The use of biologic therapy has increased over the past decade well beyond primary autoimmune diseases. Indeed, a recent trial using an anti-IL-1beta antibody reduced second myocardial infarction (MI) in those who have had MI. Psoriasis is a chronic inflammatory disease often treated with biologics when severe, is associated with increased risk of MI, in part driven by high-risk coronary plaque phenotypes by coronary computed tomography angiography (CCTA). We hypothesized that we would observe a reduction in inflammatory-driven phenotypes of coronary plaque, including non-calcified coronary plaque burden and lipid-rich necrotic core in those treated with biologic therapy after one-year compared with non-biologic therapy.

IMPORTANCE Psoriasis is a chronic inflammatory skin disease associated with increased coronary plaque burden and cardiovascular events. Biologic therapy for psoriasis has been found to be favorably associated with luminal coronary plaque, but it is unclear whether these associations are attributable to direct anti-inflammatory effects on the coronary arteries. OBJECTIVE To investigate the association of biologic therapy with coronary inflammation in patients with psoriasis using the perivascular fat attenuation index (FAI), a novel imaging biomarker that assesses coronary inflammation by mapping spatial changes of perivascular fat composition via coronary computed tomography angiography (CCTA). DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study performed from January 1, 2013, through March 31, 2019, analyzed changes in FAI in patients with moderate to severe psoriasis who underwent CCTA at baseline and at 1 year and were not receiving biologic psoriasis therapy at baseline. EXPOSURES Biologic therapy for psoriasis. MAIN OUTCOMES AND MEASURES Perivascular FAI mapping was performed based on an established method by a reader blinded to patient demographics, visit, and treatment status. RESULTS Of the 134 patients (mean [SD] age, 51.1 [12.1] years; 84 [62.5%] male), most had low cardiovascular risk by traditional risk scores (median 10-year Framingham Risk Score, 3% [interquartile range, 1%-7%]) and moderate to severe skin disease. Of these patients, 82 received biologic psoriasis therapy (anti-tumor necrosis factor α, anti-interleukin [IL] 12/23, or anti-IL-17) for 1 year, and 52 did not receive any biologic therapy and were given topical or light therapy (control group). At baseline, 46 patients (27 in the treated group and 19 in the untreated group) had a focal coronary atherosclerotic plaque. Biologic therapy was associated with a significant decrease in FAI at 1 year (median FAI −71.22 HU [interquartile range (IQR), −75.85 to −68.

Visual Abstract

Rationale: Psoriasis (PSO) is a systemic inflammatory skin disease associated with cardiovascular disease (CVD) and lipid dysfunction. However, traditional lipid parameters have limited prognostic value whereas assessing oxidation-modified lipids (OMLs) in this inflammatory driven condition may capture additional risk. Recently, a study showed that PSO was associated with increased lipid rich coronary plaques, therefore, investigating potential relationships with OMLs may speed understanding of increased CVD in PSO. Objective: To understand whether OMLs associate with traditional lipid phenotypes, cardiometabolic disease biomarkers and total coronary plaque, with focus on non-calcified burden (NCB) by CCTA in psoriasis. Methods and Results: PSO subjects and controls (n=252) had profiling for oxidation-modified LDL, HDL, Lp(a), cholesterol efflux capacity (CEC), lipoprotein particle size and number by NMR spectroscopy and paraoxonase (PON1) activity. Blinded CCTA coronary artery disease characterization included total burden (TB), NCB and dense-calcified burden (DCB). Compared to healthy volunteers (HV), PSO subjects were older (mean age=50.1), had increased BMI and HOMA-IR. PSO subjects had increase in oxLp(a), Lp(a) and oxHDL (p<0.05 for all) with significant association of oxLDL (β=0.10, p=0.020) and oxHDL (β=−0.11, p=0.007) with NCB. Moreover, PSO subjects expressed significantly higher PON1 (kU/μl) activity compared to HV (8.55 ± 3.21 vs. 6.24 ± 3.82, p=0.01). Finally, PSO treatment was associated with a reduction in oxHDL (U/ml) (203.79 ± 88.40 vs. 116.36 ± 85.03, p<0.001) and with a concomitant decrease in NCB at one year (1.04 ± 0.44 vs. 0.95 ± 0.32, p=0.03). Conclusions: Traditional lipids did not capture risk of lipid rich plaque as assessed by NCB, whereas assaying oxidation-modification of lipids revealed significant association with oxLDL and oxHDL. The PON-1 activity was increased in PSO suggesting possible compensatory anti-oxidative effect. Psoriasis treatment was associated with a reduction in oxHDL. These findings support performance of larger studies to understand oxidation-modified lipids in inflammatory states.

and received payment for continuing medical education work related to psoriasis that was supported indirectly by Lilly and Ortho Dermatologics. 3.Dr. Tawakol reports grants from Genentech and Actelion for research outside the submitted work. 4.Dr. Powell-Wiley has received funding from the National Institutes of Health Intramural Research Program (ZIA HL006168).

Background: Lipid-rich necrotic core (LRNC), a high-risk coronary plaque feature assessed by coronary computed tomography angiography, is associated with increased risk of future cardiovascular events in patients with subclinical, nonobstructive coronary artery disease. Psoriasis is a chronic inflammatory condition that is associated with increased prevalence of high-risk coronary plaque and risk of cardiovascular events. This study characterized LRNC in psoriasis and how LRNC modulates in response to biologic therapy. Methods: Consecutive biologic naïve psoriasis patients (n=209) underwent coronary computed tomography angiography at baseline and 1-year to assess changes in LRNC using a novel histopathologically validated software (vascuCAP Elucid Bioimaging, Boston, MA) before and after biologic therapy over 1 year. Results: Study participants were middle-aged, predominantly male with similar cardiometabolic and psoriasis status between treatment groups. In all participants at baseline, LRNC was associated with Framingham risk score (β [standardized β]=0.12 [95% CI, 0.00–0.15]; P =0.045), and psoriasis severity (β=0.13 [95% CI, 0.01–0.26]; P =0.029). At 1-year, participants receiving biologic therapy had a reduction in LRNC (mm 2 ; 3.12 [1.99–4.66] versus 2.97 [1.84–4.35]; P =0.028), while those who did not receive biologic therapy over 1 year demonstrated no significant change with nominally higher LRNC (3.12 [1.82–4.60] versus 3.34 [2.04–4.74]; P =0.06). The change in LRNC was significant compared with that of the nonbiologic treated group (ΔLRNC, −0.22 mm 2 versus 0.14 mm 2 , P =0.004) and remained significant after adjusting for cardiovascular risk factors and psoriasis severity (β=−0.09 [95% CI, −0.01 to −0.18]; P =0.033). Conclusions: LRNC was associated with psoriasis severity and cardiovascular risk factors in psoriasis. Additionally, there was favorable modification of LRNC in those on biologic therapy. This study provides evidence of potential reduction in LRNC with treatment of systemic inflammation. Larger, longer follow-up prospective studies should be conducted to understand how changes in LRNC may translate into a reduction in future cardiovascular events in psoriasis.

Aortic VI is associated with broad CAD indices, suggesting that aortic VI may be a surrogate for early CAD. Larger prospective studies need to assess these associations longitudinally and examine treatment effects on these outcomes.

No abstract