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Hallelujah! A negative comorbidity study: Putting comorbidities in perspective

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By Warren R. Heymann, MD
July 30, 2016

Upon reading the title “Assessment of the risk of cardiovascular disease in patients with rosacea,” I was braced for yet another reason why we should invest in cardiac nuclear scans in our dermatology office instead of a new laser.

Recently, we had reviewed a Taiwanese study concluding that coronary artery disease was independently associated with rosacea after adjustment of hypertension, diabetes, and dyslipidemia, especially in men (1). I was prepared for a similar conclusion from Egeberg, et al; however, I was actually pleased to learn otherwise. They identified 4948 Danish rosacea patients who were matched with 23,823 control subjects and found that rosacea was not associated with an increased risk of adverse CV outcomes (myocardial infarction, stroke) or death. There was even a trend toward having a diminished risk of having a myocardial infarction. A limitation of the study was that the authors were unable to ascertain the subtypes or severity of rosacea (2).

In the same issue of JAAD, Egeberg’s article was preceded and followed by other comorbidity articles. The first paper evaluated 68 patients with hidradenitis suppurativa (HS) and 136 age- and sex-matched healthy control subjects. Patients with history of cardiovascular events, diabetes mellitus, chronic kidney disease, or another concomitant inflammatory condition were excluded. Patients had greater, statistically significant, carotid intima-media thickness values than control subjects, indicating that patients with HS have an increased frequency of subclinical atherosclerosis which could translate into an elevated cardiovascular risk (3). In the other article, the authors identified 2,722,375 individuals, including 25,774 and 4504 patients with mild and severe psoriasis, respectively. A family history of CVD was found among 16,080 (62.4%) and 3009 (66.8%) patients with mild and severe psoriasis, respectively. In patients with psoriasis and a family history of CVD, the adjusted incidence rate ratios (95% CI) of MACE (major adverse cardiovascular events) were 1.28 and 1.62 for mild and severe disease, respectively. In patients with psoriasis but without a family history of CVD, there was no increased risk of MACE. The authors concluded that when assessing cardiovascular risk in psoriatic patients, there should be a focus on the family history of cardiovascular disease (4).

A decade ago Joel Gelfand published his seminal work associating the risk of myocardial infarction with severe psoriasis (5). Since then the field of comorbidities has become a proverbial cottage industry. Indeed if you search any chronic inflammatory or autoimmune disease and cross-reference it on PubMed with “metabolic syndrome,” you will see an exhaustive literature (For example, as of July 30, 2016, if you search “rheumatoid arthritis and MACE” you will find 28 articles, “RA and metabolic syndrome” yields 365 manuscripts). The data is incontrovertible — severe chronic inflammatory disorders are associated with increased cardiovascular risk. What the rosacea and psoriasis articles detailed in this commentary point out, however, is that all patients are not at risk. Certainly, it is our obligation to inform those who are clearly at risk for MACE or metabolic syndrome (obese patients with severe psoriasis, for example) to seek help in modifying lifestyle or receive medications for controllable risk factors (such as diabetes or hypertension). It is also our duty to mollify the fears of our anxious patients who are at minimal risk for these adverse effects, when they read and worry about a relative risk that may be no risk at all. These articles are a step in the right direction. I look forward to having Joel and other dermatoepidemiologists further define the subsets of patients who are truly at risk, so that they can avoid the ravages of MACE, while not adding extra stress for our patients who are otherwise well.

1. Hua T-C, et al. Cardiovascular comorbidities in patients with rosacea: A nationwide case-control study from Taiwan. J Am Acad Dermatol 2015; 73: 249-54.
2. Egeberg A, et al. Assessment of the risk of cardiovascular disease in patients with rosacea. J Am Acad Dermatol 2016; 75: 336-9.
3. González-López MA, et al. Increased prevalence of subclinical atherosclerosis in patients with hidradenitis suppurativa (HS). J Am Acad Dermatol 2016; 75: 329-35.
4. Egeberg A, et al. Family history predicts major adverse cardiovascular events (MACE) in young adults with psoriasis. J Am Acad Dermatol 2016; 75: 340-6.
5. Gelfand JM, et al. Risk of myocardial infarction in patients with psoriasis. JAMA 2006; 296: 1735-41.

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