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      Cardiovascular findings in patients with psoriasis

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          To the Editor: Psoriasis is a common, genetically determined, inflammatory and proliferative disease of the skin. The etiology of psoriasis has not exactly been determined.1 Besides atypical psoriasis, other forms have been observed, including forms with systemic sympthoms, associations with some skin disorders, gout, hypocalcaemia, intestinal disease and malabsorption, anterior uveitis, myopathia and cardiovascular disorders.1–4 Variations in lipid metabolism, diabetes mellitus, renal failure and malignancies may be associated with psoriasis.3,5–7 An increased incidence of occlusive vascular disease has been reported in psoriatic patients in retrospective studies. Because associations between psoriasis and cardiovascular disorders have been seen so often, we aimed to investigate cardiovascular findings in psoriatic patients. Thirty-six patients with histopatologically proven psoriasis, 21 female and 15 male, aged 13–77 years, applied to the dermatology outpatient clinic of Celal Bayar University and were enrolled in our study. Psoriasis area and severity index (PASI) values were calculated for all patients. Informed consent was obtained from each patient. Complete blood count (CBC), erythrocyte sedimentation rate (ESR), biochemical analysis, lipid levels, chest radiography, electrocardiography, echocardiography and exercise electrocardiography (according to the Bruce protocol) were performed on the patients. Diastolic and systolic functions were examined with echocardiography. For diastolic functions peak early (E) wave velosity, peak atrial (A) wave velosity, E/A ratios, E wave deceleration time (EDT) and isovolemic relaxation time (IVRT) were calculated. For systolic functions, end-systolic and end-diastolic volumes were calculated and then EF (ejection fraction) was determined. Ischemic findings were examined with electrocardiography and exercise electrocardiography. All tests were applied to the 20 volunteers in the control group and the results were compared with the patient group. Data obtained from the patient and control groups were analyzed by SPSS for Windows. In the statistical analyses, Fisher’s exact test and Student’s t test were used. The mean age of psoriatic patients was 44.7 (±14.9) years and the median value was 46.5 years. Duration of disease varied from 1–35 years. The range of PASI values were 0.7–23.6. Laboratory findings revealed anemia in three patients (8.3%), high ESR, tricgylceride (TG), cholesterol and low density lipoprotein (LDL) levels in 4 (11.1%), 5 (13.9%), 14 (38.9%) and 14 (38.9%) patients, respectively. High density lipoprotein (HDL) levels were found to be low in 7 (19.4%) psoriatic patients. There was no anemia in the control group. ESR was high in 5% of cases, whereas high levels were also observed in TG (5%), cholesterol (35%), and LDL (35%). HDL levels were normal in all control cases. Chest radiograms were normal for both groups. Electrocardiographies were pathologic in three patients. One of them had P pulmonale and early repolarization at precordial derivations; the second had a 2 mm Q-wave at DII, DIII and aVF; the third had negativity of T at DI, aVL, V5–6 and an intraventriculary conduction disorder. In the control group, electrocardiography was pathologic in one person. He had an absence of R at V1–2 and rS at DIII and aVF. EF values and systolic functions with echocardiography were normal for all cases. Diastolic dysfunction was determined in 15 (41.7%) patients, but in the control group it was seen in 5 (25%) persons. Ischemia was not seen in the electrocardiography and exercise tests in the patient group, but it was seen in one case (5%) in the control group. In the patient group, exercise times ranged between 2.34 and 14.59 minutes. Mean exercise time (MET) values were calculated for determining exercise performance. MET values varied from 4.6 to 17.2 minutes in the patient group and were normal in all patients. MET values were also normal in control cases. Both cardiac and exercise capacities were adequate in all cases. A hypertensive answer to exercise was seen in 4 (11.1%) psoriatic patients, but only in 1 (5%) control case. Psoriasis is a disorder that is characterized by abnormal proliferation and regeneration of keratinocytes, acute and chronic inflamation and microangiopathic changes.8 Because of these microangiopathic changes, there are pathologic findings and complications at internal organs,9 causing cardiovascular disorders and variations in lipid methabolism.4,6 Altered reninangiotensine system activity and increased endothelin levels disturb circulation in psoriatic patients, so that cardiovascular disorders may occur.5,8 Ena et al reported that the prevelance of hypertension, cardiovascular disorders and diabetes mellitus increased in psoriasis. Also, they found high cholesterol and trigylceride levels and low HDL levels.5 Seçkin et al attributed increased atherosclerosis risk to changes in lipid and lipoprotein composition in psoriatic patients and determined that lipoprotein (a) levels were increased in psoriasis, depending on the severity of the disease.10 Cardin et al found elevated blood cholesterol in children with psoriasis, as in adult subjects with psoriasis.11 Pietrzak et al demonstrated a statistically significant decrease in HDL cholesterol concentration and a statistically significant increase in triglyceride concentration in psoriatic patients.12 In our study, we found that 13.9% of our patients had high TG levels, 38.9% had high cholesterol, 38.9% had raised LDL levels, and 19.4% had low HDL levels. Low HDL levels were significant (P<0.05), whereas the differences between the TG, LDL and cholesterol levels in the two groups were not statistically significant (P >0.05). There was no correlation between lipid levels and PASI scores of psoriatic patients. The differences in CBC, ESR, urine analysis, electrocardiography and echocardiography findings were statistically insignificant (P >0.05). Torok et al reported cardiovascular complications in 18 of 137 psoriasis patients in their study (3 myocardial infarction, 5 angina pectoris, 3 deep vein thrombosis, 6 superficial thrombophlebitis, and 1 sudden death). They proposed that psoriasis was not a predisposing factor for cardiovascular complications except for psoriatic arthritis.4 In our study, we found no ischemic findings in the patient group. Systolic functions and exercise capasities were adequate in all cases. According to echocardiography, there was diastolic dysfunction in 41.7% of patients. Although the electrocardiographic and echocardiographic differences were not significant between the two groups, diastolic dysfunction and a hypertensive answer to exercise were prominent in the patient group (41.7% versus 25%). As a result, we want to draw attention to the low HDL levels and diastolic dysfunction in psoriatic patients in our study. Our data suggest that psoriasis patients must be considered as a group at risk for cardiovascular disease. Thus, regular cardiological follow-ups must be performed in psoriatic patients in order to eliminate the cardiovascular risk factors.

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          High prevalence of cardiovascular diseases and enhanced activity of the renin-angiotensin system in psoriatic patients.

          We have observed a significant higher prevalence of essential hypertension, cardiovascular diseases and diabetes in a group of 100 psoriatic patients compared with sex and age matched hospitalized controls. Thirty-five psoriatic patients exhibited and enhanced plasma renin activity (PRA), while urinary aldosterone excretion was raised in 27% of the group. The autonomic responsiveness of psoriatic patients, studied by cold pressure test and tilting was normal; this finding supports the hypothesis that the enhanced activity of renin-angiotensin system is not due to an increased sympathetic function in these psoriatic patients. High values of cholesterol, triglycerides and depressed HDL-cholesterol concentrations were also observed. A complete clinical and laboratory examination is very useful in psoriasis in order to initiate an appropriate treatment of the risk factors whenever present.
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              Are lipoprotein profile and lipoprotein (a) levels altered in men with psoriasis?

              Previous studies have demonstrated that patients with psoriasis may have an increased risk of a variety of noncutaneous diseases, including arterial and venous occlusive diseases. Changes in plasma lipid and lipoprotein composition in patients with psoriasis may be the reason for the increased risk of atherosclerosis in these patients. Lipoprotein (a) (Lp(a)) is a genetically determined lipoprotein associated with an increased prevalence of atherosclerotic and thrombotic cardiovascular diseases. The aim of this prospective study was to determine the lipid profile and to define the significance of Lp(a) levels in men with psoriasis. The other purpose was to learn whether a correlation exists between psoriasis area and severity index score and serum Lp(a) or other lipids. Serum Lp(a) levels were measured with a commercially available noncompetitive enzyme-linked immunosorbent assay in 32 men with psoriasis and in 13 healthy men. Total serum cholesterol, triglyceride, high-density lipoprotein, low-density lipoprotein, apolipoprotein A-I and apolipoprotein B levels, and atherosclerotic risk factors other than hyperlipidemia were determined. Secondary hyperlipidemia from various diseases and drugs was ruled out in both groups. Serum Lp(a) levels were higher in men with psoriasis than in healthy male subjects, but the difference was not significant (p = 0.063). Serum fasting glucose levels were also found to be higher in the psoriasis group (p 0.05). Our results suggest that the increased Lp(a) level might be a factor involved in occlusive vascular disorders in patients with psoriasis and that patients with extensive and severe skin involvement are more predisposed to relatively high Lp(a) levels.

                Author and article information

                Ann Saudi Med
                Ann Saudi Med
                Annals of Saudi Medicine
                King Faisal Specialist Hospital and Research Centre
                Mar-Apr 2006
                : 26
                : 2
                : 159-161
                Author notes
                Correspondence: Aylin Türel Ermertcan, Celal Bayar Üniversitesi Tıp Fakültesi, Dermatoloji Anabilim Dalı, 45010 Manisa, Turkey, Tel: +90 532 2243384, Fax: +90 236 2370213, draylinturel@
                Copyright © 2006, Annals of Saudi Medicine



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