Cardiovascular risk factors in patients with plaque psoriasis: a systematic review of epidemiological studies

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1 DOI: /j x JEADV REVIEW ARTICLE Cardiovascular risk factors in patients with plaque psoriasis: a systematic review of epidemiological studies S Prey, C Paul,,* V Bronsard, E Puzenat, P-A Gourraud, S Aractingi, ** F Aubin, M Bagot, B Cribier, P Joly, D Jullien, M Le Maitre, M-A Richard-Lallemand, J-P Ortonne Dermatology Department, Paul Sabatier University, Larrey Hospital, Toulouse, France Dermatology Department, Nice University, L Archet II Hospital, Nice, France Dermatology Department, Franche Comté University, Besançon, France Epidemiology Department, Toulouse University Hospital; Inserm, Unit 558, Toulouse, France and Neurology Department, University of California, San Francisco, USA **Dermatology Department, Tenon Hospital, APHP, Paris 6 University, Paris, France Dermatology Department, Saint Louis Hospital, Paris, France Dermatology Department, Strasbourg, France Dermatology Department, Rouen University Hospital, University of Rouen, Rouen, France Dermatology Department, Edouard Herriot Hospital, Lyon, France Dermatologist, Caen, France Université de la Méditerranée Aix Marseille II - Dermatology Department Sainte Marguerite Hospital, Marseille, France *Correspondence: C Paul. paul.c@chu-toulouse.fr Abstract Introduction Many epidemiological studies have associated psoriasis with an increased risk of coronary artery disease, resulting from a higher prevalence of cardiovascular risk factors in psoriasis patients compared with unmatched controls. However, the results of epidemiological studies vary depending upon the populations studied. The aim of this systemic review was to evaluate the risk of diabetes, hypertension, dyslipidaemia and obesity in adults with plaque psoriasis. In addition, we assessed the relationship between the risk of cardiovascular risk factors and psoriasis severity. Methods A systematic search was performed on Pubmed, Cochrane and Embase databases, using the key-words psoriasis, diabetes, hypertension, high blood pressure, dyslipidaemia, metabolic syndrome and obesity, during the period from 1980 to June Results The initial literature search identified 353 articles. The final selection included 18 cross-sectional casecontrol studies. An increased risk of metabolic syndrome was observed in psoriatic patients (OR = ), and a trend for a higher risk of obesity (OR = ), especially in patients with severe psoriasis. For hypertension, hypertriglyceridaemia, and diabetes, the association was not significant in all studies. Discussion There was important heterogeneity in study design preventing from pooling results. Most often lifestyle factors such as smoking, alcohol consumption, physical activities were not taken into account. Conclusion There is an increased risk of obesity and metabolic syndrome in psoriasis. For hypertension, diabetes and dyslipidaemia no consistency was found across studies. Prospective epidemiological studies with thorough recording of cardiovascular risk factors are required in psoriasis patients. Received: 28 May 2009; Accepted: 18 December 2009 Keywords cardiovascular diseases, comorbidity, diabetes, dyslipidemia, hypertension, metabolic syndrome, obesity, psoriasis, review literature Sources Abbott France provided financial support for publication but took no further part in the project. The authors have no financial interest in the subject matter or materials discussed in the manuscript. Conflicts of interest C. Paul has received research grants and has been a paid consultant of Abbott France; S. Aractingi has given conferences in symposia sponsored by Wyeth and has been a consultant for Abbott and Schering-Plough; the remaining authors declare no conflicts of interests.

2 24 Prey et al. Introduction Psoriasis is a common disease, affecting 2 3% of the population worldwide. 1 Psoriasis is a multigenic inflammatory disease and more than 20 predisposition genes have been identified. The role of environmental factors such as infection, drugs, stressful events and smoking has been suggested. The association of psoriasis with cardiovascular disease dates back from Recent epidemiological studies in registry databases have confirmed a consistent association between adult psoriasis and an increased risk of coronary heart disease and stroke. 3,4 In this study, we systematically evaluated the relationship between psoriasis and cardiovascular risk factors (diabetes, hypertension, dyslipidaemia, obesity and metabolic syndrome) from published epidemiological studies. Material and methods We performed a systematic review of all epidemiological studies (prospective and retrospective) investigating the risk of cardiovascular comorbidities in psoriasis patients and published between January 1980 and June The Cochrane, Pubmed and Embase databases were systematically searched. The research used different combinations of the Medical Subject Headings (MeSH): Psoriasis [title] AND (diabetes OR hypertension OR high blood pressure OR dyslipidaemia OR metabolic syndrome OR obesity). We limited the literature search to articles on human subjects, articles written in English or in French, and articles including original data. For all the articles, the following data were retrieved: type of database, author, year, inclusion period, number of psoriatic patients, number and origin of control subjects (i.e. general population or dermatology patients), existence of matching, criteria used for the definition of the comorbidity (e.g. patients history, measurement), odds ratio and 95% confidence interval. To determine the effect of disease severity, we attempt when possible to separate data for patients with moderate to severe psoriasis versus patients with mild psoriasis. Patients with moderate to severe psoriasis were defined as patients treated with systemic therapy (cyclosporine, methotrexate or biological therapy). Two reviewers (SP, CP) independently performed parts of the systematic electronic search and the data extraction. When not provided in the paper, odds ratio (OR) and or the corresponding 95% confidence intervals (CI) were calculated from the available data of the selected articles. When statistical significance was reassessed, uncorrected P-values are given. All computations were performed using Stata V.10 (StataCorp College Station, TX, USA). Results We identified a total of 353 eligible articles by searching Medline, Cochrane and Embase databases, five by hand-searching reference lists. The majority of articles (N = 264) were excluded by reading the abstract because they did not directly deal with the subject, 13 were not written in English or in French, 12 were reviews, 38 were out of scope and in five articles there was no control group. Eight studies for which there was not enough information to recompute OR were excluded. A total of 18 articles were finally selected (Fig. 1). The control population used in the studies originated from the general population from registry databases in 12 articles, 3,5,6,8,9,12,13,15,17,18,21,22 outpatients attending dermatology departments in five studies performed in dermatology departments, 10,11,14,16,20 and female nurses in one study. 9 Analytical approaches were heterogeneous between studies. Adjustment for age, sex, smoking or area of living was not systematically performed. Diabetes Fourteen cross sectional studies were found, three were performed in the USA, 5 7 and the others in Europe. 3,8 17 (Table 1 and Fig. 2). Eleven studies were based on automated databases (General Practice Research Database = GPRD 3,13,17 in the UK, Clalit Health Service 12 and Maccabi Healthcare Services 15 in Israel, National Health Wellness Survey, 6 IMS Health, 5 Marketscan 5 and Nurses Health Study = NHS 7 in US) and four were performed in dermatology departments. 10,11,14,16 The definition of diabetes varied from one study to another: code in databases, the use of diabetic medications, diabetes mellitus type II in medical history 8 or fasting blood glucose higher than 6.1 mmol L. A significant association between diabetes and psoriasis was found in 11 studies with OR varying from 1.20, CI = [ ] to 2.80, CI = [ ]. In three studies, no significant association was found. 8,11,14 In a recent study by Qureshi et al. 7 the multivariable analysis (adjusting for weight, smoking, physical activity and alcohol) showed an increased risk of diabetes in Figure 1 Study selection procedure.

3 Cardiovascular risk factors in patients with plaque psoriasis 25 Table 1 Cross sectional studies about risk of diabetes in psoriasis References Country Psoriatic Patients nb Nb Type Match OR diabetes Qureshi USA F* Y 2.08 [ ] Brauchli UK G Y 1.31 [ ] 2.56 [ ] Gerdes Germany G Y 2.27 [ ] Kimball USA G Y 1.27 [ ] G 1.20 [ ] Driessen the Netherlands D N 1.91 [ ] Wu USA G Y 1.42 [ ] Naldi Italy D Y 1.1 [ ] Cohen Israel G N 2.80 [ ] Kaye UK G Y 1.33 [ ] Gisondi Italy D N 0.9 [ ] Shapiro Israel G N 1.27 [ ] Gelfand UK G Y 1.61 [ ] 1.62 [ ] Sommer Germany D N 2.48 [ ] Neimann UK G Y 1.27 [ ] 1.86 [ ] population: F*, Nurse female; G, General population; D, Dermatology outpatients; Matching: Y, yes N, no. with moderate to severe psoriasis (OR ranged from 1.62, CI = [ ] to 1.91, CI = [ ]) when compared with patients with mild psoriasis. Figure 2 Cross sectional studies about risk of diabetes in psoriasis (OR with 95% confidence interval) : Dermatological patients (red), General population from databases (green). Matching: Yes (x), No (e). Type of psoriasis: Severe ("), Mild and moderate ()). psoriasis patients with an OR of = 1.63, CI = [ ]. In studies investigating the effect of psoriasis severity on the risk of diabetes (n = 4), the risk of diabetes appeared to be higher in patients Dyslipidaemia Twelve studies were selected. 3,5,6,8,10,12 14,16 18,20 (Table 2 and Fig. 3) Definition of dyslipidaemia was very heterogeneous between studies: code in databases, use of dyslipidaemia medications, hypertriglyceridaemia or hypercholesterolaemia in medical history or results of serum tests (hypertriglyceridaemia > 1.7 mmol L, HDL-cholesterol < mmol L in men or mmol Linwomen). When considering all criteria, there was a trend for a higher risk of dyslipidaemia, which was significant in seven of 12 studies, 3,5,6,8,13,16,17 with OR ranging from 1.0 CI = [ ] to 2.09 CI = [ ] for psoriatic patients compared with the control population. For hypertriglyceridaemia, the OR varied from 1.0, CI = [ ] to 2.0, CI = [ ] and was significant in three studies. 12,14,16 For HDL-cholesterol, there was no increased risk. For total cholesterol, only one study showed a significant increased risk (OR = 1.35, CI = [ ]). 6 No apparent effect of psoriasis severity on the risk of dyslipidaemia was observed. Hypertension Twelve studies evaluated the risk of hypertension in psoriatic patients. 3,5 8,10 14,16,17 (Table 3 and Fig. 4).

4 26 Prey et al. Table 2 Cross sectional studies about risk of dyslipidaemia in psoriasis References Country Psoriasis Nb Type Match Criteria OR dyslipidaemia Gerdes Germany G Y Treatment 1.55 [ ] Kimball USA G Y Code 1.26 [ ] [ ] Driessen the Netherlands D N History 1.17 [ ] Wu USA G Y Total cholesterol 1.35 [ ] Cohen Israel G N TG flhdl 1.0 [ ] 0.9 [ ] Naldi Italia D Y History 1.1 [ ] Kaye USA G Y Code 1.17 [ ] Gisondi Italia D N TG flhdl 2.0 [ ] 0.8 [ ] Neimann UK G Y Code 1.28 [ ] 1.31 [ ] Sommer Germany D Y TG HDL 2.09 [ ] Mallbris Sweden G Y Total cholesterol TG 1.04 [ ] 0.95 [ ] Gelfand U.K G Y Code 1.11 [ ] 1.12 [ ] population: F*, Nurse female; G, General population; D, Dermatologic outpatients; Matching: Y, yes N, no; TG, Triglyceridaemia; HDL, HDL cholesterol. blood pressure > 135 mmhg or 140 mmhg for the systolic, and diastolicbloodpressure>85mmhgor90mmhg. The increased risk of hypertension was significant in 10 of 12 studies, with an OR ranging between 1.09, CI = [ ] and 3.27, CI = [ ]. 3,5 8,10,12,13,16,17 It is unclear whether the level of risk was influenced by psoriasis severity. The multivariable analysis of Qureshi et al. 7 showed a persisting modest increased risk of hypertension in psoriatic patients with an OR = 1.17 CI = [ ]. Figure 3 Cross sectional studies about risk of dyslipidaemia in psoriasis (OR with 95% confidence interval) : Dermatological patients (red), General population from databases (green). Matching: Yes (x), No (e). Type of psoriasis: Severe ("), Mild and moderate ()). The definition of hypertension in the studies was heterogeneous: specific code in the database, the use of anti-hypertensive medications, hypertension in medical history or results of systolic Obesity The definition of obesity used in studies was a body mass index (weight height 2 )higherthan30kg m 2 as defined by the World Health Organization. 19 Eight articles analysed the risk of obesity 10 14,17,20,21 (Table 4 and Fig. 5). They showed a significant increased risk with an OR ranging from 1.18, CI = [ ] to 5.49, CI = [ ] in all studies but one. 14 The level of risk appeared to be influenced by the severity of psoriasis. OR of the moderate and severe psoriasis population varied from 1.79, CI = [ ] to 5.49, CI = [ ] vs. 1.27, CI = [ ] to 1.7, CI = [ ] for mild psoriasis. Metabolic syndrome Three studies evaluated the metabolic syndrome in psoriasis patients, with different criteria for each 14,16,22 (Table 5 and Fig. 6).

5 Cardiovascular risk factors in patients with plaque psoriasis 27 Table 3 Cross sectional studies about risk of hypertension in psoriasis References Country Nb Psoriasis Nb Type Match OR Qureshi USA F* Y 1.32 [ ] Gerdes Germany G Y 1.93 [ ] Kimball USA G Y 1.20 [ ] [ ] Driessen the Netherlands D N 1.93 [ ] Cohen Israel G N 1.3 [ ] Naldi Italia D Y 0.8 [ ] Wu USA G Y 1.49 [ ] Kaye USA G Y 1.09 [ ] Gisondi Italia D N 1.06 [ ] Neimann UK G Y 1.16 [ ] 1.25 [ ] Gelfand UK G Y 1.26 [ ] 3837 G Y 1.83 [ ] Sommer Germany D N 3.27 [ ] population: F*, Nurse female; G, General population; D, Dermatology outpatients; Matching: Y, yes N, no. Figure 4 Cross sectional studies about risk of hypertension in psoriasis (OR with 95% confidence interval) : Dermatological patients (red), General population from databases (green). Matching: Yes (x), No (e). Type of psoriasis: Severe ("), Mild and moderate ()). The study of Gisondi et al. 14 used the criteria of the National Cholesterol Education Program s Adult Panel: central obesity (waist circumference > 102 cm #, > 88 cm $), hypertriglyceridaemia > 1.7 mmol L, HDL-cholesterol < 1.0 mmol L # or < 1.3 mmol L $, blood pressure > mmhg and fasting plasma glucose > 6.1 mmol L. The study of Sommer et al. 16 used the World Health Organization criteria: the presence of diabetes mellitus type II plus at least 2 of the following: antihypertensive medication and or high blood pressure (> 140 mmhg systolic or > 90 mmhg diastolic); plasma triglycerides > 1.7 mmol L; HDL-cholesterol < 0.9 mmol L #, <1.0mmol L $; BMI>30kg m 2 and or waist : hip ratio > 0.9 #, > 0.85 $; urinary albumin excretion rate 20 lg min or albumin:creatinine ratio 30 mg g. The study of Cohen et al. 22 used as criteria the presence of obesity plus any of two of the following criteria: raised triglycerides, reduced HDL-cholesterol, hypertension or diabetes. Each item was extracted from an automated database. In all articles, there was a significant increased risk of metabolic syndrome in psoriasis patients, with OR from 1.3, CI = [ ] to 5.92, CI = [ ]. Gisondi et al. 14 who studied the metabolic syndrome on patients with mild psoriasis, still found an increased risk with an OR = 1.66, CI = [ ] in this population. 14 Discussion There is a significant increased risk of obesity and metabolic syndrome in patients with psoriasis. For other risk factors, hypertension, diabetes mellitus type 2 and dyslipidaemia, the results were less consistent across studies, some studies showing a strong association between psoriasis and these risk factors, others failed to show such an association. Despite different criteria used to define metabolic syndrome across studies a significant association between metabolic syndrome and psoriasis was consistently found.

6 28 Prey et al. Table 4 Cross sectional studies about risk of obesity in psoriasis References Country Psoriasis Nb Nb Type Match OR obesity Definition Driessen the Netherlands D N 5.49 [ ] BMI 30 Naldi Italia D Y 1.7 [ ] BMI>30 Cohen Israel G N 1.7 [ ] Code Kaye UK G Y 1.18 [ ] Code Gisondi Italia G N 1.19 [ ] BMI>30 Neimann UK G Y 1.29 [ ] BMI> [ ] Naldi Italia D N 1.9 [ ] BMI>30 Herron USA G N 2.39 [ ] BMI>30 population: G, General population; D, Dermatologic outpatients; Matching: Y, yes N, no. Figure 5 Cross sectional studies about risk of obesity in psoriatic patients (OR with 95% confidence interval) : Dermatological patients (red), General population from databases (green). Matching: Yes (x), No (e). Type of psoriasis: Severe ("), Mild and moderate ()). The magnitude of the association between psoriasis and cardiovascular comorbidities appeared to be influenced by the study size and by the nature of the control population. Small studies including controls originating from dermatology outpatients tended to show the stronger association (i.e. Table 5). We found a substantial heterogeneity in design between epidemiological studies as regards: retrospective or prospective nature of the recruitment and the outcome assessment, definition of risk factors, type of database used, type of control population, matching and adjustment strategies. Nijsten et al. 23 have reported on the Strengthening the Reporting of OBservational Studies in Epidemiology (STROBE) which provide important information on the quality of observational studies. 24 Most studies evaluated in the present analysis failed to provide a rationale for sample size selection. A potential limitation of cross sectional studies concerned the selection of the control subjects: studies performed in dermatology departments used outpatients as controls; however, outpatients without psoriasis attending a dermatology department may not adequately represent the general population. The main advantage of the prospective studies conducted in dermatology department is the more thorough collections of data regarding cardiovascular risk-factors and psoriasis phenotype. Life style factors such as alcohol, smoking, sedentarity and the use of Table 5 Cross sectional studies about risk of metabolic syndrome in psoriasis References Pays Psoriasis Nb Type Match OR metabolic syndrome Cohen Israel G N 1.3 [ ] Gisondi Italia D N 1.66 [ ] Sommer Germany D N 5.92 [ ] population: G, General population; D, Dermatologic outpatients; Matching: Y, yes N, no.

7 Cardiovascular risk factors in patients with plaque psoriasis 29 3 As part of psoriasis management, the dermatologist may want to provide recommendations concerning diet and physical activity to reduce cardiovascular risk factors. Figure 6 Cross sectional studies about risk of metabolic syndrome in psoriasis (OR with 95% confidence interval) : Dermatological patients (red), General population from databases (green). Matching: Yes (x), No (e). Type of psoriasis: Severe ("), Mild and moderate ()). systemic therapy for psoriasis (i.e. cyclosporine, retinoids) are major confounding bias as these factors can influence cardiovascular risk and also may have a negative effect on some risk factors (e.g. alcohol consumption and hypertension). Lifestyle factors were most often not accounted for in the analysis. Such heterogeneity between the studies prevents from pooling the results and the lack of adjustment for possible confounding factors in some studies raises uncertainty regarding the strength of the association. The pathophysiology of the relation between psoriasis and cardiovascular risk is still debated. Some authors suggest that the high incidence of metabolic syndrome in psoriasis may be at least in part explained by the chronic systemic inflammation present in psoriasis. Obese psoriasis patients have low level of adiponectine (compared with normal weight psoriasis) and an increased level of IL-6 and gluthation redox status (oxidative stress). 25 Leptin, a proinflammatory peptide hormone secreted by adipose tissue is higher in severe psoriasis than in mildmoderate psoriasis. 26 Psoriasis is a multigenic disease and predisposition to metabolic syndrome in psoriasis may have a genetic component. 27 Genetic studies performed in the UK on 1256 psoriatic patients (vs controls) showed a significant association between psoriasis and CDKAL1 gene, implicated in diabetes mellitus. 28 A case-control study made on 70 psoriatic patients showed an impaired glucose tolerance (18.6% in psoriasis vs. 2.5% in control subjects). 29 The evidence that psoriasis patients have an increased risk of cardiovascular risk factors should be confirmed by prospective epidemiological studies including thorough recording of cardiovascular risk factors, life style elements, psoriasis severity and parameters for systemic inflammation. In the mean time, it appears advisable to: 30 1 Document personal and familial history of cardiovascular risk in psoriasis patients and systematically evaluate weight, body mass index and blood pressure. 2 Propose blood testing for fasting glucose and lipid profile in relation with the primary care physicians. References 1 National Psoriasis Foundation. About Psoriasis: statistics. Available at: (last accessed: September 2008). 2 Reed WB, Becker SW, Rohde R, Heiskell CL. Psoriasis and arthritis. Clinicopathologic study. Arch Dermatol 1961; 83: Gelfand JM, Neimann AL, Shin DB et al. Risk of myocardial infarction in patients with psoriasis. JAMA 2006; 296: Gelfand JM, Dommasch ED, Shin DB et al. The risk of stroke in patients with psoriasis. J Invest Dermatol 2009; 129: Kimball AB, Robinson D Jr, Wu Y et al. Cardiovascular disease and risk factors among psoriasis patients in two US healthcare databases, Dermatology 2008; 217: Wu Y, Mills D, Bala M. Psoriasis: cardiovascular risk factors and other disease comorbidities. J Drugs Dermatol 2008; 7: 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: Gerdes S, Zahl VA, Knopf H et al. Comedication related to comorbidities: a study in 1203 hospitalized patients with severe psoriasis. Br J Dermatol 2008; 159: Brauchli YB, Jick SS, Meier CR. Psoriasis and the risk of incident diabetes mellitus: a population-based study. Br J Dermatol 2008; 159: Driessen RJ, Boezeman JB, Van de Kerkhof PC, De Jong EM. Cardiovascular risk factors in high-need psoriasis patients and its implications for biological therapies. J Dermatolog Treat 2008; 21: Naldi L, Chatenoud L, Belloni A et al. Evidence from an Italian casecontrol study. Dermatology 2008; 216: Cohen AD, Dreiher J, Shapiro Y et al. Psoriasis and diabetes: a population-based cross-sectional study. J Eur Acad Dermatol Venereol 2008; 22: Kaye JA, Li L, Jick SS. Incidence of risk factors for myocardial infarction and other vascular diseases in patients with psoriasis. Br J Dermatol 2008; 159: Gisondi P, Tessari G, Conti A et al. Prevalence of metabolic syndrome in patients with psoriasis: a hospital-based case-control study. Br J Dermatol 2007; 157: Shapiro J, Cohen AD, David M et al. The association between psoriasis, diabetes mellitus, and atherosclerosis in Israel: a case-control study. J Am Acad Dermatol 2007; 56: Sommer DM, Jenisch S, Suchan M et al. Increased prevalence of the metabolic syndrome in patients with moderate to severe psoriasis. Arch Dermatol Res 2006; 298: Neimann AL, Shin DB, Wang X et al. Prevalence of cardiovascular risk factors in patients with psoriasis. J Am Acad Dermatol 2006; 55: Mallbris L, Granath F, Hamsten A et al. Psoriasis is associated with lipid abnormalities at the onset of skin disease. J Am Acad Dermatol 2006; 54: World Health Organization. Available at: (last accessed April 2009). 20 Naldi L, Chatenoud L, Linder D et al. Cigarette smoking, body mass index, and stressful life events as risk factors for psoriasis: results from an Italian case-control study. J Invest Dermatol 2005; 125: Herron MD, Hinckley M, Hoffman MS et al. Impact of obesity and smoking on psoriasis presentation and management. Arch Dermatol 2005; 141: Cohen AD, Sherf M, Vidavsky L et al. Association between psoriasis and the metabolic syndrome. A cross-sectional study. Dermatology 2008; 216:

8 30 Prey et al. 23 Nijsten T, Spuls P, Stern RS. STROBE: a Beacon for observational studies. Arch Dermatol 2008; 144: von Elm E, Altman DG, Egger M et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008; 61: Kaur S, Zilmer K, Kairane C et al. Clear differences in adiponectin level and glutathione redox status revealed in obese and normal-weight patients with psoriasis. Br J Dermatol 2008; 159: Cerman AA, Bozkurt S, Sav A et al. Serum leptin levels, skin leptin and leptin receptor expression in psoriasis. Br J Dermatol 2008; 159: Li Y, Begovich AB Unraveling the genetics of complex diseases: susceptibility genes for rheumatoid arthritis and psoriasis. Semin Immunol 2009; 21: Wolf N, Quaranta M, Prescott NJ et al. Psoriasis is associated with pleiotropic susceptibility loci identified in type II diabetes and Crohn disease. J Med Genet 2008; 45: Ucak S, Ekmekci TR, Basat O et al. Comparison of various insulin sensitivity indices in psoriatic patients and their relationship with type of psoriasis. J Eur Acad Dermatol Venereol 2006; 20: Friedewald VE, Cather JC, Gelfand JM et al. AJC editor s consensus: psoriasis and coronary artery disease. Am J Cardiol 2008; 15: 102.