1. Dr Verity Blackwell West Hertfordshire Dermatology Team

2. Psoriasis 2.3% of population 125 million people world wide Associated with Arthritis Depression Reduced quality of life Increased prevalence of cardiovascular and cerebrovascular disease

3. Psoriasis Patients with severe psoriasis have increased mortality 19.6% deaths versus 9% in controls Increased risk of myocardial infarction independent of other risk factors Increased risk of Stroke

4. Prevalence of cardiovascular risk factors in patients with psoriasis. Prevalence of cardiovascular risk factors in patients with psoriasis. [J Am Acad Dermatol. 2006 Gelfand et al] Prospective UK based study 20-90 yr olds, mean 5.4 yr follow up Controlled for age, sex, previous MI,diabetes,hypertension,smoking, hyperlipidaemia,BMI Psoriasis absent(controls),mild or severe Severe if ever received systemic therapy

5. Prevalence of cardiovascular risk factors in patients with psoriasis. Prevalence of cardiovascular risk factors in patients with psoriasis. [J Am Acad Dermatol. 2006 Gelfand et al] 555,995 controls 127,139 mild psoriasis 3837 severe psoriasis MI controls=2% mild psoriasis =1.8% severe psoriasis= 2.9% Relative risk of MI with severe psoriasis Aged 30=3.1 aged 60 =1.36 Aged 40=2.69 aged 60= 1.92(Danish study 2009)

6. Psorisiasis and risk of AF and Ischaemic Stroke Danish study July 2011 >36,000 pts with mild psoriasis,2793 pts with severe psoriasis versus controls Rate ratio for AF Mild psoriasis 50yrs=1.16 Severe psoriasis 50yrs 1.29 Rate ratio for Ischaemic stroke Mild psoriasis 50yrs =1.13 Severe psoriasis 50yrs =1.34

7. Why? Genetics Lifetime burden of inflammation

8. Association of cardiovascular risk factors and psoriasis Large UK study showed increased incidence of Obesity Hypertension Dyslipidaemia Diabetes Hyperhomocysteinaemia Smoking

9. Atherosclerosis Chronic immuno-inflammatory disorder of arterial wall Chronic inflammation implicated in formation of fatty streaks Activation of TH1 mediated cytokine cascade also trigger for acute coronary event

10. Psoriasis Most common Th1 disorder Chronic inappropriate activation of Th1 cytokines TNF,IFN,IL2 Also new Th –IL-17 subset that has role in pathogenesis of psoriatic lesion and via IL12 also stimulates Th1 response in arteries

11. What can we do as dermatologists Obesity Measure BMI; advice re diet and exercise Hypertension >140/90 advise repeat in primary care Diabetes ?check fasting blood sugar if obese Refer to primary care

12. What can we do? Cholesterol Refer pt to primary care Aspirin therapy Refer patient to primary care

13. What can we do? Smoking Advising pt to stop increases cessation rate by 30% Give out NHS helpline cards Single most important intervention in improving patient health

14. Summary Dermatologist and dermatology nurses may be seeing patient more frequently than primary care team May be best placed to nudge patients to see GP about controlling risk factors Severe psoriasis independently increases risk of cardiovascular disease ?will treating severe psoriasis lower this risk?