By Angela Ryan Lee, MD
Medically reviewed by Scott Zashin, MD
Psoriatic arthritis (PsA) is a chronic autoimmune condition causing inflammation of the skin and joints. But the problem doesn't end there. Systemic inflammation throughout the body from psoriatic arthritis increases the risk of cardiovascular disease.
This article discusses PSA, its association with heart disease, and ways to lower risk.
Verywell / Mira Norian
What Is Psoriatic Arthritis?
PsA is a chronic inflammatory condition that affects the joints. It occurs in up to 1 in 3 people with psoriasis (a skin condition causing red, itchy, scaly patches).1
Joint involvement in PsA can be severe and disabling, particularly when not identified and treated early. People with PsA may experience the following symptoms:
Red, scaly, and itchy plaques on the skin
Small indentations on the nails
Swollen, stiff, and painful joints, especially in the hands
Red, swollen fingers or toes, known as dactylitis
Pain and swelling of the tendons
Psoriatic Arthritis and Heart Disease
PsA increases the risk of heart disease both directly and indirectly.
First, PsA inflammation is not just in the skin and joints. PsA causes systemic inflammation throughout the body, including in the blood vessels. Blood vessel inflammation contributes to the buildup of cholesterol plaques, or atherosclerosis, which causes heart attacks, ischemic strokes, and peripheral artery disease.
In addition to the direct effect of inflammation on blood vessels, PsA and other inflammatory diseases are linked with heart disease risk factors, like high blood pressure, high cholesterol, insulin resistance, and obesity.2 These, in turn, further increase the risk of cardiovascular disease.
Untreated PsA
One large 16-year study showed that people with untreated PsA had a 36% higher risk of heart attack and stroke.3
Treatment
Since inflammation from PsA increases the risk of heart disease, controlling inflammation is an important goal of therapy.
Treating PsA includes taking anti-inflammatory medications, which can be given by mouth or injection. Some anti-inflammatory medications appear to decrease vascular inflammation and atherosclerosis in people with PsA.2
Topical medications applied to the skin and phototherapy (light therapy) may also be added to alleviate skin symptoms.
Clinical Guidelines
Current American Heart Association and American College of Cardiology cholesterol guidelines recommend that inflammatory diseases like PsA be considered risk-enhancers that lower the threshold for starting statins (cholesterol medications).4
In people whose heart disease risk makes them a borderline candidate for statins, a screening test called a coronary calcium score can be considered. This noninvasive test involves taking pictures of the heart with a CT (computed tomography) scan to look for calcium deposits in the coronary arteries.
Ways to Reduce the Risk of Heart Disease in PsA
Understand the Risk Factors
PsA and other inflammatory conditions are known risk factors for heart disease. When combined with other risk factors for heart disease, the risk is even higher.
The following are other risk factors that further increase heart disease risk:
High cholesterol
Insulin resistance and diabetes
Obesity
Smoking
Sedentary lifestyle
Regular Screening Tests
Psoriatic arthritis is associated with several other heart disease risk factors, and the following tests can help screen for risks:
Blood pressure screening
Lipid panel to screen for high cholesterol
Hemoglobin A1c or blood sugar test to screen for diabetes or insulin resistance
Body mass index (BMI) to screen for clinical obesity
Inflammatory markers, like C-reactive protein (CRP), to demonstrate levels of systemic inflammation
Coronary calcium score, to be considered for those with borderline to intermediate cardiac risk to help decide if cholesterol-lowering medications are needed
Review Medication Choices with a Healthcare Provider
Rheumatologists (doctors who specialize in inflammatory disease) can help choose an individualized treatment plan for people with PsA based on the severity of symptoms and inflammation.
Medications for treating PsA include:
Nonsteroidal anti-inflammatory drugs (such as ibuprofen and naproxen), especially for mild disease
Disease-modifying anti-rheumatic drugs (DMARDS) which include Otrexup (methotrexate)
Biologic medications, like TNF-inhibitors and interleukin inhibitors
Some anti-inflammatory medications for PsA appear to reduce vascular inflammation and atherosclerosis. For example, one study showed that those on TNF-alpha inhibitors had favorable effects in people with coronary atherosclerosis.5 More research is needed to determine the exact role for particular PsA therapies in reducing heart disease risk.
Another aspect to consider is that certain anti-inflammatory medications may increase blood pressure and blood sugar, and cause weight gain. Furthermore, some medications used to treat PsA may not be as effective in people with clinical obesity.6
Lifestyle Changes
While the increased risk of heart disease with PsA is concerning, there are ways to decrease risk that apply to everyone, including:
Eat a healthy diet. The Mediteranean diet has known benefits for heart health, and has some evidence for improving psoriasis symptoms.7
Exercise regularly.
Quit smoking.
Manage weight with a low-calorie diet, which has beneficial effects on heart health and PsA.
Control cholesterol and blood sugar with diet, exercise, and medications, when necessary.
Summary
Psoriatic arthritis is a chronic autoimmune condition that can lead to significant joint pain and dysfunction. The inflammatory effects of PsA also increase heart disease risk.
Treating PsA is important to prevent joint complications and improve quality of life. It also appears to reduce the risk of heart disease. Management of PsA should include monitoring for heart disease risk and implementing preventive strategies like cholesterol medication and lifestyle changes.
9 Sources
National Psoriasis Foundation. About psoriatic arthritis.
Teklu M, Parel PM, Mehta NN. Psoriasis and cardiometabolic diseases: the impact of inflammation on vascular health. Psoriasis. 2021;11:99-108. doi:10.2147/PTT.S320016
Ogdie A, Yu Y, Haynes K, et al. Risk of major cardiovascular events in patients with psoriatic arthritis, psoriasis and rheumatoid arthritis: a population-based cohort study. Ann Rheum Dis. 2015;74(2):326-332. doi:10.1136/annrheumdis-2014-205675
Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;139:e1082–e1143. doi:10.1161/CIR.0000000000000625
Elnabawi YA, Dey AK, Goyal A, et al. Coronary artery plaque characteristics and treatment with biologic therapy in severe psoriasis: results from a prospective observational study. Cardiovasc Res. 2019;115(4):721-728. doi:10.1093/cvr/cvz009
Cai J, Cui L, Wang Y, Li Y, Zhang X, Shi Y. Cardiometabolic comorbidities in patients with psoriasis: focusing on risk, biological therapy, and pathogenesis. Front Pharmacol. 2021;12:774808. doi:10.3389/fphar.2021.774808
Ford AR, Siegel M, Bagel J, et al. Dietary recommendations for adults with psoriasis or psoriatic arthritis from the medical board of the national psoriasis foundation: a systematic review. JAMA Dermatol. 2018;154(8):934–950. doi:10.1001/jamadermatol.2018.1412
Rose S, Dave J, Millo C, Naik HB, Siegel EL, Mehta NN. Psoriatic arthritis and sacroiliitis are associated with increased vascular inflammation by 18-fluorodeoxyglucose positron emission tomography computed tomography: baseline report from the Psoriasis Atherosclerosis and Cardiometabolic Disease Initiative. Arthritis Res Ther. 2014;16(4):R161. doi:10.1186/ar4676
Garg N, Krishan P, Syngle A. Atherosclerosis in psoriatic arthritis: a multiparametric analysis using imaging technique and laboratory markers of inflammation and vascular function. Int J Angiol. 2016;25(4):222-228. doi:10.1055/s-0036-1584918
By Angela Ryan Lee, MD
Angela Ryan Lee, MD, is board-certified in cardiovascular diseases and internal medicine. She is a fellow of the American College of Cardiology and holds board certifications from the American Society of Nuclear Cardiology and the National Board of Echocardiography. She completed undergraduate studies at the University of Virginia with a B.S. in Biology, medical school at Jefferson Medical College, and internal medicine residency and cardiovascular diseases fellowship at the George Washington University Hospital. Her professional interests include preventive cardiology, medical journalism, and health policy.
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