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Comparison of Carotid Artery Ultrasound and Framingham Risk Score for Discriminating Coronary Artery Disease in Patients with Psoriatic Arthritis

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Comparison of Carotid Artery Ultrasound and Framingham Risk Score for Discriminating Coronary Artery Disease in Patients with Psoriatic Arthritis RMD Open: first published as 10.1136/rmdopen-2020-001364 on 24 September 2020. Downloaded from Psoriatic arthritis Original research Comparison of carotid artery ultrasound and Framingham risk score for discriminating coronary artery disease in patients with psoriatic arthritis Isaac T Cheng,1 Ka Tak Wong,2 Edmund K Li,1 Priscilla C H Wong,3 Billy T Lai,4 Isaac C Yim,4 Shirley K Ying,5 Kitty Y Kwok,6 Martin Li,1 Tena K Li,1 Jack J Lee,7 Alex P Lee,1 Lai-Shan Tam 1 To cite: Cheng IT, Wong KT, Li ABSTRACT et al Key messages EK, . Comparison of carotid Objectives This study aimed to assess the performance of artery ultrasound and carotid ultrasound (US) parameters alone or in combination Framingham risk score for What is already known about this subject? with Framingham Risk Score (FRS) in discriminating discriminating coronary artery ► Patients with psoriatic arthritis (PsA) are of increased patients with psoriatic arthritis (PsA) with and without disease in patients with psoriatic risk of cardiovascular disease. arthritis. RMD Open 2020;6: coronary artery disease (CAD). e001364. doi:10.1136/ Methods Ninety-one patients with PsA (56 males; age: 50 What does this study add? rmdopen-2020-001364 ±11 years, disease duration: 9.4±9.2 years) without overt ► Performance of Framingham risk score (FRS) in cardiovascular (CV) diseases were recruited. Carotid intima- discriminating patients with and without coronary ► Supplemental material is media thickness (cIMT), the presence of plaque and total artery disease (CAD) is suboptimal. published online only. To view ► please visit the journal online plaque area (TPA) was determined by high-resolution US. This study is the first to report the association (http://dx.doi.org/10.1136/rmdo CAD was defined as the presence of any coronary plaque on between carotid and coronary artery disease in pen-2020-001364). coronary CT angiography (CCTA). Obstructive-CAD (O-CAD) patients with PsA using carotid ultrasound and was defined as >50% stenosis of the lumen. coronary CT angiography (CCTA). Received 17 June 2020 Results Thirty-five (38%) patients had carotid plaque. Revised 13 August 2020 Accepted 5 September 2020 Fifty-four (59%) patients had CAD (CAD+) and 9 (10%) How might this impact on clinical practice? patients had O-CAD (O-CAD+). No significant associations ► Data from this study suggest that a combination of http://rmdopen.bmj.com/ between the presence of carotid plaque and CAD were Framingham risk score and carotid intima-media found. However, cIMT and TPA were higher in both the CAD thickness may be considered for cardiovascular + and O-CAD+ group compared with the CAD− or O-CAD− risk stratification in these patients. groups, respectively. Multivariate logistic regression analysis revealed that mean cIMT was an independent explanatory variable associated with CAD and O-CAD, while spondylitis or PsA at least once every 5 years, maximum cIMT and TPA were independent explanatory so that lifestyle advice and CVD preventive variables associated with O-CAD after adjusting for 2 treatment can be initiated when indicated. on September 29, 2021 by guest. Protected copyright. covariates. The optimal cut-offs for detecting the presence Unfortunately, traditional CV risk scores of CAD were FRS >5% and mean cIMT at 0.62 mm (AUC: 3 0.71; sensitivity: 67%; specificity: 76%), while the optimal including the Framingham risk score (FRS), 4 cut-offs for detecting the presence of O-CAD were FRS QRISK2, Systematic COronary Risk Evalua- 5 >10% in combination with mean cIMT at 0.73 mm (AUC: tion (SCORE), and American College of Car- 0.71; sensitivity: 56%; specificity: 85%). diology and the American Heart Association Conclusion US parameters including cIMT and TPA may (ACC/AHA) 10-year atherosclerotic CV dis- be considered in addition to FRS for CV risk stratification in ease risk (ASCVD)6 underestimated CV © Author(s) (or their patients with PsA. 7–10 employer(s)) 2020. Re-use risks in patients with PsA. permitted under CC BY-NC. No Coronary CT angiography (CCTA) is a non- commercial re-use. See rights invasive and accurate method to assess coron- and permissions. Published Cardiovascular (CV) and cerebrovascular ary atherosclerosis, which is closely associated by BMJ. morbidity is increased by 43% and 22%, with cardiac events in the general – For numbered affiliations see respectively, in patients with psoriatic arthritis population.11 13 Further CV risk stratification end of article. (PsA) compared with the general is possible by detecting the presence of high- 1 Correspondence to population. CV disease (CVD) risk assess- risk plaques (non-calcified plaque (NCP) and 14 15 Lai-Shan Tam; lstam@cuhk. ment is recommended for all patients with mixed plaque (MP)). We and others have edu.hk rheumatoid arthritis (RA), ankylosing demonstrated that patients with PsA had Cheng IT, et al. RMD Open 2020;6:e001364. doi:10.1136/rmdopen-2020-001364 1 RMD Open: first published as 10.1136/rmdopen-2020-001364 on 24 September 2020. Downloaded from RMD Open increased prevalence, burden and severity of coronary global assessments, number of tender and swollen joints atherosclerosis assessed using CCTA,10 16 supporting the (using the 68 tender/66 swollen joint count), number of notion that a more aggressive CV evaluation strategy joints irreversibly damaged, enthesitis, number of digits should be considered in these patients.10 However, with dactylitis, levels of acute-phase reactant including there are concerns regarding costs and radiation expo- erythrocyte sedimentation rate (ESR) and (CRP) and sure using CCTA or even coronary artery calcium as functional disability as indicated by the health assessment a screening tool. questionnaire-disability index (HAQ-DI) were included. Carotid ultrasound (US) is a non-invasive imaging tech- Drug history was retrieved from case notes or elicited nique which can identify the presence of carotid plaque and during the clinical assessment. Achievement of treatment increased carotid intima-media thickness (cIMT). The bur- target was assessed using MDA23 and disease activity was den of carotid atherosclerosis is associated with an increased assessed using Disease Activity in Psoriatic Arthritis risk of developing future CV events in patients with psoriatic (DAPSA).24 Fasting blood glucose and lipid profile disease.17 Because CCTA has been shown to have accuracy (total cholesterol (TC), high-density lipoprotein- comparable with invasive angiography,18 it is perhaps cholesterol (HDL), low-density lipoprotein-cholesterol a superior method of assessing coronary artery disease (LDL) and triglycerides) were checked before CCTA (CAD) rather than using carotid artery US as a surrogate and carotid US exam. FRS was used for assessing CV risk marker of subclinical atherosclerosis. European League (FRS <10% indicates low CV risk, 10–19% indicates inter- Against Rheumatism (EULAR) suggested a multiplication mediate risk while ≥20% indicates high risk).25 factor of 1.5 should be added to the FRS to address the augmented CV risk in RA (modified FRS).2 Nevertheless, Coronary atherosclerosis assessment 10 modified FRS (mFRS) only yield moderate improvement in CCTA scans were performed as described before by identification of CAD on CCTA.19 20 Apreviousstudy a 64-multidetector row Lightspeed VCT scanner (GE including mainly patients with RA with carotid plaques Healthcare), in accordance with the protocol employed 26 showed that a combination of ultrasonographic measure- in the ACCURACY trial and were analysed by an experi- ments rather than the presence of carotid plaque alone may enced radiologist (KTW). Briefly, the presence, site and be useful in risk stratification for CAD.21 Whether this is also type of coronary plaque (including NCP, CP and MP) true in patients with PsA would need to be confirmed. were reported. CAD was defined as the presence of any Moreover, the prevalence of CAD in patients with PsA with- coronary plaque. Coronary arteries were standardised to 27 out carotid plaques remained uncertain. American Heart Association 15-segment model. Seg- The aims of this study were (1) to ascertain the correla- ment involvement score (SIS) represented the total num- tion between carotid artery atherosclerosis by carotid US ber of segments harbouring plaque. Lesions rendering with CAD, obstructive CAD (O-CAD) and three-vessel dis- over 50% stenosis of the lumen were considered as ease (TVD) assessed using CCTA; and (2) the utility of O-CAD. TVD was defined as the presence of coronary http://rmdopen.bmj.com/ carotid US parameters in combination with traditional CV plaque in left anterior descendent branch, left circumflex risk score in discriminating patients with CAD and O-CAD. branch and right coronary artery. For patients having multiple plaques, the most stenotic one was recorded. PATIENTS AND METHODS Carotid intima-media thickness (cIMT) and plaque Patients Measurement of cIMT, plaque and total plaque area This is a post-hoc analysis of the PsA CCTA study and the (TPA) was performed by high-resolution B-mode US effect of achieving minimal disease activity (MDA) on the 22 machine (Philips EPIQ7) as described before. A single on September 29, 2021 by guest. Protected copyright. progression of subclinical atherosclerosis and arterial stiff- operator who were blinded to the CCTA results per- 10 22 ness study (MDA vascular study). Ninety-one consecu- formed the US scan and corresponding offline measure- tive patients with PsA without overt CVD attending the ment of US parameters. The mean and maximum cIMT outpatient clinic of the Prince of Wales Hospital (PWH) in bilateral distal common carotid artery, bulb and prox- who were recruited for the MDA vascular study and had imal internal carotid artery were reported. Plaque was carotid US performed at baseline were referred for CCTA. defined as a localised thickening >1.2 mm that do not Patients who had successfully performed CCTA and caro- uniformly involve the whole artery. TPA was the sum of tid US assessment were included in this analysis.
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