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Original Investigation |

Association Between Changes in Coronary Artery Disease Progression and Treatment With Biologic Agents for Severe Psoriasis ONLINE FIRST

Kasper Fjellhaugen Hjuler, MD1; Morten Bøttcher, MD, PhD2; Christian Vestergaard, MD, PhD, DMSc1; Hans Erik Bøtker, MD, PhD3; Lars Iversen, MD, DMSc1; Knud Kragballe, MD, DMSc1
[+] Author Affiliations
1Department of Dermatology, Aarhus University Hospital, Aarhus, Denmark
2Department of Internal Medicine, Cardiac Imaging Center, Hospital Unit West, Herning, Denmark
3Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
JAMA Dermatol. Published online July 07, 2016. doi:10.1001/jamadermatol.2016.1984
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Importance  Inflammatory pathways of psoriasis share similarities with the mechanisms identified in atherosclerosis, and the association between psoriasis and cardiovascular disease due to accelerated coronary artery disease is well established. The effect of anti-inflammatory drugs on the development of coronary atherosclerosis remains essentially unknown.

Objective  To investigate the association of biological therapy with changes in coronary artery disease progression, measured by repeated coronary computed tomography (CT).

Design, Setting, and Participants  This single-center prospective, controlled, observer-blinded clinical study at a tertiary dermatology university hospital clinic enrolled patients with severe psoriasis initiating biological therapy and matched controls not receiving systemic therapy from April 11, 2011, through June 30, 2014.

Interventions  Biological therapy approved for psoriasis (adalimumab, etanercept, infliximab, ustekinumab) with the possibility to switch between treatments to ensure tight control of inflammation.

Main Outcomes and Measures  Patients underwent noncontrast coronary artery calcium (CAC) CT and contrast-enhanced coronary CT angiography at baseline and after 13 months of follow-up. Changes in CAC score, number of coronary plaques, severity of narrowing, composition, and vessel wall volume were measured.

Results  There were 28 treated patients (mean [SD] age, 49.2 [10.2] years; 71% men; mean [SD] Psoriasis Area Severity Index [PASI], 15.4 [4.3]) and 28 controls (mean [SD] age, 52.8 [10.6] years; 71% men; mean [SD] PASI, 12.4 [3.9]). The CAC scores remained stable in the intervention group (mean [SD] yearly CAC change, −16 [56]; P = .15) and progressed in the control group (14 [29]; P = .02) (intervention vs controls: P = .02). The number of segments with luminal abnormalities remained unchanged in both groups. The severity of luminal narrowing in the diseased segments was unchanged in the intervention group (Wilcoxon W = 76, n = 483, P = .39) but increased at follow-up in the control group (Wilcoxon W = 281, n = 414, P = .02). Automated vessel wall volume index remained unchanged from baseline to follow-up in the intervention group (mean [SD] baseline, 7.1 [1.5], follow-up, 7.1 [1.7]; P = .91), while controls demonstrated statistically nonsignificant progression (baseline, 8.3 [1.6], follow-up, 8.9 [2.2]; P = .06).

Conclusions and Relevance  Clinically effective treatment with biologic agents was associated with reduced coronary artery disease progression in patients with severe psoriasis. These findings support a beneficial effect of biologic anti-inflammatory agents in preventing cardiovascular disease progression in addition to disease control in inflammatory diseases.

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Figure 1.
Psoriasis Area Severity Index (PASI) During Treatment With Biological Agents

Disease control was generally tight, with switch in biologic treatment when less than a 50% reduction in PASI was obtained or in case of adverse events. Symbols represent individual patients, and lines connect paired observations for each patient.

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Figure 2.
Coronary Artery Calcium Scores at Baseline and Follow-up

The progression of coronary calcium scores from baseline to follow-up in both groups is shown. Results of repeated-measures statistics and between-group statistics are shown. Symbols represent individual patients, and lines connect paired observations for each patient.

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Figure 3.
Number of Segments With Luminal Abnormalities and Severity of Abnormalities at Baseline and Follow-up

A, Number of segments with luminal narrowing on a patient level at baseline and at follow-up. Lines symbolize a change in the number of segments with abnormalities for 1 or more patients. B, Severity of the luminal narrowing for all analyzable segments on an ordinal scale. Symbols represent individual segments, and lines represent the change in severity of luminal narrowing for 1 or more segments.

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