It can take a lot to manage psoriatic arthritis (PsA), an inflammatory disease of the joints that tends to occur in people with psoriasis, an inflammatory disease that affects the skin. (Psoriatic arthritis can sometimes affect people without psoriasis, however.)
Because you may be spending your time and energy managing the daily symptoms of PsA, such as joint stiffness, pain, and swelling, as well as fatigue, you may not always think about how the disease impacts other systems of your body — notably your heart. Your doctor might not be talking to you about it either, and that’s why it’s time to get the link between psoriatic arthritis and cardiovascular risk on your radar.
Rekha Mankad, MD, a cardiologist with the Cardio-Rheumatology Clinic at the Mayo Clinic in Rochester, Minnesota, points out that much of the existing research on the connection between rheumatological diseases and heart disease has been done in the rheumatoid arthritis and psoriasis population, although PsA-specific evidence is starting to mount.
Researchers discovered that having psoriatic arthritis means that your risk of cardiovascular disease is as much as 43 percent higher than that of people without PsA, according to a 2016 study in the journal Arthritis Care & Research that looked at the combined data on 32,973 patients with psoriatic arthritis from 11 studies.
The findings, the researchers wrote, support the idea that psoriatic arthritis is an independent risk factor for cardiovascular disease.
Researchers also found that certain symptoms of PsA — namely, sacroiliitis, or inflammation of the sacroiliac joints that connect the spine and pelvis — can increase the chance of a person with PsA having a cardiovascular event. A study published in the journal Arthritis Research and Therapy found that people with psoriatic arthritis who had inflammation of the sacroiliac joints had more aortic inflammation (aortitis) that those without the symptom. Aortitis is a precursor to cardiovascular disease.
The Link Between PsA and Heart Disease
Both PsA and heart disease are inflammatory conditions. Inflammation from the immune system’s overactivity triggers a body-wide response that affects not just the joints and skin, but also the cardiovascular system.
‘Traditional’ heart disease risk factors
In addition to underlying inflammation, people with psoriatic arthritis also tend to be more likely to have other known heart disease risk factors, such as obesity and type 2 diabetes.
A 2019 study in the journal Clinical Rheumatology of more than 3,000 participants found that people with PsA are more likely to have obesity, hyperlipidemia, hypertension, and type 2 diabetes. The majority of these heart disease risk factors are more prevalent in people with PsA than in those with RA or psoriasis alone.
One 2015 study in the Journal of Rheumatology found that metabolic syndrome — a group of cardiovascular disease risk factors that often “travel” together — was highly prevalent in people with PsA. Out of 283 people with psoriatic arthritis, 44 percent had metabolic syndrome, which means people have at least three of five criteria:
- High blood pressure
- High blood sugar
- High triglyceride levels
- High cholesterol levels
- Waist circumference greater than 40 inches in men and greater than 35 inches women
People with more severe psoriatic arthritis (as well as people who smoked) were more likely to have metabolic syndrome.
Blood vessel damage
“To develop heart disease, a couple things have to happen: You need to have high cholesterol, but you also need to have damage to the endothelium, which are the cells lining blood vessels,” says Michael S. Garshick, MD, the director of the Cardio-Rheumatology Program at NYU Langone Health in New York City.
One study in the journal Arthritis and Rheumatism showed endothelial cell dysfunction in people with PsA, despite their not having a previous diagnosis of coronary artery disease nor cardiovascular risk factors. This blood vessel damage plays a key role in atherosclerosis, in which fats and cholesterol clog the blood vessels, which reduces blood flow and contributes to the development of heart attack or stroke.
Atherosclerosis (clogged arteries)
Studies have found higher incidence of plaque buildup in the carotid arteries (the major blood vessels in the neck that supply blood to the brain) in people with psoriasis and PsA compared to healthy adults. And psoriatic arthritis patients may have a greater risk than those with only psoriasis.
In fact, a 2013 study in the journal Annals of the Rheumatic Diseases found that psoriatic arthritis patients have more severe “subclinical” (meaning, without symptoms) atherosclerosis than people with skin psoriasis alone. Worse plaque was linked with people who had a longer duration of PsA, worse skin disease, and higher inflammatory markers.
Research also shows that patients with psoriasis are more likely to have high cholesterol, particularly those with severe disease. And the risk appears to go both ways. Other evidence has found that high cholesterol is associated with a 68 percent increased risk of PsA. One reason is that artery-damaging inflammation makes it more likely for cholesterol deposits to develop.
Other metabolic abnormalities
In addition to cholesterol, other types of fats and metabolic molecules circulate in the bloodstream. Some preliminary research suggests that there are distinct differences in the types and levels of these molecules between people with psoriatic disease and healthy people — and that their presence may be able to better predict someone’s risk of developing clogged arteries than traditional cardiovascular risk factors alone.
While these aren’t part of routine blood tests yet, in the future, psoriatic patients may be able to get more advanced blood testing to assess their cardiovascular risk based on whether they have higher levels of these different metabolic biomarkers in their blood.
Increased risk of gout/high uric acid levels
There is also a clear link between cardiovascular disease and gout, another type of arthritis. Gout causes an excessive amount of uric acid build up (also called hyperuricemia) in your blood, which causes inflammation and joint pain. At the 2019 American College of Rheumatology annual meeting, researchers revealed that people with PsA have a prevalence of hyperuricemia that is three times greater than those without the condition. This prolonged exposure to high levels of uric acid in the blood can interfere with endothelial dysfunction as well as structural changes in the heart (called atrial and ventricular remodeling), which is associated with congestive heart failure.
Mental health issues
Mental health plays a role in the link between psoriatic arthritis and heart disease. People with PsA are at an increased risk for depression and anxiety, which are also linked to heart disease. If left unchecked, these mental health conditions can also lead to unhealthy behaviors — such as smoking, drinking, physical inactivity, and overeating — that can further increase your heart disease risk.
Signs of Heart Disease PsA Patients Need to Know
In general, someone with PsA who has heart disease would experience similar symptoms as someone in the general population, says Dr. Mankad. It’s not just a chest-clutching heart attack to look out for, though. “Not everyone has classic chest pain,” she says. Symptoms of heart disease may include:
- Chest pressure, tightness, or discomfort
- Shortness of breath
- Pain in the neck, throat, or jaw
- Pain in the upper abdomen or back
- Pain, numbness, weakness, or coldness in legs and arms
- Indigestion, heartburn, or stomach pain
- Feeling dizzy or lightheaded
- Excessive sweating
People may not always pay close attention to these symptoms, because they can be vague or people may assume they’re related to their psoriatic arthritis. “The problem is that any symptoms get attributed to your PsA. Patients may think that a pain in the chest is related to the arthritis,” says Dr. Mankad.
As such, patients may be more likely to delay seeking help, particularly if they are not aware of the link between PsA and heart disease.
Sometimes heart disease symptoms are silent or so subtle that people are not aware of them. Many people are tuned into a heart problem when they exercise or exert themselves in some way and are hit with chest tightness or pressure. “If you’re not exerting yourself as much because your joints hurt, you may not be doing enough to bring on these symptoms,” Dr. Mankad says. You may not realize something is wrong until later.
Screening for Heart Disease in Psoriatic Arthritis
Sometimes there is just so much to talk about at your visit with your rheumatologist or dermatologist that discussing the possibility of future heart disease risk may not take top priority. Still, when it comes to prevention, one of the most important things you can do is have this conversation with your doctor and ask about the steps you can take to improve your heart health.
Understand your risk factors
Many patients have untreated or unrecognized traditional heart disease risk factors, says Dr. Garshick — and these may affect people with PsA sooner than people without an underlying inflammatory condition.
“We have to understand that some of these risk factors that we think would cause heart disease 10 years down the line, may cause it five years sooner,” says Dr. Garshick.
Often, it’s a matter of paying more attention to them, adds Dr. Mankad. “Patients are so focused on the PsA symptoms they see in front of them, everything else goes underrecognized,” she says.
A few risk factors to consider:
- Do you have high blood pressure?
- Do you have type 2 diabetes?
- Do you have high cholesterol?
- Do you smoke?
- Are you overweight?
- Are you inactive?
Ask about regular screening tests
Unfortunately, traditional cardiovascular risk scores like the Framingham Risk Score (FRS) underestimate the risk of heart disease in people with psoriatic arthritis because they do not account for systemic inflammation, according to research shared in a special Journal of Rheumatology report called “Cardiovascular Diseases in Psoriasis and Psoriatic Arthritis.”
The FRS estimates a 10-year risk of cardiovascular disease using an algorithm that takes into account traditional risk factors like age, cholesterol, hypertension, smoking, and diabetes as well as coronary disease, cerebrovascular disease, peripheral artery disease, and heart failure.
Last year, rheumatic inflammatory diseases, including PsA, were added as a “risk enhancer” to the general scoring system recommended by the American College of Cardiology and American Heart Association. In new guidelines on preventing heart disease, the ACC/AHA advises doctors to “use additional risk-enhancing factors [like having an inflammatory disease like PsA] to guide decisions about preventive interventions for borderline- or intermediate-risk adults” after their risk score is calculated.
Dr. Mankad hopes this change will encourage more doctors to prescribe cholesterol-lowering medication sooner to people with psoriatic arthritis.
For now, your best bet is to be proactive and request that your rheumatologist or primary care physician gives you the following screenings recommended by the American Heart Association to better identify and control your risk factors:
- Blood pressure
- Fasting lipoprotein profile (cholesterol)
- Body weight/BMI
- Waist circumference
- Blood glucose
Does Treating/Controlling PsA Reduce Heart Disease Risk?
It makes sense that treating your psoriatic arthritis to keep heart-damaging inflammation at bay would reduce heart disease risk, although researchers are continuing to study this very question.
One observational study published this year in the journal Cardiovascular Research looked at 215 psoriasis patients with low cardiovascular risk. Some were on a biologic, while others opted not to be. After a year of follow-up, those who were on biologic treatment were found to have a 6 percent reduction in arterial plaque, likely because of a reduction in underlying inflammation.
“We do think treating a psoriatic condition will reduce the risk of heart disease, but we don’t know that yet,” says Dr. Garshick. “However, there are multiple other reasons to treat your PsA.”
That said, just because your PsA may be well controlled — say, in terms of minimal flares — does not mean you can assume everything is fine regarding your heart health. You still should be assessed for additional heart disease risk factors and practice healthy preventive lifestyle habits, he says.
Talk to Your Doctor About Your PsA Medication Choices
Make sure your doctor factors your heart health when creating your treatment plan. Certain medications used to treat PsA have been shown in studies to reduce heart disease risk, while others are known to increase it.
Steroids, for example, can raise cholesterol levels and make your body less sensitive to insulin, both of which contribute to cardiovascular risk. That is partly why rheumatologists use these medications carefully in people with PsA. Another reason is that the drugs can cause a flare of skin psoriasis.
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, for pain relief can increase risk of cardiovascular problems like blood clots and heart failure, according to a 2015 analysis by the FDA.
Many biologics and disease-modifying antirheumatic drugs (DMARDs), on the other hand, have been found to not only ease joint pain but also protect your heart.
A 2015 study published in the Journal of Drugs in Dermatology examined the health recorders of 8,845 people with psoriatic disease, with 1,673 of the participants taking TNF inhibitor biologics. Researchers found that people with psoriatic arthritis who took TNF inhibitors had lower incidence of plaque build-up and lower erythrocyte sedimentation rate (ESR) and C-reactive protein levels, which are levels of systemic inflammation.
A 2019 study published in the journal Arthritis & Rheumatology of PsA patients with metabolic disorder found that participants who took apremilast (Otezla) twice daily for six months had lower insulin resistance, inflammation, and endothelial dysfunction — good news for your joints and your heart.
How to Reduce Your Heart Disease Risk When You Have Psoriatic Arthritis
Here are more lifestyle changes you can make to reduce your risk of heart disease and manage your psoriatic arthritis:
Eat a plant-based diet
A Mediterranean diet (rich in legumes, vegetables, and whole grains, some fish, less red meat) is the ideal eating pattern for lowering inflammation, says Dr. Mankad. Here’s more on what a healthy diet for psoriatic arthritis looks like.
Fatty fish like salmon and mackerel are loaded with anti-inflammatory omega-3 fatty acids, which may protect people with psoriatic arthritis against heart disease, according to a 2016 study published in the journal Lipids in Health and Disease. If you’re not a fan of seafood, fish oil supplements may be good alternative. It’s important to ask your doctor about the right dosage of fish oil for you, however, because higher doses can interact with certain medications, including drugs taken to control blood pressure.
Watch your sugar intake
Sugar is not so sweet for your joints — or your heart. “Sugar is an inflammatory agent, so cutting back seems to help,” says Dr. Mankad. Here is more information on how to cut out sugar from your diet.
One of the common issues psoriatic arthritis patients express to Dr. Mankad is that they know exercise is good for them, but joint pain and stiffness makes this tough. “My advice is to pick the exercise that works with the joint that’s not bothering you at the time,” she says. For instance, if your knees are bothering you, focus on upper body exercises. If your wrists are in pain, do more walking.
Numerous studies have confirmed that excess weight can increase your risk of developing PsA as well as make it more difficult to manage the condition once you’ve been diagnosed. Having a higher body mass index (BMI) increases disease activity and PsA-related disability and may even interfere with the effectiveness of your medication.
In one study published in 2019 in the journal Arthritis Research & Therapy, PsA patients followed on an extremely low-calorie diet for 12 to 16 weeks (they stayed on their current medications to manage their disease). At the end of the study, they had lost about 18 percent of their body weight. They also reported an improvement in joint tenderness and swelling and general pain and fatigue.
However, focusing on the number on the scale may not be necessary. “Even if we don’t see weight loss, there’s often cardiometabolic improvements to following a healthy diet and good exercise habits,” says Dr. Garshick. Focusing on those can help you stay motivated to eat right and stay moving.
Ask about medication to control your cholesterol, blood pressure, and blood sugar
Depending on your risk factors and medical history, you may benefit from taking heart medications (such as drugs to lower cholesterol or blood pressure) sooner than people without psoriatic arthritis. Talk to your doctor about what kind of medication you can take to keep your numbers (such as blood pressure, cholesterol, and blood sugar) in a heart-healthy range.
Statins, for example, work in the liver to lower cholesterol by blocking a liver enzyme that produces cholesterol. They also have strong anti-inflammatory properties. Yet the use of aspirin and statins among people with PsA is underutilized, according to a 2018 study published in the journal Arthritis & Rheumatology.
Bottom line: Talk to your doctor about what you can do to take care of your heart today. “PsA doesn’t go away. It’s a chronic condition. Throughout your lifetime, make sure that you’re on top of these other health factors. We can treat PsA, but that doesn’t mean we shouldn’t recognize the behind-the-scenes things that are happening,” says Dr. Mankad.
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Interview with Michael S. Garshick, MD, director of the Cardio-Rheumatology Program at NYU Langone Health in New York City
Interview with Rekha Mankad, MD, a cardiologist with the Cardio-Rheumatology Clinic at the Mayo Clinic in Rochester, Minnesota
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