Original Paper Dermatology 2014;228:55–59 DOI: 10.1159/000354726
Received: April 17, 2013 Accepted after revision: July 29, 2013 Published online: October 18, 2013
Epicardial Fat Thickness Is Independently Associated with Psoriasis Zehra Ilke Akyildiz a Sila Seremet b Volkan Emren a Sinan Ozcelik b Bilal Gediz a Ahmet Tastan c Cem Nazlı a Departments of a Cardiology and b Dermatology, İzmir Katip Çelebi University Ataturk Training and Research Hospital, and c Department of Cardiology, Faculty of Medicine, Şifa University, Izmir, Turkey
Abstract Background: Several studies have showed an association between psoriasis and cardiovascular (CV) diseases and metabolic syndrome (MS). Assessment of CV risk in patients with psoriasis has become an important issue. Epicardial fat thickness (EFT) is an emerging cardiometabolic risk factor and has been shown to be related to atherosclerosis. EFT has not been studied in the context of psoriasis. Objective: To compare the EFT in psoriasis patients with that in control subjects. Methods: 31 patients with psoriasis and 32 control subjects were included in this case-control study. EFT was evaluated by two-dimensional transthoracic echocardiography. Results: EFT was significantly higher in psoriasis patients compared to controls (p = 0.027). Multiple linear regression analysis showed that the association of EFT with psoriasis was independent of MS and age. Conclusion: EFT, which has been suggested as a cardiometabolic risk factor in various diseases, is also independently associated with psoriasis. © 2013 S. Karger AG, Basel
© 2013 S. Karger AG, Basel 1018–8665/13/2281–0055$38.00/0 E-Mail [email protected] www.karger.com/drm
Introduction
Psoriasis is a systemic, chronic, inflammatory skin disease affecting approximately 1–4% of the world population [1] and has been increasing in prevalence [2]. It has been shown that psoriasis is associated with an increased risk of cardiovascular (CV) diseases [3, 4]. The CV risk factors [5] metabolic syndrome (MS) [6, 7] and subclinical atherosclerosis [8, 9] have been found to be more prevalent in psoriatic patients. Psoriasis has also been found to be an independent risk factor for myocardial infarction regardless of the presence of CV risk factors [10]. Patients with psoriasis are prone to premature atherosclerosis. Therefore, CV risk assessment may be a part of routine evaluation of patients with psoriasis in the near future [4]. However, we still do not know if the current CV risk scoring models can capture all patients with psoriasis. Epicardial fat is a true visceral adipose tissue deposited around the heart. Epicardial fat can produce and release several inflammatory adipocytokines [11]. Epicardial fat thickness (EFT) has been proposed as a new cardiometabolic risk factor [12] as it is clinically related to abdominal visceral adiposity [13], coronary artery disease [14, 15], subclinical atherosclerosis [16] and MS [17]. Epicardial 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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Key Words Epicardial fat thickness · Psoriasis · Cardiovascular risk
Material and Methods Subjects A total of 31 consecutive patients with psoriasis attending the outpatient dermatology clinic of our hospital and 32 consecutive control subjects recruited from the outpatient cardiology clinic of our hospital were included. The diagnosis of psoriasis was based on clinical examination of the patients. Subjects with a history of established CV disease, coronary revascularization or previous myocardial infarction, concomitant inflammatory or neoplastic diseases, or known endocrine, kidney, hepatic or metabolic disease other than obesity or diabetes mellitus were excluded. Subjects younger than 18 years of age, pregnant women and subjects receiving systemic steroids or biologics were also excluded from the study. Written informed consent was obtained from all participants. Our study protocol was approved by the Şifa University ethics committee. Subject characteristics and clinical features, including age, gender, body mass index, duration and severity of psoriasis, blood pressure and smoking habits, were recorded. Disease severity was quantified using the Psoriasis Area and Severity Index (PASI) [18]. The 10-year predicted risk of fatal CV disease was calculated for all subjects. The Systematic Coronary Risk Evaluation (SCORE) project risk score was used as the risk scoring method [19, 20]. A SCORE-based relative risk chart was used for young patients of less than 40 years of age [20]. Blood samples were collected after overnight fasting. The serum levels of triglycerides, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol (HDL-C) and fasting and postprandial (2 h after breakfast) blood glucose were measured. MS was diagnosed according to National Cholesterol Education Program Adult Treatment Panel III [21] criteria as the presence of 3 or more of the following criteria: (1) waist circumference >102 cm in men and >88 cm in women; (2) plasma triglycerides ≥150 mg/dl; (3) plasma HDL-C 0.05).
Discussion
To our knowledge, this study is the first to demonstrate that EFT is significantly increased in psoriasis patients compared to controls with similar waist circumference, CV risk factors and SCORE project risk profiles. Furthermore, EFT showed an independent association with MS, psoriasis and age. Epicardial Fat Thickness in Psoriasis
Age, years Male/female SCORE project risk score PASI score Duration of psoriasis, years Diabetes mellitus Hypertension Smoking consumption, pack-years MS Waist circumference, cm Body mass index, kg/m2 Fasting blood glucose, mg/dl Postprandial blood glucose, mg/dl Total cholesterol, mg/dl Triglycerides, mg/dl HDL-C, mg/dl LDL-C, mg/dl EFT, mm
Control subjects (n = 32)
p value
41.1 ± 6.8 42 ± 11.1 14/17 13/19 2 (1 – 3) 2 (1 – 2) 6.1 ± 4 – 17.1 ± 10.5 – 4 (12.9%) 1 (3.1%) 7 (22.6%) 8 (25%) 2.5 1 (0 – 20) (0 – 1.875) 14 (45.2%) 16 (50.0%) 98.6 ± 13.9 98 ± 16.2 28.1 ± 5.6 30.9 ± 9.9 104.8 ± 23.4 102.2 ± 12.2 116.7 ± 42.9 116.7 ± 25.3
0.686a 0.801b 0.177c – – 0.196b 1.000b 0.022c
206.1 ± 34.8 165.4 ± 75.3 47.9 ± 8.0 125.1 ± 30.5 6.4 ± 2.6
0.379a 0.208a 0.100a 0.840a 0.027a
198.6 ± 31.8 143.5 ± 60.6 43.3 ± 13.4 126.6 ± 28.0 5.1 ± 1.9
0.802b 0.879a 0.183a 0.583a 0.998a
LDL = Low-density lipoprotein cholesterol. a Student’s t test. b χ2 test. c Mann-Whitney U test.
Table 2. Linear regression analysis factors associated with EFT in
the entire group and psoriasis patients only Independent variable
Age MS Female gender Psoriasis R2 (multiple coefficient of determination)
EFT in psoriasis patients only (n = 31)
EFT in all subjects (n = 63)
β
p value
β
p value
0.302 0.497 0.287 – 0.576
0.029 0.001 0.033 – 0.000
0.282 0.399 0.196 0.284 0.361
0.010 0.000 0.071 0.009 0.000
β = Standardized regression coefficient. EFT was significantly associated with MS (p < 0.01), age (p < 0.05) and female gender (p < 0.05) in psoriasis patients only. EFT was significantly associated with MS (p < 0.001), psoriasis (p < 0.01) and age (p < 0.05) in all study subjects, whereas the contribution of female gender was not significant (p = 0.071).
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found a strong relationship between smoking and psoriasis, affecting its severity and response to treatment [35– 37]. One of the underlying mechanisms of this association has been proposed to be smoking-induced oxidative damage [37]. However, studies could not assess whether there was any cause-and-effect relationship between smoking and psoriasis [38]. In our study, even though the psoriasis and control groups had similar SCORE project risk scores, EFT was found to be higher in patients with psoriasis, and furthermore, psoriasis independently affected EFT. So far, currently used CV risk models have not been investigated with regard to whether they can provide a reliable risk estimate in patients with psoriasis. For instance, one report emphasized the need for validated diabetes-specific risk calculators that can estimate CV disease risk reliably in type 2 diabetic patients [39]. The major message from our study is that EFT, which has been suggested as a cardiometabolic risk factor, is independently associated with psoriasis. Echocardiography is a noninvasive diagnostic tool which is widely used in cardiac evaluation in routine daily practice. Echocardiographic measurement of the epicardial fat tissue may be used as a simple marker for identification of psoriatic patients with higher CV risk who may need further cardiac evaluation. The number of patients included in our study is relatively small, being only 31. This might be a major limitation, causing the study to have low power. While there are some studies on EFT in various fields including larger series [40], there are some noteworthy studies [41] with small numbers of patients similar to our study. Although this study provides useful information, a conclusion on the contribution of EFT to the presence of coronary artery disease in patients with psoriasis cannot be drawn. Furthermore, to understand the predictive value of echocardiographically measured epicardial fat tissue on future CV events, prospective studies will be necessary. This study shows that psoriasis independently affects EFT. However, more evidence is necessary to evaluate whether echocardiographic EFT may become a routine cardiac assessment in the clinical setting in psoriasis patients.
Disclosure Statement The authors have no financial support or conflicts of interest to disclose.
Akyildiz /Seremet /Emren /Ozcelik /Gediz / Tastan /Nazlı
Downloaded by: UCSF Library & CKM 169.230.243.252 - 12/1/2014 10:54:50 PM
Recent studies revealed psoriasis as an independent risk factor for atherosclerosis, myocardial infarction, endothelial dysfunction, coronary artery disease, stroke and diabetes [3, 10, 22–24]. A recent study emphasized the comparable increase in major adverse CV events and CV deaths in patients with severe psoriasis and diabetes [25]. These data introduced the importance of assessment of cardiometabolic risk in patients with psoriasis [26]. A growing body of evidence suggests that regional fat distribution plays an important part in the development of an unfavorable metabolic and CV risk profile [12]. On the other hand, Balci et al. [23] demonstrated increased abdominal visceral adipose tissue in patients with psoriasis compared to controls. Visceral adipose tissue had been shown to be a risk factor for atherosclerosis [27, 28]. Epicardial fat is a kind of visceral adipose tissue located between the surface of the myocardium and the epicardium. This small fat depot is rich in proinflammatory, proatherogenic cytokines and several bioactive molecules like tumor necrosis factor-α [29]. Epicardial fat has a role in CV diseases [29]; therefore, it has been suggested as a new cardiometabolic risk factor [12, 30]. Even though recent studies have emphasized that psoriasis and atherosclerosis share the same pathogenic mechanisms, particularly through proinflammatory cytokines and tumor necrosis factor [31, 32], the contribution of EFT to this process has never been questioned in patients with psoriasis. In this study, EFT showed a significant correlation with the presence of MS in patients with psoriasis. It should be clarified that the association of EFT with psoriasis was not due to MS. Psoriasis patients and the control group were comparable in terms of the incidence of MS (45 vs. 50%, p = 0.802); therefore, it can be assumed that the effect of MS on EFT in both groups was equal, subsequently leading to a conclusion that the significant difference in EFT between the two groups was independent of MS. Furthermore, multiple linear regression analysis also showed no interaction between independent variables contributing to EFT. Increased visceral adipose tissue plays a crucial role in the development of MS and its components [33]. Waist circumference is an anthropometric indicator of central obesity and is related to visceral adiposity [33]. Studies have showed that EFT is related to anthropometric and clinical parameters of MS [30, 34]. Waist circumference was also correlated with EFT in our study. In our study, the amount of cigarettes consumed over time was significantly higher in patients with psoriasis compared to controls. Epidemiological studies have
References
Epicardial Fat Thickness in Psoriasis
16 Nelson MR, Mookadam F, Thota V, et al: Epicardial fat: an additional measurement for subclinical atherosclerosis and cardiovascular risk stratification? J Am Soc Echocardiogr 2011;24:339–345. 17 Cohen AD, Sherf M, Vidavsky L, et al: Association between psoriasis and the metabolic syndrome. A cross-sectional study. Dermatology 2008;216:152–155. 18 Berth-Jones J, Grotzinger K, Rainville C, et al: A study examining inter- and intrarater reliability of three scales for measuring severity of psoriasis: Psoriasis Area and Severity Index, Physician’s Global Assessment and Lattice System Physician’s Global Assessment. Br J Dermatol 2006;155:707–713. 19 Conroy RM, Pyorala K, Fitzgerald AP, et al: Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 2003;24:987–1003. 20 Perk J, De Backer G, Gohlke H, et al: European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur Heart J 2012;33:1635–1701. 21 Grundy SM, Cleeman JI, Daniels SR, et al: Diagnosis and management of the metabolic syndrome: an American Heart Association/ National Heart, Lung, and Blood Institute Scientific Statement. Circulation 2005; 112: 2735–2752. 22 Ludwig RJ, Herzog C, Rostock A, et al: Psoriasis: a possible risk factor for development of coronary artery calcification. Br J Dermatol 2007;156:271–276. 23 Balci D, Balci A, Karazincir S, et al: Increased carotid artery intima-media thickness and impaired endothelial function in psoriasis. J Eur Acad Dermatol Venereol 2009;23:1–6. 24 Brauchli YB, Jick SS, Miret M, et al: Psoriasis and risk of incident myocardial infarction, stroke or transient ischaemic attack: an inception cohort study with a nested case-control analysis. Br J Dermatol 2009;160:1048–1056. 25 Ahlehoff O, Gislason GH, Charlot M, et al: Psoriasis is associated with clinically significant cardiovascular risk: a Danish nationwide cohort study. J Intern Med 2011;270:147–157. 26 Kimball AB, Gladman D, Gelfand JM, et al; National Psoriasis Foundation: National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening. J Am Acad Dermatol 2008; 58: 1031–1042. 27 Kobayashi H, Nakamura T, Miyaoka K, et al: Visceral fat accumulation contributes to insulin resistance, small-sized low-density lipoprotein, and progression of coronary artery disease in middle-aged non-obese Japanese men. Jpn Circ J 2001;65:193–199.
28 Yamamoto M, Egusa G, Hara H, et al: Association of intraabdominal fat and carotid atherosclerosis in non-obese middle-aged men with normal glucose tolerance. Int J Obes Relat Metab Disord 1997;21:948–951. 29 Iacobellis G, Willens HJ: Echocardiographic epicardial fat: a review of research and clinical applications. J Am Soc Echocardiogr 2009;22: 1311–1319. 30 Iacobellis G, Ribaudo MC, Assael F, et al: 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. 31 Boehncke WH, Boehncke S: Cardiovascular mortality in psoriasis and psoriatic arthritis: epidemiology, pathomechanisms, therapeutic implications, and perspectives. Curr Rheumatol Rep 2012;14:343–348. 32 Gerkowicz A, Pietrzak A, Szepietowski JC, et al: Biochemical markers of psoriasis as a metabolic disease. Folia Histochem Cytobiol 2012;50:155–170. 33 Albu JB, Kovera AJ, Johnson JA: Fat distribution and health in obesity. Ann NY Acad Sci 2000;904:491–501. 34 Silaghi A, Piercecchi-Marti MD, Grino M, et al: Epicardial adipose tissue extent: relationship with age, body fat distribution, and coronaropathy. Obesity (Silver Spring) 2008; 16: 2424–2430. 35 Chandran V, Raychaudhuri SP: Geoepidemiology and environmental factors of psoriasis and psoriatic arthritis. J Autoimmun 2010; 34:J314–J321. 36 Setty AR, Curhan G, Choi HK: Smoking and the risk of psoriasis in women: Nurses’ Health Study II. Am J Med 2007;120:953–959. 37 Armstrong AW, Armstrong EJ, Fuller EN, et al: Smoking and pathogenesis of psoriasis: a review of oxidative, inflammatory and genetic mechanisms. Br J Dermatol 2011; 165: 1162–1168. 38 Kavli G, Forde OH, Arnesen E, et al: Psoriasis: familial predisposition and environmental factors. Br Med J (Clin Res Ed) 1985;291:999– 1000. 39 Coleman RL, Stevens RJ, Retnakaran R, et al: Framingham, SCORE, and DECODE risk equations do not provide reliable cardiovascular risk estimates in type 2 diabetes. Diabetes Care 2007;30:1292–1293. 40 Eroglu S, Sade LE, Yildirir A, et al: 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. 41 Cakir E, Doğan M, Topaloglu O, et al: 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.
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1 Kurd SK, Gelfand JM: The prevalence of previously diagnosed and undiagnosed psoriasis in US adults: results from NHANES 2003– 2004. J Am Acad Dermatol 2009;60:218–224. 2 Danielsen K, Olsen AO, Wilsgaard T, et al: Is the prevalence of psoriasis increasing? A 30 year follow-up of a population-based cohort. Br J Dermatol 2013;168:1303–1310. 3 Prodanovich S, Kirsner RS, Kravetz JD, et al: 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, et al: 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 Langan SM, Seminara NM, Shin DB, et al: Prevalence of metabolic syndrome in patients with psoriasis: a population-based study in the United Kingdom. J Invest Dermatol 2012; 132:556–562. 8 Armstrong AW, Harskamp CT, Ledo L, et al: Coronary artery disease in patients with psoriasis referred for coronary angiography. Am J Cardiol 2012;109:976–980. 9 Gelfand JM, Mehta NN, Langan SM: Psoriasis and cardiovascular risk: strength in numbers, part II. J Invest Dermatol 2011; 131: 1007– 1010. 10 Gelfand JM, Neimann AL, Shin AB, et al: Risk of myocardial infarction in patients with psoriasis. JAMA 2006;296:1735–1741. 11 Baker AR, Silva NF, Quinn DW, et al: Human epicardial adipose tissue expresses a pathogenic profile of adipocytokines in patients with cardiovascular disease. Cardiovasc Diabetol 2006;5:1. 12 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. 13 Iacobellis G, Assael F, Ribaudo MC, et al: Epicardial fat from echocardiography: a new method for visceral adipose tissue prediction. Obes Res 2003;11:304–310. 14 Jeong JW, Jeong MH, Yun KH, et al: Echocardiographic epicardial fat thickness and coronary artery disease. Circ J 2007;71:536–539. 15 Bachar GN, Dicker D, Kornowski R, et al: Epicardial adipose tissue as a predictor of coronary artery disease in asymptomatic subjects. Am J Cardiol 2012;110:534–538.
Received: April 17, 2013 Accepted after revision: July 29, 2013 Published online: October 18, 2013
Epicardial Fat Thickness Is Independently Associated with Psoriasis Zehra Ilke Akyildiz a Sila Seremet b Volkan Emren a Sinan Ozcelik b Bilal Gediz a Ahmet Tastan c Cem Nazlı a Departments of a Cardiology and b Dermatology, İzmir Katip Çelebi University Ataturk Training and Research Hospital, and c Department of Cardiology, Faculty of Medicine, Şifa University, Izmir, Turkey
Abstract Background: Several studies have showed an association between psoriasis and cardiovascular (CV) diseases and metabolic syndrome (MS). Assessment of CV risk in patients with psoriasis has become an important issue. Epicardial fat thickness (EFT) is an emerging cardiometabolic risk factor and has been shown to be related to atherosclerosis. EFT has not been studied in the context of psoriasis. Objective: To compare the EFT in psoriasis patients with that in control subjects. Methods: 31 patients with psoriasis and 32 control subjects were included in this case-control study. EFT was evaluated by two-dimensional transthoracic echocardiography. Results: EFT was significantly higher in psoriasis patients compared to controls (p = 0.027). Multiple linear regression analysis showed that the association of EFT with psoriasis was independent of MS and age. Conclusion: EFT, which has been suggested as a cardiometabolic risk factor in various diseases, is also independently associated with psoriasis. © 2013 S. Karger AG, Basel
© 2013 S. Karger AG, Basel 1018–8665/13/2281–0055$38.00/0 E-Mail [email protected] www.karger.com/drm
Introduction
Psoriasis is a systemic, chronic, inflammatory skin disease affecting approximately 1–4% of the world population [1] and has been increasing in prevalence [2]. It has been shown that psoriasis is associated with an increased risk of cardiovascular (CV) diseases [3, 4]. The CV risk factors [5] metabolic syndrome (MS) [6, 7] and subclinical atherosclerosis [8, 9] have been found to be more prevalent in psoriatic patients. Psoriasis has also been found to be an independent risk factor for myocardial infarction regardless of the presence of CV risk factors [10]. Patients with psoriasis are prone to premature atherosclerosis. Therefore, CV risk assessment may be a part of routine evaluation of patients with psoriasis in the near future [4]. However, we still do not know if the current CV risk scoring models can capture all patients with psoriasis. Epicardial fat is a true visceral adipose tissue deposited around the heart. Epicardial fat can produce and release several inflammatory adipocytokines [11]. Epicardial fat thickness (EFT) has been proposed as a new cardiometabolic risk factor [12] as it is clinically related to abdominal visceral adiposity [13], coronary artery disease [14, 15], subclinical atherosclerosis [16] and MS [17]. Epicardial 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: UCSF Library & CKM 169.230.243.252 - 12/1/2014 10:54:50 PM
Key Words Epicardial fat thickness · Psoriasis · Cardiovascular risk
Material and Methods Subjects A total of 31 consecutive patients with psoriasis attending the outpatient dermatology clinic of our hospital and 32 consecutive control subjects recruited from the outpatient cardiology clinic of our hospital were included. The diagnosis of psoriasis was based on clinical examination of the patients. Subjects with a history of established CV disease, coronary revascularization or previous myocardial infarction, concomitant inflammatory or neoplastic diseases, or known endocrine, kidney, hepatic or metabolic disease other than obesity or diabetes mellitus were excluded. Subjects younger than 18 years of age, pregnant women and subjects receiving systemic steroids or biologics were also excluded from the study. Written informed consent was obtained from all participants. Our study protocol was approved by the Şifa University ethics committee. Subject characteristics and clinical features, including age, gender, body mass index, duration and severity of psoriasis, blood pressure and smoking habits, were recorded. Disease severity was quantified using the Psoriasis Area and Severity Index (PASI) [18]. The 10-year predicted risk of fatal CV disease was calculated for all subjects. The Systematic Coronary Risk Evaluation (SCORE) project risk score was used as the risk scoring method [19, 20]. A SCORE-based relative risk chart was used for young patients of less than 40 years of age [20]. Blood samples were collected after overnight fasting. The serum levels of triglycerides, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol (HDL-C) and fasting and postprandial (2 h after breakfast) blood glucose were measured. MS was diagnosed according to National Cholesterol Education Program Adult Treatment Panel III [21] criteria as the presence of 3 or more of the following criteria: (1) waist circumference >102 cm in men and >88 cm in women; (2) plasma triglycerides ≥150 mg/dl; (3) plasma HDL-C 0.05).
Discussion
To our knowledge, this study is the first to demonstrate that EFT is significantly increased in psoriasis patients compared to controls with similar waist circumference, CV risk factors and SCORE project risk profiles. Furthermore, EFT showed an independent association with MS, psoriasis and age. Epicardial Fat Thickness in Psoriasis
Age, years Male/female SCORE project risk score PASI score Duration of psoriasis, years Diabetes mellitus Hypertension Smoking consumption, pack-years MS Waist circumference, cm Body mass index, kg/m2 Fasting blood glucose, mg/dl Postprandial blood glucose, mg/dl Total cholesterol, mg/dl Triglycerides, mg/dl HDL-C, mg/dl LDL-C, mg/dl EFT, mm
Control subjects (n = 32)
p value
41.1 ± 6.8 42 ± 11.1 14/17 13/19 2 (1 – 3) 2 (1 – 2) 6.1 ± 4 – 17.1 ± 10.5 – 4 (12.9%) 1 (3.1%) 7 (22.6%) 8 (25%) 2.5 1 (0 – 20) (0 – 1.875) 14 (45.2%) 16 (50.0%) 98.6 ± 13.9 98 ± 16.2 28.1 ± 5.6 30.9 ± 9.9 104.8 ± 23.4 102.2 ± 12.2 116.7 ± 42.9 116.7 ± 25.3
0.686a 0.801b 0.177c – – 0.196b 1.000b 0.022c
206.1 ± 34.8 165.4 ± 75.3 47.9 ± 8.0 125.1 ± 30.5 6.4 ± 2.6
0.379a 0.208a 0.100a 0.840a 0.027a
198.6 ± 31.8 143.5 ± 60.6 43.3 ± 13.4 126.6 ± 28.0 5.1 ± 1.9
0.802b 0.879a 0.183a 0.583a 0.998a
LDL = Low-density lipoprotein cholesterol. a Student’s t test. b χ2 test. c Mann-Whitney U test.
Table 2. Linear regression analysis factors associated with EFT in
the entire group and psoriasis patients only Independent variable
Age MS Female gender Psoriasis R2 (multiple coefficient of determination)
EFT in psoriasis patients only (n = 31)
EFT in all subjects (n = 63)
β
p value
β
p value
0.302 0.497 0.287 – 0.576
0.029 0.001 0.033 – 0.000
0.282 0.399 0.196 0.284 0.361
0.010 0.000 0.071 0.009 0.000
β = Standardized regression coefficient. EFT was significantly associated with MS (p < 0.01), age (p < 0.05) and female gender (p < 0.05) in psoriasis patients only. EFT was significantly associated with MS (p < 0.001), psoriasis (p < 0.01) and age (p < 0.05) in all study subjects, whereas the contribution of female gender was not significant (p = 0.071).
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found a strong relationship between smoking and psoriasis, affecting its severity and response to treatment [35– 37]. One of the underlying mechanisms of this association has been proposed to be smoking-induced oxidative damage [37]. However, studies could not assess whether there was any cause-and-effect relationship between smoking and psoriasis [38]. In our study, even though the psoriasis and control groups had similar SCORE project risk scores, EFT was found to be higher in patients with psoriasis, and furthermore, psoriasis independently affected EFT. So far, currently used CV risk models have not been investigated with regard to whether they can provide a reliable risk estimate in patients with psoriasis. For instance, one report emphasized the need for validated diabetes-specific risk calculators that can estimate CV disease risk reliably in type 2 diabetic patients [39]. The major message from our study is that EFT, which has been suggested as a cardiometabolic risk factor, is independently associated with psoriasis. Echocardiography is a noninvasive diagnostic tool which is widely used in cardiac evaluation in routine daily practice. Echocardiographic measurement of the epicardial fat tissue may be used as a simple marker for identification of psoriatic patients with higher CV risk who may need further cardiac evaluation. The number of patients included in our study is relatively small, being only 31. This might be a major limitation, causing the study to have low power. While there are some studies on EFT in various fields including larger series [40], there are some noteworthy studies [41] with small numbers of patients similar to our study. Although this study provides useful information, a conclusion on the contribution of EFT to the presence of coronary artery disease in patients with psoriasis cannot be drawn. Furthermore, to understand the predictive value of echocardiographically measured epicardial fat tissue on future CV events, prospective studies will be necessary. This study shows that psoriasis independently affects EFT. However, more evidence is necessary to evaluate whether echocardiographic EFT may become a routine cardiac assessment in the clinical setting in psoriasis patients.
Disclosure Statement The authors have no financial support or conflicts of interest to disclose.
Akyildiz /Seremet /Emren /Ozcelik /Gediz / Tastan /Nazlı
Downloaded by: UCSF Library & CKM 169.230.243.252 - 12/1/2014 10:54:50 PM
Recent studies revealed psoriasis as an independent risk factor for atherosclerosis, myocardial infarction, endothelial dysfunction, coronary artery disease, stroke and diabetes [3, 10, 22–24]. A recent study emphasized the comparable increase in major adverse CV events and CV deaths in patients with severe psoriasis and diabetes [25]. These data introduced the importance of assessment of cardiometabolic risk in patients with psoriasis [26]. A growing body of evidence suggests that regional fat distribution plays an important part in the development of an unfavorable metabolic and CV risk profile [12]. On the other hand, Balci et al. [23] demonstrated increased abdominal visceral adipose tissue in patients with psoriasis compared to controls. Visceral adipose tissue had been shown to be a risk factor for atherosclerosis [27, 28]. Epicardial fat is a kind of visceral adipose tissue located between the surface of the myocardium and the epicardium. This small fat depot is rich in proinflammatory, proatherogenic cytokines and several bioactive molecules like tumor necrosis factor-α [29]. Epicardial fat has a role in CV diseases [29]; therefore, it has been suggested as a new cardiometabolic risk factor [12, 30]. Even though recent studies have emphasized that psoriasis and atherosclerosis share the same pathogenic mechanisms, particularly through proinflammatory cytokines and tumor necrosis factor [31, 32], the contribution of EFT to this process has never been questioned in patients with psoriasis. In this study, EFT showed a significant correlation with the presence of MS in patients with psoriasis. It should be clarified that the association of EFT with psoriasis was not due to MS. Psoriasis patients and the control group were comparable in terms of the incidence of MS (45 vs. 50%, p = 0.802); therefore, it can be assumed that the effect of MS on EFT in both groups was equal, subsequently leading to a conclusion that the significant difference in EFT between the two groups was independent of MS. Furthermore, multiple linear regression analysis also showed no interaction between independent variables contributing to EFT. Increased visceral adipose tissue plays a crucial role in the development of MS and its components [33]. Waist circumference is an anthropometric indicator of central obesity and is related to visceral adiposity [33]. Studies have showed that EFT is related to anthropometric and clinical parameters of MS [30, 34]. Waist circumference was also correlated with EFT in our study. In our study, the amount of cigarettes consumed over time was significantly higher in patients with psoriasis compared to controls. Epidemiological studies have
References
Epicardial Fat Thickness in Psoriasis
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