ORIGINAL ARTICLES

Are patients with psoriasis being screened forcardiovascular risk factors? A study of screeningpractices and awareness among primary care

physicians and cardiologists

Kory K. Parsi, BS,a,d Elizabeth A. Brezinski, BA,a Tzu-Chun Lin, MS,b Chin-Shang Li, PhD,c

and April W. Armstrong, MD, MPHa

Sacramento, California, and Mesa, Arizona

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Introduction: Increasing literature suggests that patients with psoriasis who have severe disease appear tohave increased frequency of cardiovascular (CV) diseases. The National Psoriasis Foundation recommendsscreening for CV risk factors as early as 20 years of age. The extent to which these screening guidelines areimplemented in practice is unclear.

Objective: We sought to assess CV risk factor screening practices in patients with psoriasis and to assessprimary care physician (PCP) and cardiologist awareness of worse CV outcomes in patients with psoriasis.

Methods: We distributed 1200 questionnaires to PCPs and cardiologists between October 1, 2010, andApril 15, 2011. A representative national sample of physicians was obtained by random selection fromprofessional medical societies.

Results: A total of 251 PCPs and cardiologists responded to the questionnaire. Among these physicians,108 (43%) screened for hypertension, 27 (11%) screened for dyslipidemia, 75 (30%) screened for obesity,and 67 (27%) screened for diabetes. Physicians who cared for a greater number of patients with psoriasiswere significantly more likely to screen for CV risk factors (hypertension P = .0041, dyslipidemia P = .0143,and diabetes P = .0065). Compared with PCPs, cardiologists were 3.5 times more likely to screen fordyslipidemia (95% confidence interval 1.32-9.29, P = .012). A total of 113 (45%) physicians were aware thatpsoriasis was associated with worse CV outcomes.

Limitations: The questionnaire response rate was modest.

Conclusions: Most PCPs and cardiologists did not routinely screen patients with psoriasis for CV riskfactors. Educating physicians regarding potentially increased CV risk in psoriasis and adopting amultidisciplinary approach in the care of patients with psoriasis will likely lead to improved patientoutcomes. ( J Am Acad Dermatol 2012;67:357-62.)

Key words: cardiovascular disease; clinical practice; comorbidities; coronary artery disease; myocardialinfarction; psoriasis; screening.

the Departments of Dermatology,a Statistics,b and Public

ealth Sciences,c University of California, Davis; and AT Still

niversity-School of Osteopathic Medicine in Arizona.d

stical support for this publication was made possible by grant

L1 RR024146 from the National Center for Research Resources

CRR), a component of the National Institutes of Health (NIH),

d NIH Roadmap for Medical Research. Its contents are solely

e responsibility of the authors and do not necessarily

present the official view of NCRR or NIH. Information on

-engineering the Clinical Research Enterprise can be

tained from http://nihroadmap.nih.gov/clinicalresearch/over

ew-translational.asp.

Disclosure: Dr Armstrong is an investigator and consultant to

Abbott and Janssen. Mr Parsi, Ms Brezinski, Ms Lin, and Dr Li

have no conflicts of interest to declare.

Accepted for publication September 15, 2011.

Reprint requests: April W. Armstrong, MD, MPH, Department of

Dermatology, University of California Davis Health System.

E-mail: teledermatology@ucdmc.ucdavis.edu.

Other correspondence to: aprilarmstrong@post.harvard.edu.

Published online November 14, 2011.

0190-9622/$36.00

� 2011 by the American Academy of Dermatology, Inc.

doi:10.1016/j.jaad.2011.09.006

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Psoriasis is a chronic, inflammatory skin diseasewith significant comorbidities that affects 1% to 4% ofthe world’s population.1-4 Compared with thegeneral population, patients with psoriasis appearto be at increased risk for established cardiovascular(CV) risk factors and adverse CV outcomes.5-17

Specifically, patients with psoriasis appear to

CAPSULE SUMMARY

d Current literature suggests that patientswith psoriasis may have a higherprevalence of cardiovascular (CV) riskfactors and experience worse CVoutcomes compared with the generalpopulation.

d The majority of primary care physiciansand cardiologists have not implementedguidelines for screening CV risk factors inpatients with psoriasis.

d Educating physicians regardingpotentially increased CV risk in psoriasisand adopting a multidisciplinaryapproach in the care of patients withpsoriasis are necessary.

be more likely to develophypertension, diabetes melli-tus, obesity, and dyslipide-mia compared with thegeneral population.17-22

Multiple population-based studies have sup-ported the observation thatpatients with psoriasis expe-rience worse CV outcomescompared with the generalpopulation. Patients withpsoriasis who have severedisease appear to be at in-creased risk for coronary ar-tery disease, myocardialinfarction, and stroke com-pared with the general pop-ulation.7,8,23-26 In evaluationof myocardial infarction risk,psoriasis appears to contrib-

ute risks greater than or equal to that conferred byestablished CV risk factors such as diabetes, dyslipi-demia, and hypertension.7,9,24 Although the prepon-derance of epidemiologic research has thus farsuggested an association between psoriasis and CVdisease, not all studies found such a link.27,28

Differences in study and analytical methods mayaccount for varied findings regarding how psoriasiscontributes to CV risks. Clinicians will need to stayabreast of the current literature and manage CVcomorbidities as they arise in patients with psoriasis.

Current screening guidelines for the general popu-lation are developed by the US Preventive ServicesTask Force.29 For hypertension, screening is recom-mendedevery2years inadultswithbloodpressure lessthan 120/80 mm Hg and every year for persons withsystolic bloodpressureof 120 to 139mmHgordiastolicblood pressure of 80 to 89 mm Hg. Dyslipidemiascreening is recommended in men aged 35 years andolder and inwomenaged45 years andolderwhoare atincreased risk of coronary artery disease. Measuringand monitoring body mass index allows clinicians toidentify adults at increased risk forCVmortality. Finally,the American Diabetes Association recommends a3-year interval for diabetes screening.29

The mounting evidence supporting the associa-tion between psoriasis and CV risk factors and

adverse CV outcomes has prompted developmentof screening guidelines in patients with psoriasis. In2008, the National Psoriasis Foundation (NPF) andthe American Journal of Cardiology (AJC) eachreleased screening guidelines and recommendationsfor management of CV risk factors in patients withpsoriasis.30,31 Because the associations between pso-

riasis and CV disease wereunder active investigation,both groups recommendedfollowing general CVrisk fac-tor assessment accordingto the American HeartAssociation (AHA) 2002 up-date on prevention of CVdisease and stroke. TheAHA recommends CV riskfactor screening starting at20 years of age.32 The AJCpanel recommends that pa-tients with moderate to se-vere psoriasis undergo CVrisk assessment by their pri-mary care physicians (PCPs),and that dermatologists pro-vide recommendations forrisk assessment to PCPs.30

Like the NPF guidelines, the

AJC also provides recommendations for the treat-ment of established CV risk factors including hyper-tension, obesity, and dyslipidemia.30,31

Despite screening guidelines for CV risk factors inpatients with psoriasis recommended by both NPFand AJC, it is uncertain whether screening guide-lines are implemented in clinical practice. Theprimary aim of our study was to assess the screeningpractices and awareness among PCPs and cardiol-ogists with regard to CV risk factors in patients withpsoriasis.

METHODSStudy setting and instrument

This study was approved on September 22, 2010(201018438-1) by the Institutional Review Board atthe University of California, Davis. We distributed anonline questionnaire to board-certified US PCPs andcardiologists. To ensure representative sampling,permission was obtained to administer the studyquestionnaire to physicians randomly selected fromthe American College of Cardiology and theAmerican Academy of Family Physicians.Physicians from a variety of practice settings andgeographic regions were encouraged to participatein the study. Data were collected from October 1,2010, through April 15, 2011.

Abbreviations used:

AHA: American Heart AssociationAJC: American Journal of CardiologyCI: confidence intervalCV: cardiovascularNPF: National Psoriasis FoundationOR: odds ratioPCP: primary care physicianRA: rheumatoid arthritisSLE: systemic lupus erythematosus

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The questionnaire identified physicians’ screen-ing practices for CV risks factors in patients withpsoriasis and ascertained their awareness of adverseCV outcomes in patients with psoriasis. In addition,the questionnaire also asked physicians about theirawareness of CV outcomes in other autoimmuneconditions, including rheumatoid arthritis (RA) andsystemic lupus erythematosus (SLE).

Ascertainment of outcomesThe primary outcome of the studywas to ascertain

whether physicians screened for CV risk factors inpatients with psoriasis, such as hypertension, dysli-pidemia, obesity, and type 2 diabetes mellitus.

Secondary outcomes of the study were to: (1)evaluate physician awareness of increased CV out-comes among patients with psoriasis, and (2) com-pare physician screening practices for CV risk factorsand awareness of worse CV outcomes in patientswith psoriasis versus those in patients with RA andSLE.

Data analysisUnivariable logistic regression was used to com-

pare the proportion of physicians reporting screen-ing between cardiologist and PCP groups and tocompare the proportion of physicians aware ofincreased CV outcomes among patients with psori-asis. Multivariable logistic regression was used forthese same comparisons to adjust for years sincecompleting residency, physician gender, and num-ber of reported patients with psoriasis seen permonth.

The two-sided McNemar test was used to com-pare the proportion of physicians whowere aware ofincreased adverse CV outcomes in patients withpsoriasis versus those in patients with RA and SLE.The two-sided McNemar test was also used to com-pare screening practices for CV risk factors betweenpatients with psoriasis and SLE. The generalizedestimating equations approach was applied to adjustfor years since completing residency, physiciangender, and number of reported patients with pso-riasis seen per month.33 For all analyses, a P valueless than .05 was considered statistically significant.

RESULTSFrom 1200 online questionnaires that were dis-

tributed, 251 physicians responded to the onlinequestionnaire, which corresponded to a responserate of 21%. Among the 251 physician responders, 60(24%) were US board-certified cardiologists and 191(76%) were PCPs comprising board-certified USfamily medicine physicians, internists, and generalinternal medicine physicians (Table I).

Screening practices for CV risk factors inpatients with psoriasis

We assessed screening practices for establishedCV risk factors in patients with psoriasis and com-pared screening practices between PCPs and cardi-ologists. Overall, 108 (43%) physicians reportedscreening patients with psoriasis for hypertensionstarting at 20 years of age, 27 (11%) reportedscreening for dyslipidemia, 75 (30%) reportedscreening for obesity, and 67 (27%) reported screen-ing for type 2 diabetes mellitus.

Among the physician characteristics, the numberof patients with psoriasis seen per month wassignificantly associated with screening for CV riskfactors. After adjustment of specialty, number ofyears since completing residency, and physiciangender, the number of patients with psoriasis seenper month was significantly associated with screen-ing for hypertension, dyslipidemia, and diabetes.Specifically, compared with physicians who did notregularly care for patients with psoriasis, physicianswho saw between 1 to 5 and 6 to 10 patients withpsoriasis per month were 2.56 (95% confidenceinterval [CI] 1.42-4.61) and 5.28 (95% CI 1.41-19.71)times more likely to screen patients with psoriasis forhypertension (P = .0041). Similarly, compared withthose who did not care for patients with psoriasisregularly, physicians who cared for 1 to 5 and 6 to 10patients with psoriasis per month were 2.68 (95% CI0.93-7.76) and 8.93 (95% CI 1.56-51.02) times morelikely to screen for dyslipidemia (P = .0143).Furthermore, physicians who cared for 1 to 5 and 6to 10 patients with psoriasis per monthwere 2.9 (95%CI 1.42-5.90) and 5.67 (95% CI 1.53-21.03) timesmore likely to screen for diabetes (P = .0065).

Compared with PCPs, cardiologists were 2.46times more likely to screen patients with psoriasisfor dyslipidemia (95% CI 1.07-5.63, P = .034) onunivariate analysis. After adjustments for years afterresidency, gender, and number of patients withpsoriasis seen per month, cardiologists were 3.5times more likely to screen for dyslipidemia com-pared with PCPs (95% CI 1.32-9.29, P = .012). Nosignificant differences existed in screening practices

Table I. Physician demographics and clinicalcharacteristics

Characteristic

Cardiologists

(n = 60)

Primary care

physicians (n = 191)

DemographicAge, y\40 31 (52%) 63 (33%)41-50 8 (13%) 48 (25%)51-60 9 (15%) 56 (29%)[60 12 (20%) 24 (13%)

GenderFemale 13 (22%) 81 (42%)Male 47 (78%) 110 (58%)

ClinicalYears since completing residency0-10 34 (57%) 60 (31%)11-20 7 (12%) 51 (27%)21-30 8 (13%) 64 (34%)[30 11 (18%) 16 (8%)

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between PCPs and cardiologists for hypertension(odds ratio [OR] 0.849, 95% CI 0.471-1.532, P = .587),obesity (OR 0.508, 95% CI 0.252-1.024, P = .058), ordiabetes (OR 0.702, 95% CI 0.352-1.399, P = .315).

Awareness of adverse CV outcomes in patientswith psoriasis

Overall, 113 (45%) physicians were aware thatpsoriasis was associated with worse CV outcomesthan the general population. Our study showed that79 (42%) PCPs were aware of worse CV outcomesamong patients with psoriasis, such as myocardialinfarction, stroke, and coronary artery disease. Incomparison, 34 (57%) cardiologists were aware ofincreased CV risk among patients with psoriasis. Onunivariate analysis, cardiologists were 1.85 timesmore likely to be aware of worse CV outcomesamong patients with psoriasis than PCPs (95% CI1.03-3.33, P = .039). After adjustments for years afterresidency, gender, and number of patients withpsoriasis seen per month, cardiologists were 2.5times more likely to be aware of worse CVoutcomesamong patients with psoriasis (95% CI 1.29-4.85, P =.0067) compared with PCPs.

Comparisons with SLE and RASignificant differences existed in screening prac-

tices for CV risk factors in patients with psoriasisverus SLE (Fig 1). In patients with SLE, 166 (66%)physicians screened for hypertension, 81 (32%)screened for obesity, 69 (28%) screened for dyslipi-demia, and 97 (39%) screened for type 2 diabetesmellitus. Compared with screening patients withpsoriasis, physicians were more likely to screen

patients with SLE for hypertension (OR 2.81, 95%CI 2.19-3.61, P\.0001), dyslipidemia (OR 3.24, 95%CI 2.25-4.67, P\.0001), and diabetes (OR 1.79, 95%CI 1.42-2.25, P\ .0001) after adjustments for physi-cian specialty, number of years since completingresidency, and physician gender.

With regard to awareness of CV outcomes, phy-sicians were nearly twice as likely to be aware of theworse CV outcomes associated with RA than withpsoriasis (80% vs 45%, P\ .0001). Similarly, physi-cians were more than twice as likely to be aware ofthe worse CVoutcomes in SLE than in psoriasis (92%vs 45%, P\ .0001).

DISCUSSIONIn 2008, the NPF and AJC released reviews of the

available evidence for psoriasis comorbidities andrecommended physician screening practices. TheNPF suggested that patients with psoriasis bescreened for CV risk factors starting at 20 years ofage, with more rigorous screening for patients 40years of age and older.31 Both NPF and AJC guide-lines recommendedmonitoring blood pressure, lipidlevels, body mass index, and glucose intolerance atregular intervals.30,31

Our study showed that less than half of physiciansscreened patients with psoriasis for CV risk factorsstarting at 20 years of age. Compared with PCPs,cardiologists were significantly more likely to screenpatients with psoriasis for dyslipidemia. It is possiblethat cardiologists ascertain certain risk factors for CVdisease more regularly in their clinics as part of theirroutine workup compared with PCPs. The study alsorevealed that physicians who care for a greaternumber of patients with psoriasis are more likely toscreen for CV risk factors. That is, increased experi-ence caring for patients with psoriasis appears to beassociated with greater adherence to screeningguidelines.

In this study, less than half of all physicians wereaware of greater major CV adverse events in patientswith psoriasis compared with the general popula-tion. Compared with PCPs, cardiologists were morelikely to be aware of the increased CV diseases inpatients with psoriasis. Because cardiologists man-age CV diseases routinely, their awareness of worseCV outcomes in psoriasis is therefore likely to begreater than that of PCPs. Increasing publications ofthe association between psoriasis and CV diseases inthe cardiology literature may also contribute to theirincreased awareness.25,34

We also found that physicians were more likely toscreen for CV risk factors in patients with SLE than inpatients with psoriasis. They were also more awareof the increased CV adverse outcomes associated

Fig 1. Physician screening practices for cardiovascular (CV) risk factors are compared betweenpatients with systemic lupus erythematosus (SLE) and psoriasis. Physician awareness ofincreased adverse CV outcomes is compared among SLE, rheumatoid arthritis, and psoriasis.

Table II. Recommended screening guidelines for cardiovascular risk factors in patients with psoriasis

Risk factor Baseline screening Target values Frequency

Obesity d BMI measurement BMI\25 kg/m2 Routinely (at each visit)Hypertension d Blood pressure measurement Systolic blood pressure\ 130 mm Hg Routinely (at each visit)

d Ascertain family history Diastolic blood pressure\ 85 mm HgDiabetes d Fasting blood glucose measurement # 100 mm/dL (fasting level) At least once every 3 y

d Ascertain family historyDyslipidemia d Fasting blood cholesterol

measurementTotal cholesterol:\200 mg/dLLDL:\100 mg/dLHDL: $ 50 mg/dL

Once yearly

BMI, Body mass index; HDL, high-density lipoprotein; LDL, low-density lipoprotein.

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with RA and SLE than with psoriasis. These differ-ences in screening practices and awareness likelyreflect a larger body of literature supporting theassociation of CV diseases with RA and SLE, andmore intense education of physicians duringtraining.

The findings of this study need to be interpreted inthe context of study design. Limitations of the studyinclude the modest response rate and the potentialfor reporting bias, which is inherent toquestionnaire-based methodology. Furthermore, al-though PCPs and cardiologists are two groups ofphysicians most likely to screen patients for CVrisk factors, examining other medical specialties,

including dermatology, will be instructive to deter-mine the extent of screening practices and aware-ness in other fields.

Our study suggests that most PCPs and cardiolo-gists did not routinely screen patients with psoriasisfor CV risk factors per guidelines. From a dermatol-ogist’s perspective, possible ways to encouragegreater adherence to screening guidelines in PCPsand cardiologists include: (1) publishing studies onthe association between psoriasis and CV diseases ininternal medicine and cardiology literature to in-crease awareness, (2) adopting a multidisciplinaryapproach with PCPs and/or cardiologists by activelyco-treating patients with psoriasis, and (3)

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presenting studies on the association between CVdiseases and psoriasis at internal medicine andcardiology conferences. In circumstances whereattempted education of PCPs and cardiologists isineffective, dermatologists may need to take a pro-active approach to help screen patients with psori-asis at high risk for CV diseases (Table II) and referpatients to other PCPs and cardiologists capable ofcaring for these patients’ CV comorbidities. Overall,educating all physicians regarding potentially in-creased CV risk in psoriasis and adopting a multidis-ciplinary approach in the care of patients withpsoriasis will likely lead to the greatest improvementin patient outcomes.

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