Background/Purpose: There is accumulating evidence demonstrating an increased prevalence of atherosclerotic cardiovascular disease (ASCVD) among the psoriatic arthritis (PsA) population. Yet, the relationship between immunosuppressive therapies and the development of ASCVD remains unclear. This study was undertaken to investigate the ASCVD risk among PsA patients and its relationship with systemic immunosuppressive therapies, including tumor necrosis factor alpha (TNF-α) inhibitors and methotrexate (MTX).

Methods: A multicenter retrospective cohort study involving the Veterans Affairs Hospitals in Long Beach (LBVA) and Greater Los Angeles (GLAVA) was performed. PsA patients from both sites (n=189) were evaluated against controls (n=99) without autoimmune diseases. The groups were matched on age, sex, race, BMI, smoking exposure, and ASCVD risk factors (hypertension, diabetes, and hyperlipidemia). Their ASCVD risk was evaluated using the American College of Cardiology/American Heart Association’s (ACC/AHA) ASCVD risk score. The odds ratio (OR) for developing any ASCVD event, myocardial infarctions (MI), congestive heart failure (CHF), and cerebral vascular accidents (CVA) were calculated. Additionally, the OR for CHF in the PsA patients was analyzed in relation to their exposure to TNF-α inhibitors, MTX, and concomitant use of TNF-α inhibitors with MTX, with exposure defined as use of therapy ≥ 12 months.

Results: PsA and controls ACC/AHA ASCVD risk scores of 21.5% and 17.1% (p=0.005). PsA patients twice the risk for developing any ASCVD event (OR 1.9; 95% CI 1.10 to 3.35). CHF (OR 3.4; 95% CI 1.27 to 9.1) was the most likely event to develop when compared to CVA (OR 1.33; 95% CI 0.50 to 3.55) and MI (OR 1.28; 95% CI 0.69 to 2.23). The risk of developing CHF is increased in PsA patients exposed to MTX (OR 4.7; 95% CI 1.24 to 17.77) relative to TNF-α inhibitors (OR 3.42; 95% CI 1.00 to 11.05). Meanwhile, PsA patients exposed to concomitant TNF-α inhibitors with MTX had decreased risk for developing CHF (OR 1.91; 95% CI 1.26 to 12.10) when compared to the overall PsA cohort in this study, and the subgroups of PsA patients exposed to either TNF-α inhibitors or MTX alone.

Conclusion: PsA patients have an increased risk for developing ASCVD, in particular CHF. Exposure to either MTX or TNF-α inhibitor individually does not confer a protective role against CHF. However, combining the use of MTX with TNF-α inhibitor therapy decreases the risk of developing CHF relative to the overall PsA cohort and those receiving monotherapy with MTX or TNF-α inhibitor therapy alone. This suggests that the two therapies work together to attenuate adverse myocardial remodeling and offer a beneficial role against the development of CHF in PsA patients.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/the-role-of-immunosuppressive-therapy-in-the-development-of-atherosclerotic-cardiovascular-disease-in-patients-with-psoriatic-arthritis/