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Results
Cases and Controls
During the study period, 574 case and 543 control patients were assessed for eligibility. Seventy-four case patients were not included either because a dermatological examination could not be performed during hospital stay (n = 21) or because coronary angiography findings were considered to be nonsignificant according to the ACC/American Heart Association Coronary Artery Bypass Grafting Surgery Practice criteria, and thus did not correspond to inclusion criteria (n = 53). Forty-three control patients were excluded because the information on their drug intake could not be elicited (n = 21), because of their intake of glyceryl trinitrate (n = 12), the presence of Q waves on their ECG (five of 355 control patients who had an ECG) or because they refused to participate in the study (n = 5). Therefore, 500 case patients with CAD confirmed by coronary angiography findings and 500 control patients were analysed.
Coronary angiography was performed for the following reasons: acute coronary syndrome with ST segment elevation in 148 cases (29·6%), acute coronary syndrome without ST segment elevation in 155 cases (31·0%), stable angina pectoris in 128 cases (25·6%) and silent myocardial ischaemia in 69 cases (13·8%).
Control patients were admitted for the following main reasons: fracture and orthopaedic trauma in 338 patients (67·6%), wounds or burns in 105 patients (21·0%), neuropathic pain in 26 patients (5·2%) and other reasons (e.g. epistaxis or urinary lithiasis) in 31 patients (6·2%).
Table 1 shows the patients' characteristics. Mean age was 66·5 ± 11·6 years in case patients and 66·7 ± 12·0 years in controls. As expected, there was no significant difference between cases and controls for the matching variables of age (P = 0·77) and sex (P = 1·00). As expected, the following cardiovascular risk factors were more frequently observed in case patients with CAD than in control patients: obesity (28·8% vs. 18·6%, P < 0·01), hypertension (63·4% vs. 40·4%, P < 0·01), diabetes (27·8% vs. 16·0%, P < 0·01), dyslipidaemia (62·0% vs. 32·0%,P < 0·01), former cigarette smoking (36·6% vs. 28·0%, P = 0·01) and family history of CAD (20·4% vs. 10·6%, P < 0·01) (Table 1).
Prevalence and Main Characteristics of Psoriasis in Cases and Controls
The prevalence of psoriasis was higher in case patients than in control patients, as 40 case patients (36 men and four women) out of 500 (8·0%) and 17 control patients (13 men and four women) out of 500 (3·4%) had psoriasis [age- and sex-matched OR 2·64; 95% confidence interval (CI) 1·42–4·88, P < 0·01]. In both cases (90·0%) and controls (70·0%), plaque psoriasis was the most frequent clinical type of psoriasis. Finally, mean BSA involved (4·09 ± 6·89% in cases and 2·35 ± 2·50% in controls) and mean PGA score (2·05 ± 1·65 in cases and 2·11 ± 1·32 in controls) were rather limited (Table 2).
Among the 57 patients with psoriasis, no association between severity of psoriasis and CAD was observed as 22 out of the 40 patients with CAD and psoriasis (55%) and seven of the 17 patients (41%) without CAD but with psoriasis had moderate-to-severe psoriasis (P = 0·40).
A longer duration of psoriasis was not associated with a higher risk of CAD, as the mean duration (± SD) of psoriasis in the 40 patients with psoriasis and CAD was 17·8 ± 15·8 months vs. 19·6 ± 12·0 months in the 17 patients with psoriasis without CAD (P = 0·36, Mann–Whitney test) (Table 2). Upon arbitrarily separating patients with psoriasis depending on the duration of psoriasis, i.e. at most vs. more than 2 years of evolution, patients with short-lasting psoriasis accounted for only 11·0% only of patients with psoriasis, without any difference in the proportions of patients with long-lasting psoriasis between CAD cases and non-CAD controls (P = 1·00, Fisher's exact test).
Only seven of the 57 patients with psoriasis had received systemic treatment, whereas 50 had been treated topically or had received no treatment. No difference in the proportion of patients having received systemic psoriasis was found between patients with CAD [four out of 40 (10%)] and those without CAD [seven out of 17 (41%)] (P = 0·42, Fisher's exact test) (Table 2).
Factors Independently Associated With Coronary Artery Disease (Multivariate Analysis)
Multivariate analysis with unconditional logistic regression was performed, including psoriasis, the matching factors of age and sex, and the adjustment factors of weight, hypertension, diabetes mellitus, dyslipidaemia, smoking and family history of CAD. Data on at least one adjustment factor were missing for four cases and 17 controls. This analysis showed a borderline significant association between psoriasis and CAD, with a higher prevalence of psoriasis in CAD case patients (OR 1·84; 95% CI 0·99–3·40; P = 0·05) (Table 3). Futher multivariate analysis showed a borderline significant association between CAD and moderate-to-severe psoriasis relative to no psoriasis, with an OR of 2·38 (95% CI 0·96–5·86).
Ancillary Study: Comparison of Patients With Coronary Artery Disease According to the Severity of Coronary Findings
Despite the fact that patients and CAD and psoriasis were younger than those with no psoriasis (63·2 ± 9·7 vs. 66·9 ± 11·8 years, P = 0·06), the prevalence of psoriasis in multivariate analysis was higher in patients with three-vessel involvement than in patients with single- or two-vessel involvement (13·1% vs. 6·1%; OR 3·07; 95% CI 1·50–6·25; P < 0·01). Older age (OR per year 1·05; 95% CI 1·03–1·07; P < 0·01) and diabetes (OR 1·72; 95% CI 1·08–2·70; P = 0·02) were also independently associated with three-vessel involvement (Table 4).
A significant negative interaction between age and psoriasis (yes, no) with respect to CAD severity was found in multivariate analysis, with an OR for interaction of 0·96 per year (95% CI 0·93–1·00; P = 0·035), indicating a higher risk of three-vessel involvement in younger patients with psoriasis.
Additionally, a longer duration of psoriasis was not found to be associated with more severe CAD, as, on the contrary, the mean duration of psoriasis in patients with three-vessel involvement was 13·5 ± 14·8 months compared with 21·3 ± 16·1 months in patients with single- or two-vessel involvement (P = 0·07). Similarly, no difference between the proportions of patients receiving systemic treatment for psoriasis was found according to severity of CAD (single- or two-vessel involvement vs. three-vessel involvement) (P = 1·00, Fisher's exact test).
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