Cardiovascular Risk in IMIDs: The Latest With Dr Joel Gelfand

In his presentation “Update on CV Risk in IMIDs,” senior advisor Joel Gelfand, MD, MSCE, discussed the overall knowledge and recent literature of cardiovascular risk in immune-mediated inflammatory diseases (IMIDs) such as psoriatic arthritis (PsA), rheumatoid arthritis (RA), and inflammatory bowel disease (IBD).

Risk of cardiometabolic disease in psoriasis is relatively well-known, noted Dr Gelfand. Moderate to severe psoriasis is associated with an increased risk for major cardiovascular events and mortality independent of traditional risk factors, resulting in a 5-year reduction in life expectancy. Further, chronic inflammation and metabolic abnormalities are common to psoriasis and cardiovascular disease, nodding to commonality as comorbidities. It is interesting to note that both RA and IBD have some evidence of association with cardiovascular disease, though the literature has not explored these associations as deeply as psoriasis.

With this evidence, said Dr Gelfand, “we’re still asking the question, does targeting inflammation prevent cardiovascular disease?” The challenge in getting this answer, however, is that observational studies and clinical trials can vary greatly in the results that they found. He also noted that there is some further complication due to the immune system being naturally unpredictable. He highlighted recent evidence published on cardiovascular risk in patients with psoriasis on a variety of biologics, finding that the literature is sometimes contradictory.

Recommendations on atherosclerotic cardiovascular disease (ASCVD) prevention from the American College of Cardiology and the American Heart Association note that psoriasis and RA are risk enhancers for ASCVD, along with familial hypercholesterolemia, coronary artery calcium (CAC), metabolic syndrome, and chronic kidney disease.

Specialists in dermatology, rheumatology, and even gastroenterology are encouraged to discuss a moderate-intensity statin in patients who present with these risks, said Dr Gelfand. In the Q&A hosted by Joseph F. Merola, MD, MMSc, Dr Gelfand further emphasized that many times these patients with severe disease are only seeing their specialist; therefore, specialists may need to take on an active role in screening for cardiovascular diseases and connecting the patient with primary care physician or cardiologist for further treatment.

An audience member asked “what testing do you recommend to screen patients for cardiovascular disease?” Dr Gelfand mentioned completing a computerized tomography coronary angiogram to evaluate for CAC, but other screening should include for hypertension and hyperlipidemia. He recommended introducing a 1.5 multiplication factor into risk models for patients with psoriasis as well, given their high associations with other risk enhancers per the ASCVD recommendations. Making changes to other cardiovascular risk factors, such as cholesterol, weight, and smoking, can also play a role in improving care.

Dr Merola posed a final question regarding JAK inhibitors and their known risk of thromboembolism. “We tend to use JAK inhibitors in patients with tough underlying disease. The excess risk is pretty small, and yes, it is something to be mindful of, but if you have a patient with horrible ulcerative colitis, RA, or PsA, the risk is probably worth it given the circumstances.”

Reference
Gelfand J. Update on CV risk in IMIDs. Presented at: Interdisciplinary Autoimmune Summit; April 15-18, 2021; virtual.