Turkiye Klinikleri Journal of Dermatology

.: ORIGINAL RESEARCH
Subclinical Left Ventricular Dysfunction in Patients with Psoriasis Assessed Using Speckle Tracking Echocardiography
Psöriyazis Hastalarında Subklinik Sol Ventriküler Disfonksiyonun Speckle Tracking Ekokardiyografi ile Değerlendirilmesi
Ezgi AKTAŞ KARABAYa, Aslı AKSU ÇERMANb, Damla DEMİRc, İlknur KIVANÇ ALTUNAYb, Mutlu ÇAĞAN SÜMERKANd
a Department of Skin and Venereal Diseases, Bahçeşehir University Medical Park Göztepe Hospital,
Clinics of
b Skin and Venereal Diseases,
d Cardiology,
İstanbul University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital,
c Department of Dermatology and Venereology, Ümraniye Training and Research Hospital,
İstanbul, TURKEY
Turkiye Klinikleri J Dermatol. 2019;29(2):51-7
doi: 10.5336/dermato.2019-70951
Article Language: EN
Full Text
ABSTRACT
Objective: Psoriasis, which is a chronic inflammatory disease is associated with an increased risk of cardiovascular (CV) diseases (CVD). Currently, no method is available to evaluate subclinical CV dysfunction in patients with psoriasis. The aim of the study was to evaluate left ventricular (LV) function in patients with untreated psoriasis but no risk factors for CV disease (CVD). Material and Methods: Thirty patients with psoriasis without any CVD or risk factors for CVD and 20 age- and gender-matched controls were recruited. All patients underwent detailed transthoracic echocardiography, including speckle tracking-derived strain analysis. Results: Speckle tracking echocardiography showed significantly lower global circumferential strain in psoriatic patients compared to healthy controls (mean ±SD: -23.34±6.74% vs. -27.53±4.11%, respectively, p<0.001). No significant differences were found in terms of global longitudinal strain, aortic flow velocity, pulmonary arterial flow velocity, LV end-systolic volume, LV end-diastolic volume, LV ejection fraction, peak of early diastolic (E) and late diastolic (A) flow velocity, E⁄A ratio, and levels of biochemical markers, including C-reactive protein, between the patients and controls (p>0.05). Conclusion: Subclinical myocardial dysfunction was seen in the patients with psoriasis who had no conventional risk factors for CVD using two-dimensional strain imaging. We believe that this imaging technique may be useful for early detection of CVD development in patients with psoriasis.

Keywords: Cardiovascular diseases; psoriasis; two-dimensional strain imaging
ÖZET
Amaç: Kronik, inflamatuar bir hastalık olan psöriyazis artmış kardiyovasküler (KV) hastalık (KVH) riski ile ilişkilidir. Şu anda, psöriyazis hastalarında subklinik KV disfonksiyonu inceleyen bir yöntem bulunmamaktadır. Bu çalışmanın amacı, tedavi almayan ve KVH gelişimi açısından hiçbir risk faktörü bulunmayan psöriyazisli hastalarda sol ventrikül fonksiyonunu incelemektir. Gereç ve Yöntemler: Bilinen KVH öyküsü veya KVH gelişimi için hiçbir risk faktörü bulunmayan 30 psöriyazis hastası ve yaş ve cinsiyet açısından uyumlu 20 sağlıklı kontrol çalışmaya dahil edildi. Tüm hastalara speckle traking derivasyonlar da dahil olmak üzere detaylı transtorasik ekokardiyografi yapıldı. Bulgular: Speckle traking ekokardiyografi ile global sirkümferensiyal gerilme, psöriyazis hastalarında kontrollere göre belirgin olarak daha düşük saptandı (ortalama ±SS: -23,34±%6,74 vs.-27,53±%4,11, sırasıyla, p<0,001). Global longitudinal gerilme, aort akım hızı, pulmoner arter akım hızı, sol ventrikül sistolsonu hacmi, sol ventrikül ejeksiyon fraksiyonu, erken diyastolik akım hızı (E) ve geç diyastolik (A) akım hızı tepe noktası sistol sonu volüm, E⁄A oranı ve C-reaktif protein de dahil olmak üzere biyokimyasal parametreler açısından psöriyazis hastaları ve kontrol grubu arasında anlamlı fark saptanmadı (p>0,05). Sonuç: Kardiyovasküler hastalık gelişimi açısından geleneksel risk faktörü bulunmayan psöriyazis hastalarında iki-boyutlu gerilme görüntüleme kullanılarak subklinik myokard disfonksiyonu saptandı. Bu görüntüleme tekniğinin psöriyazis hastalarında KVH gelişimini erken dönemde belirlemek açısından faydalı olabileceğini düşünmekteyiz.

Anahtar Kelimeler: Kardiyovasküler hastalık; psöriyazis; iki boyutlu gerilme görüntüleme
REFERENCES:
  1. Boehncke WH, Schön MP. Psoriasis. Lancet. 2015;386(9997):983-94. [Crossref] 
  2. McDonald CJ. Cardiovascular disease in psoriasis. J Invest Dermatol. 1989;92(4):646-7. [Crossref]  [PubMed] 
  3. Wakkee M, Thio HB, Prens EP, Sijbrands EJ, Neumann HA. Unfavorable cardiovascular risk profiles in untreated and treated psoriasis patients. Atherosclerosis. 2007;190(1):1-9. [Crossref]  [PubMed] 
  4. Singh VP, Le B, Khode R, Baker KM, Kumar R. Intracellular angiotensin II production in diabetic rats is correlated with cardiomyocyte apoptosis, oxidative stress, and cardiac fibrosis. Diabetes. 2008;57(12):3297-306. [Crossref]  [PubMed]  [PMC] 
  5. Gelfand JM, Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB. Risk of myocardial infarction in patients with psoriasis. JAMA. 2006;296(14):1735-41. [Crossref]  [PubMed] 
  6. Ludwig RJ, Herzog C, Rostock A, Ochsendorf FR, Zollner TM, Thaci D, et al. Psoriasis: a possible risk factor for development of coronary artery calcification. Br J Dermatol. 2007;156(2):271-6. [Crossref]  [PubMed] 
  7. Zhao CT, Yeung CK, Siu CW, Tam S, Chan J, Chen Y, et al. Relationship between parathyroid hormone and subclinical myocardial dysfunction in patients with severe psoriasis. J Eur Acad Dermatol Venereol. 2014;28(4):461-8. [Crossref]  [PubMed] 
  8. Ardic I, Kaya MG, Yarlioglues M, Karadag Z, Dogan A, Yildiz H, et al. Impaired aortic elastic properties in normotensive patients with psoriasis. Blood Press. 2010;19(6):351-8. [Crossref]  [PubMed] 
  9. Karadag AS, Yavuz B, Ertugrul DT, Akin KO, Yalcin AA, Deveci OS, et al. Is psoriasis a pre-atherosclerotic disease? Increased insulin resistance and impaired endothelial function in patients with psoriasis. Int J Dermatol. 2010;49(6):642-6. [Crossref]  [PubMed] 
  10. Shang Q, Tam LS, Yip GW, Sanderson JE, Zhang Q, Li EK, et al. High prevalence of subclinical left ventricular dysfunction in patients with psoriatic arthritis. J Rheumatol. 2011;38(7):1363-70. [Crossref]  [PubMed] 
  11. Bülbül Şen B, Ekiz Ö, Rifaioğlu EN, Büyükkaya E, Karakaş MF, Büyükkaya Ş, et al. Assessment of subclinical left ventricular dysfunction in patients with psoriasis by speckle tracking echocardiography: a Speckle Tracking Study. Int J Dermatol. 2016;55(2):158-64. [Crossref]  [PubMed] 
  12. Thomas G. Response to "non-Doppler two-dimensional strain imaging by echocardiography-from technical considerations to clinical applications." J Am Soc Echocardiogr. 2007;20(8):1020. [Crossref]  [PubMed] 
  13. Blessberger H, Binder T. NON-invasive imaging: two dimensional speckle tracking echocardiography: basic principles. Heart. 2010;96(9):716-22. [Crossref]  [PubMed] 
  14. Yiu KH, Schouffoer AA, Marsan NA, Ninaber MK, Stolk J, Vlieland TV, et al. Left ventricular dysfunction assessed by speckle-tracking strain analysis in patients with systemic sclerosis: sclerosis: relationship to functional capacity and ventricular arrhythmias. Arthritis Rheum. 2011;63(12):3969-78. [Crossref]  [PubMed] 
  15. Sitia S, Tomasoni L, Cicala S, Atzeni F, Ricci C, Gaeta M, et al. Detection of preclinical impairment of myocardial function in rheumatoid arthritis patients with short disease duration by speckle tracking echocardiography. Int J Cardiol. 2012;160(1):8-14. [Crossref]  [PubMed] 
  16. Fredriksson T, Pettersson U. Severe psoriasis--oral therapy with a new retinoid. Dermatologica. 1978;157(4):238-44. [Crossref]  [PubMed] 
  17. Delgado V, Ypenburg C, van Bommel RJ, Tops LF, Mollema SA, Marsan NA, et al. Assessment of left ventricular dyssynchrony by speckle tracking strain imaging comparison between longitudinal, circumferential, and radial strain in cardiac resynchronization therapy. J Am Coll Cardiol. 2008;51(20):1944-52.
  18. Samarasekera EJ, Neilson JM, Warren RB, Parnham J, Smith CH. Incidence of cardiovascular disease in individuals with psoriasis: a systematic review and meta-analysis. J Invest Dermatol. 2013;133(10):2340-6. [Crossref]  [PubMed] 
  19. Armstrong AW, Harskamp CT, Armstrong EJ. Psoriasis and the risk of diabetes mellitus: a systematic review and meta-analysis. JAMA Dermatol. 2013;149(1):84-91. [Crossref]  [PubMed] 
  20. Alexandroff AB, Pauriah M, Camp RD, Lang CC, Struthers AD, Armstrong DJ. More than skin deep: atherosclerosis as a systemic manifestation of psoriasis. Br J Dermatol. 2009;161(1):1-7. [Crossref]  [PubMed] 
  21. Ahlehoff O, Hansen PR, Gislason GH, Frydland M, Bryld LE, Elming H, et al. Myocardial function and effects of biologic therapy in patients with severe psoriasis: a prospective echocardiographic study. J Eur Acad Dermatol Venereol. 2016;30(5):819-23. [Crossref]  [PubMed] 
  22. Yilmazer B, Sahin T, Cefle A. Impaired myocardial deformation in psoriatic arthritis patients assessment by speckle trackingecho-cardiography. Acta Reumatol Port. 2016; 41(2):131-7.
  23. Kimball AB, Gladman D, Gelfand JM, Gordon K, Horn EJ, Korman NJ, et al; National Psoriasis Foundation. National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening. J Am Acad Dermatol. 2008;58(6): 1031-42. [Crossref]  [PubMed]  [PMC] 
  24. El-Mongy S, Fathy H, Abdelaziz A, Omran E, George S, Neseem N, et al. Subclinical atherosclerosis in patients with chronic psoriasis: a potential association. J Eur Acad Dermatol Venereol. 2010;24(6):661-6. [Crossref]  [PubMed] 
  25. Channual J, Wu JJ, Dann FJ. Effects of tumor necrosis factor-alpha blockade on metabolic syndrome components in psoriasis and psoriatic arthritis and additional lessons learned from rheumatoid arthritis. Dermatol Ther. 2009;22(1):61-73. [Crossref]  [PubMed] 
  26. Herron MD, Hinckley M, Hoffman MS, Papenfuss J, Hansen CB, Callis KP, et al. Impact of obesity and smoking on psoriasis presentation and management. Arch Dermatol. 2005;141(12):1527-34. [Crossref]  [PubMed] 
  27. Qureshi AA, Choi HK, Setty AR, Curhan GC. Psoriasis and the risk of diabetes and hypertension: a prospective study of US female nurses. Arch Dermatol. 2009;145(4):379-82. [Crossref]  [PMC] 
  28. Prodanovich S, Kirsner RS, Kravetz JD, Ma F, Martinez L, Federman DG. Association of psoriasis with coronary artery, cerebrovascular, and peripheral vascular diseases and mortality. Arch Dermatol. 2009;145(6):700-3. [Crossref]  [PubMed] 
  29. Mehta NN, Azfar RS, Shin DB, Neimann AL, Troxel AB, Gelfand JM. Patients with severe psoriasis are at increased risk of cardiovascular mortality: cohort study using the General Practice Research Database. Eur Heart J. 2010;31(8):1000-6. [Crossref]  [PubMed]  [PMC] 
  30. Hahn BH, Grossman J, Chen W, McMahon M. The pathogenesis of atherosclerosis in autoimmune rheumatic diseases: roles of inflammation and dyslipidemia. J Autoimmun. 2007;28(2-3):67-75. [Crossref]  [PubMed] 
  31. Herédi E, Végh J, Pogácsás L, Gáspár K, Varga J, Kincse G, et al. Subclinical cardiovascular disease and it's improvement after long-term TNF-a inhibitor therapy in severe psoriatic patients. J Eur Acad Dermatol Venereol. 2016;30(9):1531-6. [Crossref]  [PubMed] 

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