedforthisanalysis.

Applying the 2018 ACC/AHA guidelines, the following recommendations weretaken intoaccountfor patients in primaryprevention:(a)inpatients40---75yearsofagewith diabetes mellitus and LDL-C ≥70mg/dL, start moderate-intensity statin therapy without estimating the ten-year ASCVD risk calculator; (b) in patients 20---75 yearsof age withan LDL-Clevel of190mg/dLor higher,high-intensity statintherapyisrecommendedwithoutestimatingthe ten-yearASCVDriskcalculator;(c)inadults40---75yearsofage withoutdiabetesmellitusandten-yearrisk≥20%,start high-intensity statin therapy; (d) in adults40---75 yearsof age without diabetes mellitus and ten-year risk of 7.5---19.9% (intermediaterisk), risk-enhancing factors favor initiation ofmoderate-intensitystatintherapy.Risk-enhancingfactors includepsoriasis.

Applying the 2016 ESC/EAS guidelines, the following recommendations weretaken intoaccountfor patients in primaryprevention:(a)inpatientswithdiabetes>40years of age,start moderate/high-intensitystatin therapy with-outestimatingSCOREriskcalculator;(b)inpatientswithan LDL-Clevelof190mg/dLorhigher,statintherapyis recom-mended;(c)inadults>40yearsofagewithoutevidenceof CVDor diabeteswithacalculatedSCORE≥1% and<5%for ten-yearfatalCVDandLDL-C≥100mg/dL,startstatin ther-apy;(d)inadults>40yearsofagewithoutevidenceofCVD ordiabeteswithacalculatedSCORE≥5%and<10%for ten-yearfatalCVDandLDL-C≥70mg/dL,startstatintherapy; (e) inadults>40 yearsofagewithout evidenceof CVDor diabeteswithacalculatedSCORE≥10%forten-yearriskof fatalCVD,startstatintherapy.

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Table1 Characteristicsofthepopulation.

Continuousvariables,mean(SD) n=892

Age,years 59.9(16.5)

Systolicbloodpressure,mmHg 127.5(15.9) Diastolicbloodpressure,mmHg 77.9(9.7) Bodymassindex,kg/m2 _28.2_(5.9)

Totalcholesterol,mg/dL 198.3(42.2) LDL-C,mg/dL 123.6(34.2) HDL-C,mg/dL 51.5(14.5) Triglycerides,mg/dL 119.6(70.5) NonHDL-C,mg/dL 146.9(40.5) Bloodglucose,mg/dL 100.8(25.8)

HbA1c,%(patientswithdiabetes) 6.3(1.0)

Creatinine,mg/dL 0.87(0.22) Categoricalvariables(%) Malegender 45.5 Hypertension 54.3 Smoking 24.8 Diabetes 13.9 Obesity 30.9 Psoriaticarthritis 7.0

Continuousdatabetweentwogroupswereanalyzedusing Student’st-testifthevariableswerenormallydistributedor withtheWilcoxon---Mann---Whitneytestotherwise. Categori-caldataanalysiswasperformedusingthechi-squaredtest. Continuous variables aregiven as mean±standard devia-tion,while categoricalvariablesaregivenaspercentages. Theagreementbetweenbothstrategiesinselectingpatients withstatinindicationwasanalyzed,usingtheFleisskappa index.Mildorpoor,acceptableordiscrete,moderate, signif-icant,oralmostperfectagreementwasdeﬁnedifthekappa valuewas<0.20,between0.21and0.40,0.41and0.60,0.61 and0.80,or0.81and1,respectively.Thechi-squaredtest forhomogeneitywasperformedtocomparebetweenkappa values.Avalue ofp<0.05wasconsidered statistically sig-niﬁcant.STATAv.13.0andEPIDATv.3.1softwarepackages wereusedforstatisticalanalysis.

The study was conducted in compliance with the recommendations for medical research contained in the Declaration of Helsinki, the Good Clinical Practice stan-dards,andtheapplicableethicalregulations.

Results

Atotalof892patients(meanage59.9±16.5years,54.5% women) were included in the study. The average body mass index was 28.2±5.9 and the mean HDL-C, triglyc-eride,andtotalcholesterolvalueswere51.5±14.5mg/dL, 119.6±70.5mg/dL, and 198.3±42.2mg/dL, respectively. Importantly,54.3%ofpatientswerehypertensiveand24.8% were active smokers. The baseline characteristics of the populationaredescribedinTable1.

The median 2018 ACC/AHA score and SCORE risk cal-culator valueswere 13.4% (IQR 6.1---27.0%) and 1.9% (IQR 0.4---5.2), respectively. According to the 2018 ACC/AHA score,20.1%,11.0%,32.9%,and36.4%ofthepopulationwas classiﬁedatlow,borderline,moderate,orhighrisk, respec-tively. Applying the SCORE risk calculator, 26.5%, 42.9%,

No statin Diabetes Score 1-5% $ LDL-C 100-190mg/dL Score > 10% LDL-C > 190mg/dL Score 5-10% & LDL-C 70-190mg/dL 39,1 13,3 10,1 20,3 11,7 5,5 45 40 35 30 25 20 15 10 5 0 %

Figure1 Thereasonswhystatintherapywasindicatedusing

the2016EuropeanSocietyofCardiology/EuropeanSocietyof Atherosclerosis(ESC/EAS)guidelines.

No statin

ASCVD score 7.5-20% ASCVD score > 20%

Diabetes LDL-C > 190mg/dL 45 40 35 30 25 20 15 10 5 0 % 39,9 7,3 9,8 21,9 _21,1

2018AmericanCollegeofCardiology/AmericanHeart Associa-tion(ACC/AHA)guidelines.

20.8%,and9.8% ofpatients werestratiﬁedashavinglow, moderate,high,orveryhighrisk,respectively.

Overall,theproportionofsubjectswithstatinindication wassimilarusingbothstrategies(p=0.91).Accordingtothe 2018ACC/AHAguidelinesandbasedontheASCVD calcula-tor,theuseofstatinswasrecommendedin60.1%ofcases. Whenthe2016ESC/EAS guidelineswereappliedusingthe SCOREriskcalculator,statinswererecommendedin60.9%of cases.However,the concordancebetweenboth strategies in selecting patients with statin indication was moderate (Ä=0.46). The reasons why statin therapy was indicated usingbothstrategiesareshowninFigs.1and2.

The patients with statin therapy indication, by both guidelines,showedmorecardiovascular riskfactors anda higherprevalenceofpsoriaticarthritisthansubjects with-outthispharmacologicalindication.Characteristicsofthe population according to the indication of statin therapy recommended by the 2018 ACC/AHA and 2016 ESC/EAS guidelinescanbeseeninTable2.

Intheanalysisaccordingtosex,menhadagreater indica-tionforstatintherapycomparedtowomen(75.9%vs.46.9%,

p<0.001)accordingtothe2018ACC/AHAguidelines.Similar ﬁndingswerefoundwhenapplying2016ESC/ESCguidelines

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Table2 Characteristicsofthepopulationaccordingtotheindicationofstatintherapyrecommendedbythe2018ACC/AHA andthe2016ESC/EASguidelines.

2018ACC/AHAguidelines

Withstatin-indication(n=536) Withoutstatin-indication(n=356) p Continuousvariables,mean(SD)

Age,years 63.7(11.6) 54.3(12.7) <0.001

Systolicbloodpressure,mmHg 131.4(16.2) 121.7(13.7) <0.001

Diastolicbloodpressure,mmHg 79.8(9.7) 75.0(9.1) <0.001

Bodymassindex,kg/m2 _28.9_(6.2) _27.1_(5.6) _0.002

Totalcholesterol,mg/dL 202.1(44.1) 192.7(38.4) 0.001 LDL-C,mg/dL 128.1(35.9) 117.3(30.6) <0.001 HDL-C,mg/dL 49.8(13.8) 54.1(15.1) <0.001 Triglycerides,mg/dL 125.7(67.9) 110.4(73.4) 0.002 NonHDL-C,mg/dL 152.4(42.1) 138.7(36.3) <0.001 Bloodglucose,mg/dL 103.9(29.4) 96.2(18.2) <0.001 Creatinine,mg/dL 0.91(0.26) 0.88(0.26) 0.362 Categoricalvariables(%) Malegender 57.5 27.5 <0.001 Hypertension 66.9 35.1 <0.001 Smoking 29.5 17.7 <0.001 Diabetes 14.9 12.4 0.278 Obesity 37.4 21.4 <0.001 Psoriaticarthritis 8.6 4.5 0.019 2016ESC/EASguidelines

Withstatin-indication(n=536) Withoutstatin-indication(n=356) p Continuousvariables,mean(SD)

Age,years 67.4(12.7) 47.9(14.7) <0.001

Systolicbloodpressure,mmHg 130.7(16.3) 122.5(13.9) <0.001

Diastolicbloodpressure,mmHg 78.7(9.6) 76.6(9.7) 0.002

Bodymassindex,kg/m2 _28.6_(6.1) _27.5_(5.8) _0.074

Totalcholesterol,mg/dL 203.2(42.6) 190.5(40.2) 0.001 LDL-C,mg/dL 129.4(34.3) 115.5(32.4) <0.001 HDL-C,mg/dL 51.5(14.9) 51.3(13.9) 0.865 Triglycerides,mg/dL 124.2(70.8) 112.2(69.5) 0.014 NonHDL-C,mg/dL 151.7(40.7) 139.2(38.8) <0.001 Bloodglucose,mg/dL 105.4(30.6) 93.5(12.2) <0.001 Creatinine,mg/dL 0.91(0.27) 0.87(0.64) 0.341 Categoricalvariables(%) Malegender 50.6 37.4 <0.001 Hypertension 66.2 35.1 <0.001 Smoking 26.7 21.6 0.08 Diabetes 21.9 1.4 <0.001 Obesity 34.3 25.4 <0.001 Psoriasicarthritis 7.9 5.4 0.196

(men67.7%vs.women55.1%,p<0.001).Theapplicationof the2018ACC/AHAguidelinesselectedahigherproportion ofmenwithstatin indicationincomparisonwiththe2016 ESC/ESC guidelines(75.9% vs. 67.7%,p=0.01). Contrarily, theuseofthe2016ESC/ESCguidelinesselectedahigher pro-portionofwomenwithstatinindicationincomparisonwith the2018ACC/AHAguidelines(55.1%vs.46.9%,p=0.005).

The concordance between two strategies in selecting patientswithstatinindicationwasmoderateinbothsexes (men:Ä=0.46,women:Ä=0.42;p=0.29).Thereasonswhy

statin therapy wasindicated using both strategies in the analysisaccordingtosexshowedinFigs.3and4.

Discussion

Psoriasisis achronic inﬂammatoryskin diseaseassociated withincreasedcardiovascularmorbidityandmortality.11,12

Severalmechanismshavebeenproposedtoexplainthe rela-tionshipbetweenpsoriasisandcardiovascularrisk.Indeed,

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No statin LDL-C > 190mg/dL Score 5-10% & LDL-C 70-190mg/dL Diabetes Score 1-5% $ LDL-C 100-190mg/dL Score > 10% 45 50 32,3 21,4 19,3 11,5 11,3 3,5 44,9 9,5 15,5 10,84 12,1 7,9 40 35 30 % 20 25 15 10 5 0 Men Women

the2016EuropeanSocietyofCardiology/EuropeanSocietyof Atherosclerosis(ESC/EAS)guidelinesaccordingtosex.

No statin

ASCVD score 7.5-20% ASCVD score > 20%

Diabetes LDL-C > 190mg/dL 60 50 40 30 20 10 0 24,1 37,2 9,4 10,8 18,5 53,1 23,3 8,9 9,3 5,6 Men Women %

the2018AmericanCollegeofCardiology/AmericanHeart Asso-ciation(ACC/AHA)guidelinesaccordingtosex.

patients with psoriasis have an increased prevalence of classiccardiovascularriskfactors,includingobesity, hyper-tension,diabetes, dyslipidemia, metabolicsyndrome, and nonalcoholicfattyliverdisease.13---16_However,_psoriasis_may

provide anadditional andindependentcardiovascularrisk factor,mostlikelybecauseseveralcytokines(tumor necro-sis factor-alpha, interferon, interleukin-17, interleukin-6) released by skin lesions can directly favor the develop-ment and progression of atherosclerosis.17 _Likewise, _the

risk of CVDs is increased in chronic inﬂammatory disor-ders,withevidencethatriskisassociatedwithseverityof inﬂammation.18

The SCORErisk calculatorisrecommendedforCVDrisk predictioninthegeneralpopulationbytheESC/EAS guide-lines. However,CVD risk prediction modelsdeveloped for thegeneralpopulation donotincludenon-traditionalCVD risk factors. If these models are appliedin patients with psoriasis,thereisapossibilityofunderestimatingtheCVD risk.

In addition to appropriate cardiovascular risk manage-ment, some authors believe that the risk score models

shouldbeadaptedforpatientswithpsoriasisbyintroducing amultiplicationfactorthattakesintoaccountthepresence ofpsoriasis.9

Other authors establish that psoriasis is a ‘‘risk enhancer’’thatcanbeusedtofavorinitiationor intensiﬁca-tionofstatintherapy,particularlyinstratiﬁedpatientswith intermediaterisk.Thisstrategy,basedontheASCVD calcu-lator,isrecommendedbythenew2018ACC/AHAguidelines forcholesterolmanagementanddoesnotcontemplateany multiplicationoradjustmentfactor.10

In the present study, when it was applied the 2018 ACC/AHAguidelines,themajorityofpatientswereclassified asintermediateorhighrisk.However,whenitwasapplied the2016ECS/EASguidelines,themajorityofpatientswith psoriasiswerestratifiedasintermediaterisk.Thesefinding coincideswithacross-sectionalstudy of234patientswith psoriasisthatshowedthatthecardiovascularriskestimated bytheFraminghamscorewasonaverage11.2% (intermedi-aterisk).19_Similarly,_a_study_that_analyzed₃₉₅_patients_with

psoriasisshowed that the proportionof patients at inter-mediateandhigh risk of suffering a majorcardiovascular eventinthe nexttenyearswas30.5%and11.4%, respec-tively,basedontheFraminghamriskscore.7_Another_study

conductedinBrazilinvolvingtheassessmentof190patients withpsoriasisshowedthat47%hadmoderateorhighriskof fatalandnon-fatalcoronaryeventsintenyears.20

The main ﬁnding of the study was that by using two different strategies of cardiovascular prevention for the managementof patients with psoriasis, theproportion of eligible patients for statin therapy was similar (close to 60%). However,the concordance between both strategies inselecting patientswithstatin indicationwasmoderate, indicating that individually, some subjects had different indicationsaccordingtotheguidelineused.

Theseﬁndingsdifferfromanotherstudythatevaluated patientswithrheumatoidarthritis.Tournadreetal. calcu-latedtheproportionofpatientseligibleforstatinsaccording toESC guidelines,the Adult Treatment PanelIII, and the ACC/AHA in a French cohort of statin-naïve rheumatoid arthritispatients at least 40 years of age. A marked dis-cordanceinriskassessmentandcholesteroltreatmentwas observedbetween the threesetsof guidelines.21 _The

dif-ferencewith thepresent work could beexplainedby the populationsstudied,plusthefactthatamultiplication fac-torwasusedinthisstudy.

Severalpublications showed thatmen morefrequently receivean indication of statin therapy thanwomen when analyzingthegeneralpopulation.22,23 _Regarding_this_topic,

butanalyzingonlypatientswithpsoriasis,thepresentstudy showedthattheproportionofsubjectswithanindicationfor statintherapywashigherinmenthanwomen,regardlessof thechosenstrategy.

Todeterminewhetherapatientisacandidateforstatin therapy,clinicians must ﬁrst determine the patient’s risk ofhaving a futureCVD event.However,clinicians’ ability to accurately identify a patient’s true risk is imperfect, becausethecurrentlyavailable risk estimationtools have been shown to underestimate the risk in patients with chronicinﬂammatorydiseases.6,24,25_{Consequently,}_the

cur-rentmethodsofcardiovascularriskassessmentinthecourse ofchronicinﬂammatorydiseasesareasubjectof consider-ablecontroversy.

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Inthepresentstudy,themainreasonfortheindication ofstatintreatmentwastheintermediatecardiovascularrisk calculatedwiththescoringmethod.Inaddition,thisfinding wasobservedwhenusingbothstrategiesandinbothsexes. Thesefindingsreinforcetheimportanceofusingtoolsforthe stratificationofcardiovascularrisk,despiteitslimitations.

Accordingtotheresultsofthisstudy,theauthorsbelieve thatnot allpatients withpsoriasisshould receive statins. European andNorth Americanstrategies,analyzed in this study,agreethat patientsin primarypreventionwith dia-betes and/or a level of LDL-C>190mg/dL should receive statins, whether they have psoriasis or not. The other group of patients, who arecandidates for statins,should bedeﬁnedaccordingtotheestimatedcardiovascularrisk. EuropeansguidelinesuseSCOREandadjustthevaluebya correctionfactor.AmericansguidelinesusetheASCVD cal-culatoranddonotuseanadjustmentfactor.Bothstrategies willrecommendgivingstatinstopatientsatintermediateor highrisk.

In synthesis, every psoriatic patient with a very high cholesterol value, diabetes, or an intermediate/high risk shouldreceivestatins.Takingintoaccountthatpatientswith psoriasishaveahighercardiovascularriskindependentlyof thepresenceofconventionalriskfactors,itwouldbe advis-abletoapplyacorrectionfactortothecardiovascularrisk scorecalculatedastheEuropeansrecommendationsdo.

This study had some limitations. It was a secondary databasestudy(electronicmedicalrecords);consequently, therecouldbeinformationbias.Furthermore,thedataon the severity of psoriasis and pharmacological treatments couldnot bereliably obtainedretrospectively; therefore, thisdatacouldnotbeincludedintheanalysis.Despiteits limitations, thisstudy represents a valuablecontribution, asalargegroupofpatientswithpsoriasisbutwithoutCVD was examined. Research for risk factors and proper risk stratiﬁcationarerareinpatientswithpsoriasis.Knowledge oftheapplication ofdifferentstrategiesincardiovascular preventioncouldfavorthedifﬁculttaskofestimating car-diovascularriskinthisparticulargroupofpatients.

Conclusion

Thisstudy’sﬁndingsshowedthatnotallpatientswith pso-riasisshouldreceive statins.Thepopulation withpsoriasis without CVD wasmostly classiﬁed at moderate---highrisk, andthestatintherapyindicationwassimilarwhenapplying thetwostrategiesevaluated.

Financial

support

Nonedeclared.

Author’s

contribution

Walter Masson: Statistical analysis; approval of the ﬁnal versionofthemanuscript;conceptionandplanningofthe study; elaboration andwriting of themanuscript; obtain-ing,analyzingandinterpretingthedata;criticalreviewof theliterature;criticalreviewofthemanuscript.

MartínLobo:Statisticalanalysis;approvaloftheﬁnal ver-sionofthemanuscript;obtaining,analyzingandinterpreting thedata.

Graciela Molinero:Approval of the ﬁnal version of the manuscript; conception andplanning of the study; elabo-rationandwritingofthemanuscript;criticalreviewofthe manuscript.

EmilianoRossi:Statisticalanalysis;approvaloftheﬁnal version of the manuscript;elaboration and writing of the manuscript;obtaining,analyzingandinterpretingthedata; criticalreviewoftheliterature.

Conﬂicts

of

interest

Nonedeclared.

References

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