terça-feira, 6 de janeiro de 2009

Psoríase e Doença Coronariana

Psoriasis and CAD: New call to recognize link January 5, 2009 Lisa Nainggolan
Notre Dame, IN - A new report is reiterating the increased risk of coronary artery disease (CAD) observed in patients with the inflammatory skin disease psoriasis—particularly those with severe forms—and stressing that patients must be informed of this link and have their cardiovascular risk factors regularly assessed [1]. Dr Vincent E Friedewald (University of Notre Dame, IN) and colleagues—an expert panel of cardiologists, dermatologists, and scientists—have penned an editor's consensus on the subject in the December 15, 2008 issue of the American Journal of Cardiology (AJC).
"This is a particularly interesting and unique document in that it bridges current knowledge from two medical disciplines—dermatology and cardiology—that rarely interrelate. Very, very few cardiologists are aware of the relationship between psoriasis and CAD and certainly very few dermatologists are, either," Friedewald told heartwire. "The most important thing of a practical nature," he says, "is that every patient who has psoriasis, and definitely every person who has severe psoriasis, ought to have their cardiovascular risk factors looked at and treated."
Every patient who has psoriasis . . . ought to have their cardiovascular risk factors looked at and treated.
But part of the problem from the patient's perspective, he says, is: "If you have psoriasis, particularly moderate or severe, you already have a terrible disease that you are coping with, and you are not thinking about your blood pressure or cholesterol, but it needs to be assessed, because [these things] are a big killer. These people need to be treated more aggressively than they are being treated today," he stresses. A paradigm shift
Friedewald, who is an assistant editor at the American Journal of Cardiology, explained that the catalyst for this new report was a case-control study performed using the UK's General Practice Research Database, by Dr Joel M Gelfand (University of Pennsylvania, Philadelphia) and colleagues [2], published in the Journal of the American Medical Association two years ago—as reported by heartwire—that showed that patients with psoriasis have a significantly increased risk of MI independent of traditional CV risk factors.
"Not a lot of people have noticed [the Gelfand study], and the important thing—and what really is new and in a state of real evolution—is the role of inflammation in CAD. Psoriasis is one piece of the puzzle and may hold the key to unlocking a lot of the mysteries about coronary disease," Friedewald remarks.
Psoriasis is one piece of the puzzle, and may hold the key to unlocking a lot of the mysteries about coronary disease.
He says it is becoming increasingly evident that inflammation plays a key role in heart disease, citing the fact that many people who have an MI—by today's standards—don't have elevated cholesterol. Add to this the recent JUPITER results, showing a marked effect of lowering high-sensitivity C-reactive protein (hs-CRP) on the incidence of coronary disease, even in those with low LDL cholesterol, and "we start to see a huge paradigm shift going on here," he says.
He believes that there is interplay between the chronic process of atherogenesis that goes on for years and years and the changing, dynamic risk of coronary events related to inflammation, which alters constantly—for example, risk is higher in the colder winter months.
"We have all of these inflammatory conditions—rheumatoid arthritis (there's no question there is a link between this and CAD), psoriasis, and periodontal disease, and we know that during periods of acute infection—particularly respiratory or renal infections—there is an increased risk for a coronary event, but very few doctors are aware of these relationships."
"This AJC editor's consensus focuses on a large new area of evidence strengthening the connection between inflammatory processes and CAD," he adds.A central repository of data is needed
One of the problems with trying to increase awareness of the link between psoriasis, other inflammatory conditions, and CAD is that "the data come from many sources that cardiologists don't normally read," says Friedewald. "And dermatologists don't normally read the cardiology literature, either. So one of the recommendations we made in this paper was that we need a resource center whereby information on inflammation from all of these different sources is in a central repository so people can access it and see what's going on."
We need a resource center whereby information on inflammation from all of these different sources is in a central repository.
As cardiologists, he adds, "we have a responsibility to educate our peers and others, to say, 'Look, these patients with psoriasis and other inflammatory diseases are at increased risk and need to be treated more aggressively.' "
But this is not happening, he says. "The challenge for dermatologists is that they say they don't have time—in the US, dermatologists generally allocate only five minutes each to a patient—but as a bare minimum they should have a brochure in their waiting room to inform patients that if they have psoriasis they may be at increased risk for coronary disease."
"Ideally, psoriasis patients should be referred to a family practitioner or primary-care doctor to have a proper cardiovascular risk evaluation performed, with a minimum assessment of hs-CRP, a lipid panel, and blood-pressure measurements," he says.
Dermatologist Gelfand, a coauthor on this new editor's consensus, agrees. "Based on the evolving science, we recommend that patients with moderate to severe psoriasis be educated about the association of psoriasis and cardiovascular disease and that these patients receive appropriate screening and treatment of modifiable cardiovascular risk factors," he says in an AJC statement.
"This [editors'] consensus statement . . . calls for a new standard of care for patients with moderate to severe psoriasis," he concludes.
Friedewald VE, Cather JC, Gelfand JM, et al. AJC editors' consensus: psoriasis and coronary artery disease. Am J Cardiol 2008; 102:1631-43.
Gelfand JM, Neimann AL, Shin DB, et al. Risk of myocardial infarction in patients with psoriasis. JAMA 2006; 296:1735-1741.

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