10.5826/dpc.1201a11
Introduction: Psoriasis (PsO), a chronic inflammatory, multisystemic, and multifactorial disease can cause endothelial dysfunction, artery calcification, and atherosclerotic disease. A higher incidence of vascular occlusive events has been observed in psoriatic patients compared to healthy controls, and multiple studies confirm the association between moderate-severe PsO and atherosclerosis, coronary artery calcification, and higher cardiovascular risk.
Objective: We sought to analyze atherosclerotic disease prevalence in epiaortic vessels of psoriatic and non-psoriatic patients to understand if PsO could represent an independent risk factor predisposing to atherosclerotic disease.
Methods: We evaluated 47 psoriatic patients without cardiovascular risk factors with color Doppler ultrasound (CDUS). If atheromatous plaques were detected, a computed tomography angiography (CTA) was performed. We evaluated 47 non-psoriatic patients without cardiovascular risk factors with CDUS. Atherosclerosis prevalence in both groups were statistically analyzed. CDUS performance was compared to CTA.
Results: In the psoriatic group (mean age 50.9 years), 6 had atheromatous plaques and 12 had an intima-media thickness (IMT) &gt; 1 mm (overall prevalence of atherosclerotic disease: 38.2%). All plaques detected with CDUS were confirmed at CTA. In the control group (mean age 51.3 years), CDUS revealed atheromatous plaques in 4 patients and IMT &gt; 1 mm in 4 ones (overall prevalence of 17%). The difference of atherosclerotic disease prevalence between the groups was statistically significant (P &lt; 0.05).
Conclusion: Our results highlight that PsO could be considered a predisposing factor for atherosclerotic disease development in epiaortic vessels, as it causes an increased IMT, that is also considered an independent cardiovascular risk factor.
text/xml
2160-9381
1745
en
Luca  Bianchi 
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
psoriasis, color-Doppler Ultrasound, Angio-CT; IMT; risk-factor
Prevalence of Atherosclerosis in Psoriatic Patients Detected with Epiaortic Color Doppler Ultrasound and Computed Tomography Angiography
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-02-02
2021-04-02
2022-02-02
2022-02-09
e2022011
Dermatol Pract Concept
Introduction: Psoriasis (PsO), a chronic inflammatory, multisystemic, and multifactorial disease can cause endothelial dysfunction, artery calcification, and atherosclerotic disease. A higher incidence of vascular occlusive events has been observed in psoriatic patients compared to healthy controls, and multiple studies confirm the association between moderate-severe PsO and atherosclerosis, coronary artery calcification, and higher cardiovascular risk.
Objective: We sought to analyze atherosclerotic disease prevalence in epiaortic vessels of psoriatic and non-psoriatic patients to understand if PsO could represent an independent risk factor predisposing to atherosclerotic disease.
Methods: We evaluated 47 psoriatic patients without cardiovascular risk factors with color Doppler ultrasound (CDUS). If atheromatous plaques were detected, a computed tomography angiography (CTA) was performed. We evaluated 47 non-psoriatic patients without cardiovascular risk factors with CDUS. Atherosclerosis prevalence in both groups were statistically analyzed. CDUS performance was compared to CTA.
Results: In the psoriatic group (mean age 50.9 years), 6 had atheromatous plaques and 12 had an intima-media thickness (IMT) &gt; 1 mm (overall prevalence of atherosclerotic disease: 38.2%). All plaques detected with CDUS were confirmed at CTA. In the control group (mean age 51.3 years), CDUS revealed atheromatous plaques in 4 patients and IMT &gt; 1 mm in 4 ones (overall prevalence of 17%). The difference of atherosclerotic disease prevalence between the groups was statistically significant (P &lt; 0.05).
Conclusion: Our results highlight that PsO could be considered a predisposing factor for atherosclerotic disease development in epiaortic vessels, as it causes an increased IMT, that is also considered an independent cardiovascular risk factor.
Luca  Bianchi 
2022/02/02
10.5826/dpc.1201a11
e2022011
Dermatology Department, University of Rome “Tor Vergata”, Rome, Italy
2160-9381
psoriasis, color-Doppler Ultrasound, Angio-CT; IMT; risk-factor
en
e2022011
Koelemay MJ, Nederkoorn PJ, Reitsma JB, Majoie CB. Systematic review of computed tomographic angiography for assessment of carotid artery disease. Stroke. 2004;35(10):2306-2312. DOI: 10.1161/01.STR.0000141426.63959.cc. PMID: 15345798.
Prevalence of Atherosclerosis in Psoriatic Patients Detected with Epiaortic Color Doppler Ultrasound and Computed Tomography Angiography
https://dpcj.org/index.php/dpc/article/download/1745/1469
                    Dermatology Practical & Conceptual


  Prevalence of Atherosclerosis in Psoriatic Patients
  Detected with Epiaortic Color Doppler Ultrasound
      and Computed Tomography Angiography
          Annunziata Dattola1, Guglielmo Manenti2, Donatella Ferrari2, Laura Vollono1,
         Salvatore Marsico2, Feliciana Lamacchia2, Maria Esposito1, Mattia Marchesano1,
              Arianna Zangrilli1, Roberto Floris2, Alessandro Giunta1, Luca Bianchi1


1 Dermatology Department, University of Rome “Tor Vergata”, Rome, Italy
2 Biomedicine and Prevention Department, UOC of Diagnostic Imaging, University of Rome “Tor Vergata”, Rome, Italy



Key words: psoriasis, color-doppler ultrasound, angio-CT, IMT, risk-factor
Citation: Dattola A, Manenti G, Ferrari D, et al. Prevalence of atherosclerosis in psoriatic patients detected with epiaortic color doppler
ultrasound and computed tomograpgy angiography. Dermatol Pract Concept. 2022;12(1):e2022011.
DOI: https://doi.org/10.5826/dpc.1201a11
Accepted: May 6, 2021; Published: January 2022
Copyright: ©2022 Dattola et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: AD and GM have equally contributed to this article.
Corresponding author: Annunziata Dattola, MD, PhD. Dermatology Department, University of Rome “Tor Vergata”, Rome, Italy.
E-mail: nancydattola@gmail.com




  ABSTRACT              Introduction: Psoriasis (PsO), a chronic inflammatory, multisystemic, and multifactorial disease can
                        cause endothelial dysfunction, artery calcification, and atherosclerotic disease. A higher incidence of
                        vascular occlusive events has been observed in psoriatic patients compared to healthy controls, and
                        multiple studies confirm the association between moderate-severe PsO and atherosclerosis, coronary
                        artery calcification, and higher cardiovascular risk.
                        Objective: We sought to analyze atherosclerotic disease prevalence in epiaortic vessels of psoriatic and
                        non-psoriatic patients to understand if PsO could represent an independent risk factor predisposing
                        to atherosclerotic disease.
                        Methods: We evaluated 47 psoriatic patients without cardiovascular risk factors with color Doppler
                        ultrasound (CDUS). If atheromatous plaques were detected, a computed tomography angiography
                        (CTA) was performed. We evaluated 47 non-psoriatic patients without cardiovascular risk factors with
                        CDUS. Atherosclerosis prevalence in both groups were statistically analyzed. CDUS performance was
                        compared to CTA.
                        Results: In the psoriatic group (mean age 50.9 years), 6 had atheromatous plaques and 12 had an
                        intima-media thickness (IMT) > 1 mm (overall prevalence of atherosclerotic disease: 38.2%). All
                        plaques detected with CDUS were confirmed at CTA. In the control group (mean age 51.3 years),




Original Article | Dermatol Pract Concept. 2022;12(1):e2022011                                                                                1
                      CDUS revealed atheromatous plaques in 4 patients and IMT > 1 mm in 4 ones (overall prevalence of
                      17%). The difference of atherosclerotic disease prevalence between the groups was statistically signif-
                      icant (P < 0.05).
                      Conclusion: Our results highlight that PsO could be considered a predisposing factor for atheroscle-
                      rotic disease development in epiaortic vessels, as it causes an increased IMT, that is also considered an
                      independent cardiovascular risk factor.




Introduction                                                       prevalence with non-psoriatic patients, in order to understand
                                                                   if PsO could be considered as an independent risk factor for
Psoriasis (PsO) is a chronic inflammatory, multisystemic, and      atherosclerotic disease.
multifactorial disease that affects about 3% of the world pop-
ulation [1]. The chronic systemic inflammatory process, that
primarily affects the skin, also causes endothelial dysfunction,
                                                                   Methods
artery calcification, and atherosclerotic disease [2]. A higher    This study was conduct in collaboration between the Depart-
incidence of vascular occlusive events has been observed in        ments of Dermatology and Diagnostic Imaging at the Uni-
psoriatic patients compared to healthy controls, and multiple      versity of Rome Tor Vergata. The study was conducted from
studies confirm the association between moderate-severe PsO        January 2017 to July 2017 at the Department of Dermatol-
and atherosclerosis, coronary artery calcification, and higher     ogy. We enrolled 280 consecutive patients (males and females)
cardiovascular risk [3-8]. Young adults affected by severe PsO     with psoriasis vulgaris or arthropathic psoriasis. The patients
are 3 times more likely to face myocardial infarction than         underwent clinical and laboratory exams, including abdom-
controls [9], and the risk of fatal myocardial infarction or       inal circumference measurements and arterial pressure. We
stroke is even higher in patients hospitalized with PsO [10].      determined if the patients were cigarette smokers and if had
Moreover, a higher frequency of ischemic heart disease and         hypercholesterolemia, hypertriglyceridemia, and glycemia.
cerebral and peripheral vascular disease has been observed            The inclusion criteria of the study were: male and female
in patients affected by moderate-severe disease compared           patients aged 35-85 years, with an abdominal circumference
with controls [11]. Thus, current opinion holds that PsO is an     < 102 cm for males and < 88 cm for females, cholesterol plas-
independent risk factor for cardiovascular disease [2,12,13].      matic level < 200 mg/dl, plasma glucose level < 126 mg/dl
    Color Doppler ultrasonography (CDUS) of the carotid            on 2 separate analyses, systolic pressure < 140 mmHg and
arteries is a first-level imaging technique performed in the       diastolic pressure < 90 mmHg, and non-smoker or < 5 ciga-
diagnosis of carotid atherosclerotic disease. Ultrasonography      rettes/day smoker.
(US) is the modality of choice for screening, diagnosis, and          The exclusion criteria were: contraindications to iodin-
monitoring atheromatous disease because it is a fast, non-in-      ated contrast agent administration, pregnancy, regular use of
vasive, low-cost technique that evaluates the macroscopic          alcohol (> 2 drinks/day), oncological history, family history
appearance of atheromatous plaques as well as flow char-           of vascular disease, transient ischemic attack or stroke in the
acteristics in the carotid artery. Although US is considered a     previous 5 years, and current or past use of intravenous drugs.
useful tool in the assessment of the cardiovascular risk, there       The final study group was composed of 47 psoriatic
are few studies so far conducted regarding its use in patients     patients (patient group: 26 males and 21 females, aged 35-70
affected by psoriasis vulgaris and psoriatic arthritis.            years), without conventional cardiovascular risk factors, and
    Computerized tomography angiography (CTA) is a very            an equal number of non-psoriatic subjects, who had under-
accurate technique for evaluating carotid stenosis, outper-        gone epiaortic vessel CDUS at the Department of Diagnostic
forming CDUS [14], but not as accurate in describing carotid       Imaging, recruited retrospectively between January 2017 and
plaques and assessing their vulnerability.                         July 2017, (control group: 27 males and 20 females, aged
                                                                   35-70 years). They underwent CDUS as a general exam, and

Objectives                                                         from the medical interview carried out before the US exam-
                                                                   ination it was determined they were in good health with no
The aim of this study is to evaluate the prevalence of ath-        noteworthy diseases or underlying conditions, and without
erosclerotic disease in epiaortic vessels of psoriatic patients    conventional cardiovascular risk factors.
without conventional cardiovascular risk factors, using CDUS          Among the psoriatic patients, 37 were affected by psori-
and CTA, and to analyze the presence of any difference in          asis vulgaris and 10 by severe psoriatic arthritis, and all of



2                                                                      Original Article | Dermatol Pract Concept. 2022;12(1):e2022011
them were being treated with systemic drugs including cyclo-       to ensure adequate therapeutic diagnostic planning of the
sporine and/or methotrexate and anti-tumor necrosis factor         incidental finding, according to the current clinical practice.
α (TNF-α) biologic drugs. All the subjects gave informed           The CTA was performed using a Lightspeed VCT 64-slice
consent prior to their inclusion in the study.                     scanner (General Electric), with a pre-contrast phase and an
    All the subjects underwent epiaortic vessels CDUS. These       arterial phase with bolus tracking, with a non-ionic iodin-
evaluations were executed with a high-resolution US equip-         ated contrast agent injection (350 mg/ml) with a flow rate of
ment (Philips iU22 Ultrasound System,), using a high-fre-          3.5 ml/s, followed by a bolus of 20 ml of saline flush at
quency linear probe (9-3 MHz) and a carotid preset. The            the same speed. The images were also analyzed in 3D, with
neck vessels studied were common carotid arteries, internal        multiplanar reconstruction and volume rendering and inter-
carotid arteries and external carotid arteries, and we evalu-      preted in consensus with the same two radiologists. When a
ated both side regions of the neck for each subject for a total    plaque was detected, the carotid stenosis was quantified by
of 94 common carotid arteries, 94 internal carotid arteries,       the NASCET method: (distal diameter of the internal carotid
and 94 external carotid arteries in the psoriatic patients and     − residual diameter / distal diameter of the internal carotid)
an equal number of vessels in the non-psoriatic subjects. The      ×100 [16]. The radiological features of the detected plaques
vertebral arteries were examined in all participants, but the      analyzed with CDUS and CTA were the percentage of steno-
results obtained were not included in the study.                   sis, structure, and surface.
    The US examinations were carried out by a radiologist             Continuous variables, normally distributed (patient age,
with 5 years of experience, and the images were evaluated          IMT thickness) were presented as the mean ± standard
in consensus with a radiologist with 25 years of experience.       deviation (SD) and categorical variables were presented as
The US exams were performed at first in B-mode with axial          counts (percentage). Fisher exact test was used to compare
and longitudinal scans in order to identify arterial wall inti-    differences in atherosclerotic disease prevalence between
ma-media thickness (IMT) of common carotid arteries and            psoriatic patients and healthy subjects. Any P value < 0.05
the presence of common and internal carotid plaques.               was considered statistically significant.
    The IMT measurement was performed automatically with
dedicated software. The mean value between left and right
sides was taken into consideration and an IMT <1 mm was
                                                                   Results
considered normal. The presence of a plaque was considered         The mean (SD) age of the psoriatic group was 50.9 ± 8 years
when a focal IMT was greater than 50% of the surrounding           (range 35-70 years), and of the control group 51.3 ± 8 years
area [15]. Subsequently CDUS, and pulsed Doppler spectral          (range 35-70 years). In the psoriatic patients an IMT > 1 mm
analysis were performed: peak systolic velocity (PSV cm/s)         without carotid plaques (Figure 1) was found in 12 patients
and end diastolic velocity (EDV cm/s) values were analyzed         (25.5%), with a mean value of 1.4 mm (range 1.1-1.8 mm).
to determine the percentage of stenosis and plaque hemo-           Atheromatous plaques were found in 6 patients, mean age
dynamics.                                                          57.5 ± 4.6 years (range 50-64 years), with a prevalence of
    When at least 1 carotid plaque or an increased IMT of the      12.7%. In 4 patients, an increase of IMT coexisted, thus the
common carotid on a side was detected with US examination,
the patient was considered positive for atherosclerotic disease.
If both carotids had an IMT >1 mm, the average thickness of
the 2 was taken into consideration.
    In the psoriatic patient group, if CDUS examination
detected atherosclerotic plaque, the patient had to go simul-
taneous CTA of the extracranial vessels in order to confirm
its presence, better define plaque features, determine the per-
centage of stenosis, and search for the presence of additional
plaques in other locations. Psoriatic patients who at CDUS
presented an IMT >1 mm were asked to follow-up after 12
months with another CDUS to check for vascular disease.
The psoriatic patients who did not present any atherosclerotic
pathology at CDUS were asked to follow-up with regular
dermatological visits.
    Subjects of the control group underwent epiaortic vessel       Figure 1. Longitudinal US of the right common carotid artery of a
CDUS. If a plaque revealed severe stenosis (> 70%) or if signs     51-year-old female psoriatic patient with an IMT > 1 mm without
of surface ulceration were detected, they underwent a CTA          plaque. IMT = intima-media thickness; US = ultrasonography.



Original Article | Dermatol Pract Concept. 2022;12(1):e2022011                                                                    3
increase of IMT was detected in a total of 16 patients with              8 cases (67%). The plaque surface was smooth (83.4%) or
a prevalence of 34%. A total number of 18 patients showed                irregular (16.6%), no ulceration signs were detected at US
carotid atherosclerotic disease with an overall prevalence               examination. In these 12 cases the plaques revealed mild ste-
of 38.2%.                                                                nosis, with a percentage of stenosis variable at 10-30%. Pulsed
    Plaques were found in 6 patients and were localized in               Doppler spectral analysis consistently showed a PSV < 125
carotid arteries bilaterally in each patient, with a total number        cm/s with an EDV < 40 cm/s in the ICA, demonstrating that
of 12 plaques. Among these, US revealed 2 plaques located                the stenosis was not hemodynamically significant (Figure 2).
in internal carotid artery (ICA), 4 plaques located in carotid               All plaques detected with CDUS analysis were confirmed
bifurcations, and 6 plaques located in carotid bifurcations              with CTA examination (Figure 3). At the final CTA, 4 plaques
extended to the ipsilateral ICA. Moreover, the structure of the          were in a left bifurcation and ICA (33.3%), 3 plaques were
plaques was hypoechoic in 4 cases (33%) and fibrocalcific in             in a right bifurcation and ICA (25%), 2 plaques were in a




Figure 2. (A) Longitudinal ultrasonography of a hypoechoic plaque in the right internal carotid artery of a 50-year-old male psoriatic patient
with a smooth surface that produced stenosis of about 25%. (B) Axial ultrasonography of the same plaque. (C) longitudinal color Doppler ul-
trasonography and pulsed Doppler spectral analysis of this plaque showing a peak systolic velocity of 40 cm/s, not hemodynamically significant.



4                                                                             Original Article | Dermatol Pract Concept. 2022;12(1):e2022011
right bifurcation (16.6%), 1 in a left bifurcation (8.3%), 1              showed features of vulnerable plaques following both CDUS
in a right ICA (8.3%) and 1 in a left ICA (8.3%); 8 plaques               and CTA examinations. Our results showed good agreement
were fibrocalcific (67%), 2 hypoechoic plaques which were                 between the two imaging techniques, with a concordance rate
previously documented at US showed a wide fibrous cap                     of 92% between CDUS and CTA regarding plaque localiza-
(16.5%), and 2 were lipid-rich plaques (16.5%) (Table 1).                 tion, 83% regarding plaque structure, and 100% regarding
All of them produced a stenosis < 30% and none of them                    both percentage of stenosis and plaque surface morphology.




            Figure 3. (A) Axial ultrasound of a fibrocalcific plaque in left internal carotid artery of a 58-year-old male psoriatic
            patient, with a smooth surface that produced stenosis of about 20%. (B) Oblique reconstruction of computed to-
            mography angiography of the plaque that produced a stenosis of about 20%.


  Table 1. Epidemiological Characteristics of Psoriatic Patients with Plaques (n = 6) and Features of
                   These Plaques (n = 12) With CDUS and CTA Examinations*
     Psoriatic Patient            Technique                  Location                Stenosis              Structure               Surface
                                     CDUS           Right bifurcation + ICA             30%              Fibrocalcific            Irregular
                                      CTA           Right bifurcation + ICA             30%              Fibrocalcific            Irregular
 Male, 60 years
                                     CDUS            Left bifurcation + ICA             30%              Fibrocalcific            Irregular
                                      CTA            Left bifurcation + ICA             30%              Fibrocalcific            Irregular
                                     CDUS                   Right ICA                   25%                Lipid-rich              Smooth
                                      CTA                   Right ICA                   25%                Lipid-rich              Smooth
 Male, 50 years
                                     CDUS            Left bifurcation + ICA             20%              Fibrocalcific             Smooth
                                      CTA            Left bifurcation + ICA             20%              Fibrocalcific             Smooth
                                     CDUS               Right bifurcation               15%              Fibrocalcific             Smooth
                                      CTA               Right bifurcation               15%              Fibrocalcific             Smooth
 Male, 58 years
                                     CDUS                    Left ICA                   20%              Fibrocalcific             Smooth
                                      CTA                    Left ICA                   20%              Fibrocalcific             Smooth
                                     CDUS           Right bifurcation + ICA             30%              Fibrocalcific             Smooth
                                      CTA           Right bifurcation + ICA             30%              Fibrocalcific             Smooth
 Female, 64 years
                                     CDUS                Left bifurcation               20%                Lipid-rich              Smooth
                                      CTA            Left bifurcation + ICA             20%                Lipid-rich              Smooth
                                     CDUS               Right bifurcation               20%                Lipid-rich             Irregular
                                      CTA               Right bifurcation               20%          Fibrous + lipid core         Irregular
 Female, 57 years
                                     CDUS            Left bifurcation + ICA             10%              Fibrocalcific             Smooth
                                      CTA            Left bifurcation + ICA             10%              Fibrocalcific             Smooth
                                     CDUS           Right bifurcation + ICA             15%              Fibrocalcific             Smooth
                                      CTA           Right bifurcation + ICA             15%              Fibrocalcific             Smooth
 Female, 56 years
                                     CDUS                Left bifurcation               20%                Lipid-rich              Smooth
                                      CTA                Left bifurcation               20%          Fibrous + lipid core          Smooth

*CDUS errors compared to CTA are highlighted in gray.
CDUS = color Doppler ultrasonography; CTA = computed tomography angiography; ICA = internal carotid artery.



Original Article | Dermatol Pract Concept. 2022;12(1):e2022011                                                                                5
Moreover, CTA did not reveal the presence of additional               Innate and adaptive immune systems are likewise considered
plaques along the carotid axes or along vertebral arteries.           responsible for pathological changes in both epidermis and
     Regarding subjects of the control group, US examination          vascular walls [2].
revealed IMT > 1 mm without carotid atheromatous plaques                 A recent meta-analysis of 4 genome-wide association
in 4 people (8.5%) bilateral or unilateral, with a mean value of      studies selected a broad number of single nucleotide poly-
1.2 mm (range 1.1-1.5). Atheromatous plaques were detected            morphisms (SNPs) that showed a significant association with
in 4 subjects, mean age 62.5 ± 2.6 years (range 59-64), with          cardiovascular disease, hypertension, body mass index, hyper-
a prevalence of 8.5%. Plaques were unilateral in 2 cases and          lipidemia, or type II diabetes. They then investigated which
bilateral in 2 cases, with a total number of 6 plaques. The           one of these polymorphisms was also associated with PsO
structure of these plaques was hypoechoic in 2 cases (33.3%),         [17] and identified 8 main SNPs codifying for a key protein
and fibrocalcific in 4 cases (66.7%), with a variable percent-        in the process of lymphocyte differentiation, thrombogenesis,
age of stenosis at 10-20%, and none of them were hemody-              and in the induction of VCAM1 and E-selectin on the surface
namically significant at color Doppler analysis. Other plaque         of endothelial cells under the stimulation of TNF-α. This
features of the control group subjects are explained in Table 2.      might explain its dual role in establishing a susceptibility
In 2 cases an increased IMT coexisted, thus an increased IMT          to multiple immune-mediated and cardiovascular diseases.
was detected in a total of 6 subjects with a prevalence of            Subcutaneous tissue is able to produce proinflammatory cyto-
12.7%. A total number of 8 cases showed carotid atheroscle-           kines and C-reactive protein under the influence of mediators
rotic disease with an overall prevalence of 17%. The Fisher           such as TNF-α [18].
exact test statistic value was 0.0368, and this result highlights        Modifications in the adipocyte metabolic profile,
the presence of a statistically significant difference (P < 0.05)     including alterations of adiponectin, leptin and resistin,
between the prevalence of carotid atherosclerotic disease             are considered responsible in starting or maintaining the
(increase of IMT and/or atheromatous plaques) in patients             inflammatory process [19]. In particular, high blood lev-
without cardiovascular risk factors affected by PsO and those         els of resistin seem to be related to a proinflammatory
without cardiovascular risk factors and without PsO.                  systemic state, insulin-resistance, and atherosclerosis [2].
                                                                      Metabolic syndrome is more frequent in psoriatic patients

Conclusions                                                           than in the general population [12], and its prevalence
                                                                      directly correlates to PsO duration and severity [20]. Of
PsO is a chronic systemic inflammatory disease. With the term         note, the abovementioned effects are particularly relevant
“psoriasis march,” Boehncke et al described the process that          when dealing with central or visceral obesity [21]. A direct
starts from genetic and environmental predisposing factors            correlation between severity of PsO, central obesity and
and leads to a dysregulation of the immune system that gives          vascular inflammation has been reported, with concurrent
rise to a chronic systemic inflammatory state that also causes        reduction of these parameters after 12 months of systemic
endothelial dysfunction, atherosclerosis, and coronary events.        or biologic therapy [22].



      Table 2. Epidemiological Characteristics of Non-Psoriatic Patients (n = 8) with Atheromatous
    Pathology (IMT >1 mm and/or plaques) and Features of the Plaques (n°=6) Detected With CDUS
    Non-Psoriatic Subjects              Location                Pathology            Stenosis        Structure          Morphology
 Male, 64 years                 Right bifurcation                   Plaque             15%           Lipid-rich            Smooth
                                Left bifurcation                    Plaque             20%          Fibrocalcific          Smooth
                                Bilateral                           IMT 1.2              -                 -                   -
 Male, 65 years                 Right bifurcation + ICA             Plaque             20%          Fibrocalcific          Smooth
 Male, 59 years                 Left bifurcation + ICA              Plaque             10%           Lipid-rich            Smooth
 Female, 62 years               Left bifurcation                    Plaque             15%          Fibrocalcific          Smooth
                                Right bifurcation + ICA             Plaque             15%          Fibrocalcific          Smooth
                                Bilateral                           IMT 1.2              -                -                    -
 Female, 61 years               Right                               IMT 1.2              -                -                    -
 Male, 68 years                 Bilateral                           IMT 1.3              -                -                    -
 Male, 61 years                 Left                                IMT 1.1              -                -                    -
 Female, 62 years               Bilateral                           IMT 1.1              -                -                    -

CDUS = color Doppler ultrasonography; ICA = internal carotid artery; IMT = intima-media thickness.



6                                                                            Original Article | Dermatol Pract Concept. 2022;12(1):e2022011
    Recently, sonoelastography has been proposed as a tool          regarding both percentage of stenosis and plaque surface
in monitoring the response to treatment in psoriatic patients,      morphology.
as it evaluates hypodermal adipose tissue inflammation                  Ultrasound errors were made only in determining the
underneath lesioned plaques at baseline and during systemic         plaque composition in 2 cases (2 hypoechoic plaques previ-
treatment [23].                                                     ously documented at US showed a wide fibrous cap at CTA),
    Twenty-five years ago, McDonald and Calabresi performed         and in determining the complete plaque extension along the
the first study showing that patients with PsO had more             vessel in 1 case (a plaque that at US examination seemed
vascular occlusive events than patients without PsO [3]. Sub-       localized only in the carotid bifurcation and at CTA appeared
sequently, multiple studies confirmed the association between       extended to the ipsilateral ICA). In spite of being a fast, non-
moderate-severe PsO and atherosclerosis, coronary artery            invasive, well tolerated, and low-cost imaging method, US
calcification, higher cardiovascular risk, myocardial infarction,   is an operator-dependent examination that requires a good
stroke and peripheral vascular disease [4-11]. It is hypothesized   understanding of Doppler physics and hemodynamic physiol-
that this association might be due to an overrepresentation in      ogy. A more precise evaluation of the percentage of stenosis,
the psoriatic population with a Framingham Risk Score (age,         of the composition and of the morphology of the plaque is
hypertension, obesity, smoking, diabetes, hypercholesterol-         made with CTA, but it uses ionizing radiation and potentially
emia, hyperlipidemia, and familial history) [12]. In addition,      allergenic and nephrotoxic contrast agents. In fact, CTA has
many traditional systemic therapies for PsO seem to affect          been proved to be an accurate modality for detection of severe
cardiovascular risk, increasing cardiovascular risk factors such    carotid artery disease and, especially, for detection of occlu-
as hyperlipidemia, hypertension, and hyperhomocysteinemia.          sions [32]. This means that CDUS should not be replaced as
Nevertheless, recent studies identified PsO as an independent       the first-line investigation for epiaortic vessels.
risk factor for cardiovascular disease [9,10,11,12,13,20].              Although our results are based on a small cohort of patients,
    An increased prevalence and severity of coronary artery         we concluded that PsO could be considered a risk factor for the
calcification and atherosclerosis (measured by cardiac com-         development of atheromatous pathology in epiaortic vessels,
puted tomography, CTA, or coronary angiography) has been            because primarily it causes a thickening of the IMT. Therefore,
reported in psoriatic patients compared to healthy controls         this study contributes to support the hypothesis that PsO should
[24-30]. A lower coronary flow reserve has been observed in         be considered as an independent cardiovascular risk factor.
young subjects, otherwise healthy patients with severe PsO              The American Society of Echocardiography more recently
compared to controls, suggesting that early impairment of           recommended the cut-off value for IMT at ≥ 1.5 mm, but set
coronary microvascular function is independent of conven-           IMT above 1 mm [15]. The main limitation of this study is the
tional cardiovascular risk factors.                                 small cohort of subjects included and, in this regard, further
    Our study reveals abnormalities in the vessel walls of          studies with larger cohorts, carried on in close cooperation
carotid arteries in a great percentage of psoriatic patients        with different medical specialists, finalized to a correct selec-
who did not have any cardiovascular risk factors. In par-           tion of patients, are necessary to confirm and improve our
ticular, we highlighted a higher prevalence of carotid ath-         results. This could be relevant in order to aid in the clinical
erosclerotic disease (increased IMT and/or atheromatous             management of psoriatic patients and offer them better diag-
plaques) in patients affected by PsO than in healthy subjects       nostic/therapeutic pathways to prevent cardiovascular disease.
regardless of cardiovascular risk factors. It was detected in           We propose that epiaortic CDUS as the most suitable
an increased IMT, which represents a predisposing risk fac-         method in assessing cardiovascular risk and in the early
tor for stroke events [31]. Analysis of the data also showed        identification of minor changes and atheromatous plaques
a higher mean age in the control group affected by athero-          of epiaortic vessels of psoriatic patients.
matous plaques than that of psoriatic patients affected by
atheromatous plaques. In fact, in the control group plaques         References
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Original Article | Dermatol Pract Concept. 2022;12(1):e2022011                                                                        9
