Letter to Dermatology Received: November 18, 2013 Accepted: November 18, 2013 Published online: February 8, 2014
Reply Zehra Ilke Akyildiz, Cem Nazlı Department of Cardiology, Izmir Katip Çelebi University Ataturk Training and Research Hospital, Izmir, Turkey
We read with interest the comments of Balta et al. [1] regarding our study [2] that was recently published in this journal. Psoriasis is associated with an increased risk of cardiovascular diseases [3, 4]. Patients with psoriasis are prone to premature atherosclerosis. Cardiovascular risk factors [5], metabolic syndrome [6] and subclinical atherosclerosis [7] have been found to be more prevalent in psoriatic patients. Those data introduced the importance of the assessment of cardiometabolic risk in patients with psoriasis [8]. Epicardial fat thickness (EFT) has been proposed as a new cardiometabolic risk factor [9]. Our study is the first to demonstrate that EFT is significantly increased in psoriasis patients compared to controls with similar waist circumference, cardiovascular risk factors and Systematic Coronary Risk Evaluation (SCORE) project risk profiles. Transthoracic echocardiography is commonly performed in individuals with cardiovascular risk factors and can accurately assess EFT [10]. EFT measured by echocardiography has been reported to be associated with abdominal visceral adiposity [11], coronary artery disease [12], subclinical atherosclerosis [10] and metabolic syndrome [13]. Even though epicardial fat can be measured most accurately by magnetic resonance or computed tomographic imaging [9], studies suggest that echocardiographic assessment of epicardial fat might be a simple and practical measure in clinical practice and research [9]. It has been shown that echocardiographic calculation of epicardial fat shows good reliability with magnetic resonance epicardial fat measurements [9]. Therefore, echocardiographic EFT can be applied as an easy and reliable imaging indicator of cardiovascular risk [13]. Many previous studies [10, 12–17] have evaluated EFT with the help of echocardiography by a method similar to that used in our study. Many studies suggest that inter- and intraobserver agreement on echocardiographic EFT measurement is excellent [14–16]. The aim of our study was not to test the inter- and intraobserver reliability of echocardiographic EFT measurement, which has already been demonstrated in several studies [14–16]. Furthermore, there are noteworthy studies evaluating echocardiographic EFT by a single observer’s measurements [17, 18]. EFT measurement was performed in only parasternal long-axis view in our study. In the current literature, there are reported data evaluating echocardiographic EFT from the parasternal long-axis view as in line with our study [12, 17]. Since these issues have been confirmed in previous
© 2014 S. Karger AG, Basel 1018–8665/14/2282–0134$39.50/0 E-Mail [email protected] www.karger.com/drm
reports, EFT was measured by an experienced echocardiologist from the parasternal long-axis view in our study. EFT itself may not provide enough information to evaluate the systemic inflammation process, however, our study has shown that EFT is an independent contributing factor in psoriatic patients. The major message of our study is that EFT is independently associated with psoriasis. The combined predictive value of EFT and inflammatory markers in psoriasis patients is another issue that needs to be determined by further prospective studies. References 1 Balta I, Balta S, Ozturk C, Demirkol S, Demir M: Epicardial fat thickness in psoriasis patients. Dermatology DOI: 10.1159/000357403. 2 Akyildiz ZI, Seremet S, Emren V, Ozcelik S, Gediz B, Tastan A, Nazlı C: Epicardial fat thickness is independently associated with psoriasis. Dermatology DOI: 10.1159/000354726. 3 Prodanovich S, Kirsner RS, Kravetz JD, Ma F, Martinez L, Federman DG: Association of psoriasis with coronary artery, cerebrovascular, and peripheral vascular diseases and mortality. Arch Dermatol 2009; 145: 700– 703. 4 Friedewald VE, Cather JC, Gelfand JM, Gordon KB, Gibbons GH, Grundy SM, Jarratt MT, Krueger JG, Ridker PM, Stone N, Roberts WC: AJC editor’s consensus: psoriasis and coronary artery disease. Am J Cardiol 2008;102:1631–1643. 5 Gelfand JM, Azfar RS, Mehta NN: Psoriasis and cardiovascular risk: strength in numbers. J Invest Dermatol 2010;130:919–922. 6 Armstrong AW, Harskamp CT, Armstrong EJ: Psoriasis and metabolic syndrome: a systematic review and meta-analysis of observational studies. J Am Acad Dermatol 2013;68:654–662. 7 Armstrong AW, Harskamp CT, Ledo L, Rogers JH, Armstrong EJ: Coronary artery disease in patients with psoriasis referred for coronary angiography. Am J Cardiol 2012;109:976–980. 8 Kimball AB, Gladman D, Gelfand JM, Gordon K, Horn EJ, Korman NJ, Korver G, Krueger GG, Strober BE, Lebwohl MG; National Psoriasis Foundation: National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening. J Am Acad Dermatol 2008;58:1031–1042. 9 Iacobellis G, Corradi D, Sharma AM: Epicardial adipose tissue: anatomic, biomolecular and clinical relationships with the heart. Nat Clin Pract Cardiovasc Med 2005;2:536–543. 10 Nelson MR, Mookadam F, Thota V, Emani U, Al Harthi M, Lester SJ, Cha S, Stepanek J, Hurst RT: Epicardial fat: an additional measurement for subclinical atherosclerosis and cardiovascular risk stratification? J Am Soc Echocardiogr 2011;24:339–345. 11 Iacobellis G, Assael F, Ribaudo MC, Zappaterreno A, Alessi G, Di Mario U, Leonetti F: Epicardial fat from echocardiography: a new method for visceral adipose tissue prediction. Obes Res 2003;11:304–310. 12 Jeong JW, Jeong MH, Yun KH, Oh SK, Park EM, Kim YK, Rhee SJ, Lee EM, Lee J, Yoo NJ, Kim NH, Park JC: Echocardiographic epicardial fat thickness and coronary artery disease. Circ J 2007;71:536–539. 13 Iacobellis G, Ribaudo MC, Assael F, Vecci E, Tiberti C, Zappaterreno A, Di Mario U, Leonetti F: Echocardiographic epicardial adipose tissue is related to anthropometric and clinical parameters of metabolic syndrome: a new indicator of cardiovascular risk. J Clin Endocrinol Metab 2003;88:5163–5168.
Zehra Ilke Akyildiz, MD Department of Cardiology İzmir Katip Çelebi University Ataturk Training and Research Hospital TR–35360 Basin Sitesi, Izmir (Turkey) E-Mail ziakyildiz @ hotmail.com
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Dermatology 2014;228:134–135 DOI: 10.1159/000357425
17 Cakir E, Doğan M, Topaloglu O, Ozbek M, Cakal E, Vural MG, Yeter E, Delibasi T: Subclinical atherosclerosis and hyperandrogenemia are independent risk factors for increased epicardial fat thickness in patients with PCOS and idiopathic hirsutism. Atherosclerosis 2013;226:291–295. 18 Malavazos AE, Ermetici F, Cereda E, Coman C, Locati M, Morricone L, Corsi MM, Ambrosi B: Epicardial fat thickness: relationship with plasma visfatin and plasminogen activator inhibitor-1 levels in visceral obesity. Nutr Metab Cardiovasc Dis 2008;18:523–530.
Letter to Dermatology
Dermatology 2014;228:134–135 DOI: 10.1159/000357425
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14 Iacobellis G, Barbaro G, Gerstein HC: Relationship of epicardial fat thickness and fasting glucose. Int J Cardiol 2008;128:424–426. 15 Iacobellis G, Singh N, Wharton S, Sharma AM: Substantial changes in epicardial fat thickness after weight loss in severely obese subjects. Obesity (Silver Spring) 2008;16:1693–1697. 16 Eroglu S, Sade LE, Yildirir A, Bal U, Ozbicer S, Ozgul AS, Bozbas H, Aydinalp A, Muderrisoglu H: Epicardial adipose tissue thickness by echocardiography is a marker for the presence and severity of coronary artery disease. Nutr Metab Cardiovasc Dis 2009;19:211–217.
Reply Zehra Ilke Akyildiz, Cem Nazlı Department of Cardiology, Izmir Katip Çelebi University Ataturk Training and Research Hospital, Izmir, Turkey
We read with interest the comments of Balta et al. [1] regarding our study [2] that was recently published in this journal. Psoriasis is associated with an increased risk of cardiovascular diseases [3, 4]. Patients with psoriasis are prone to premature atherosclerosis. Cardiovascular risk factors [5], metabolic syndrome [6] and subclinical atherosclerosis [7] have been found to be more prevalent in psoriatic patients. Those data introduced the importance of the assessment of cardiometabolic risk in patients with psoriasis [8]. Epicardial fat thickness (EFT) has been proposed as a new cardiometabolic risk factor [9]. Our study is the first to demonstrate that EFT is significantly increased in psoriasis patients compared to controls with similar waist circumference, cardiovascular risk factors and Systematic Coronary Risk Evaluation (SCORE) project risk profiles. Transthoracic echocardiography is commonly performed in individuals with cardiovascular risk factors and can accurately assess EFT [10]. EFT measured by echocardiography has been reported to be associated with abdominal visceral adiposity [11], coronary artery disease [12], subclinical atherosclerosis [10] and metabolic syndrome [13]. Even though epicardial fat can be measured most accurately by magnetic resonance or computed tomographic imaging [9], studies suggest that echocardiographic assessment of epicardial fat might be a simple and practical measure in clinical practice and research [9]. It has been shown that echocardiographic calculation of epicardial fat shows good reliability with magnetic resonance epicardial fat measurements [9]. Therefore, echocardiographic EFT can be applied as an easy and reliable imaging indicator of cardiovascular risk [13]. Many previous studies [10, 12–17] have evaluated EFT with the help of echocardiography by a method similar to that used in our study. Many studies suggest that inter- and intraobserver agreement on echocardiographic EFT measurement is excellent [14–16]. The aim of our study was not to test the inter- and intraobserver reliability of echocardiographic EFT measurement, which has already been demonstrated in several studies [14–16]. Furthermore, there are noteworthy studies evaluating echocardiographic EFT by a single observer’s measurements [17, 18]. EFT measurement was performed in only parasternal long-axis view in our study. In the current literature, there are reported data evaluating echocardiographic EFT from the parasternal long-axis view as in line with our study [12, 17]. Since these issues have been confirmed in previous
© 2014 S. Karger AG, Basel 1018–8665/14/2282–0134$39.50/0 E-Mail [email protected] www.karger.com/drm
reports, EFT was measured by an experienced echocardiologist from the parasternal long-axis view in our study. EFT itself may not provide enough information to evaluate the systemic inflammation process, however, our study has shown that EFT is an independent contributing factor in psoriatic patients. The major message of our study is that EFT is independently associated with psoriasis. The combined predictive value of EFT and inflammatory markers in psoriasis patients is another issue that needs to be determined by further prospective studies. References 1 Balta I, Balta S, Ozturk C, Demirkol S, Demir M: Epicardial fat thickness in psoriasis patients. Dermatology DOI: 10.1159/000357403. 2 Akyildiz ZI, Seremet S, Emren V, Ozcelik S, Gediz B, Tastan A, Nazlı C: Epicardial fat thickness is independently associated with psoriasis. Dermatology DOI: 10.1159/000354726. 3 Prodanovich S, Kirsner RS, Kravetz JD, Ma F, Martinez L, Federman DG: Association of psoriasis with coronary artery, cerebrovascular, and peripheral vascular diseases and mortality. Arch Dermatol 2009; 145: 700– 703. 4 Friedewald VE, Cather JC, Gelfand JM, Gordon KB, Gibbons GH, Grundy SM, Jarratt MT, Krueger JG, Ridker PM, Stone N, Roberts WC: AJC editor’s consensus: psoriasis and coronary artery disease. Am J Cardiol 2008;102:1631–1643. 5 Gelfand JM, Azfar RS, Mehta NN: Psoriasis and cardiovascular risk: strength in numbers. J Invest Dermatol 2010;130:919–922. 6 Armstrong AW, Harskamp CT, Armstrong EJ: Psoriasis and metabolic syndrome: a systematic review and meta-analysis of observational studies. J Am Acad Dermatol 2013;68:654–662. 7 Armstrong AW, Harskamp CT, Ledo L, Rogers JH, Armstrong EJ: Coronary artery disease in patients with psoriasis referred for coronary angiography. Am J Cardiol 2012;109:976–980. 8 Kimball AB, Gladman D, Gelfand JM, Gordon K, Horn EJ, Korman NJ, Korver G, Krueger GG, Strober BE, Lebwohl MG; National Psoriasis Foundation: National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening. J Am Acad Dermatol 2008;58:1031–1042. 9 Iacobellis G, Corradi D, Sharma AM: Epicardial adipose tissue: anatomic, biomolecular and clinical relationships with the heart. Nat Clin Pract Cardiovasc Med 2005;2:536–543. 10 Nelson MR, Mookadam F, Thota V, Emani U, Al Harthi M, Lester SJ, Cha S, Stepanek J, Hurst RT: Epicardial fat: an additional measurement for subclinical atherosclerosis and cardiovascular risk stratification? J Am Soc Echocardiogr 2011;24:339–345. 11 Iacobellis G, Assael F, Ribaudo MC, Zappaterreno A, Alessi G, Di Mario U, Leonetti F: Epicardial fat from echocardiography: a new method for visceral adipose tissue prediction. Obes Res 2003;11:304–310. 12 Jeong JW, Jeong MH, Yun KH, Oh SK, Park EM, Kim YK, Rhee SJ, Lee EM, Lee J, Yoo NJ, Kim NH, Park JC: Echocardiographic epicardial fat thickness and coronary artery disease. Circ J 2007;71:536–539. 13 Iacobellis G, Ribaudo MC, Assael F, Vecci E, Tiberti C, Zappaterreno A, Di Mario U, Leonetti F: Echocardiographic epicardial adipose tissue is related to anthropometric and clinical parameters of metabolic syndrome: a new indicator of cardiovascular risk. J Clin Endocrinol Metab 2003;88:5163–5168.
Zehra Ilke Akyildiz, MD Department of Cardiology İzmir Katip Çelebi University Ataturk Training and Research Hospital TR–35360 Basin Sitesi, Izmir (Turkey) E-Mail ziakyildiz @ hotmail.com
Downloaded by: Lund University Libraries 130.235.136.21 - 5/13/2015 12:44:41 PM
Dermatology 2014;228:134–135 DOI: 10.1159/000357425
17 Cakir E, Doğan M, Topaloglu O, Ozbek M, Cakal E, Vural MG, Yeter E, Delibasi T: Subclinical atherosclerosis and hyperandrogenemia are independent risk factors for increased epicardial fat thickness in patients with PCOS and idiopathic hirsutism. Atherosclerosis 2013;226:291–295. 18 Malavazos AE, Ermetici F, Cereda E, Coman C, Locati M, Morricone L, Corsi MM, Ambrosi B: Epicardial fat thickness: relationship with plasma visfatin and plasminogen activator inhibitor-1 levels in visceral obesity. Nutr Metab Cardiovasc Dis 2008;18:523–530.
Letter to Dermatology
Dermatology 2014;228:134–135 DOI: 10.1159/000357425
135
Downloaded by: Lund University Libraries 130.235.136.21 - 5/13/2015 12:44:41 PM
14 Iacobellis G, Barbaro G, Gerstein HC: Relationship of epicardial fat thickness and fasting glucose. Int J Cardiol 2008;128:424–426. 15 Iacobellis G, Singh N, Wharton S, Sharma AM: Substantial changes in epicardial fat thickness after weight loss in severely obese subjects. Obesity (Silver Spring) 2008;16:1693–1697. 16 Eroglu S, Sade LE, Yildirir A, Bal U, Ozbicer S, Ozgul AS, Bozbas H, Aydinalp A, Muderrisoglu H: Epicardial adipose tissue thickness by echocardiography is a marker for the presence and severity of coronary artery disease. Nutr Metab Cardiovasc Dis 2009;19:211–217.
