Heart Rate and Arrhythmia in Patients with Psoriasis Vulgaris

doi:10.1016/j.arcmed.2006.08.004

Archives of Medical Research

Volume 38, Issue 1, January 2007, Pages 64-69

https://doi.org/10.1016/j.arcmed.2006.08.004 Get rights and content

Background

Psoriasis is a chronic inflammatory disease involving 1–3% of the human population worldwide. Many systemic diseases including cardiovascular disturbances have been described in psoriatic patients. However, there is a scarcity of data on heart rate, heart rate variability, arrhythmia and conduction abnormalities in this group of patients.

Methods

The study comprised 32 patients with chronic psoriasis vulgaris and negative personal history of heart problems. Severity of the disease was evaluated by Psoriasis Area and Severity Index (PASI). Twenty-four-h continuous electrocardiographic monitoring (24-h Holter ECG) was performed in all patients.

Results

Heart rate was significantly higher both during the day and at night in patients with psoriasis vulgaris than in the control group (p <0.0001). There was a positive correlation between the increased heat rate, both during the day and at night, in psoriatic patients and severity of the disease expressed as PASI. Single supraventricular beats were significantly more frequently observed in psoriatic patients vs. the control group (p <0.0001).

Conclusions

An active inflammatory process observed in psoriasis seems to exert its influence on increased heart rate and supraventricular beats development. However, to confirm the above findings, further studies on larger groups of psoriatic patients, presenting different types of the disease are mandatory.

Introduction

Psoriasis is one of the most prevalent T-cell-mediated chronic inflammatory diseases affecting around 1–3% of human population worldwide (1). Despite quite considerable advances in the last years, its pathogenesis is still not fully elucidated; however, inflammatory processes and oxidative stress are among those most frequently delineated (2). There is a clear genetic component with multifactorial inheritance and interactions between genetic predisposition and the environmental factors observed in the majority of patients 3, 4.

Psoriasis is characterized by hyperproliferation and distorted differentiation of epidermal keratinocytes, lymphocytic infiltration, predominantly composed of T lymphocytes, endothelial vascular abnormalities in the dermis including angiogenesis, dilatation and excessive endothelial venule formation (5). T lymphocytes with neutrophils, natural killer cells, endothelial cells, mast cells, fibroblasts and mediators released are regarded as important factors in psoriatic lesion development and maintenance (6). It is widely accepted that Th1 cytokines, i.e., tumor necrosis factor alpha (TNF-α), interferon gamma (IFN-γ) and interleukin 2 (IL-2) are key factors in psoriasis 4, 7. Th1-type cytokines lead to release of cytokines from other cells, producing a virtual cascade of mediators that effect development of psoriatic lesions. 4, 8, 9, 10, 11.

Data in the literature point to cardiovascular abnormalities in the course of this disease. The following conditions are most frequently observed: arterial hypertension, arterial atherosclerosis, and heart valve abnormalities 12, 13, 14, 15, 16, 17.

Virtually, there is scarcity of data on heart rate abnormalities, heart rate variability, and conduction disturbances in psoriatic patients, despite a quite clear connection between arrhythmia occurrence and chronic inflammatory processes 18, 19.

The aim of the study was to evaluate heart rate variability and arrhythmia in patients with long-lasting psoriasis.

Section snippets

Patients

The study comprised 32 patients (17 females, 15 males; aged 26–65 years, mean ± SD: 48 ± 11) with chronic psoriasis vulgaris hospitalized at the Department of Dermatology, Medical University of Łódź because of exacerbation of psoriasis. Disease duration ranged from 1–37 years (mean ± SD: 17 ± 10.7 years). Severity of the disease was evaluated by Psoriasis Area and Severity Index (PASI), which ranges from 0–72 points. Extension of skin lesions situated on the head, trunk, upper and lower limbs

Results

Heart rate was significantly higher, both during the day and at night, in patients with psoriasis vulgaris (mean ± SD: 88 ± 8 beats/min and 71 ± 7 beats/min, respectively) (Figure 1, Figure 2) than in the control group (mean ± SD: 73 ± 6 beats/min and 63 ± 4 beats/min, respectively) (both p <0.0001) (Figure 3, Figure 4). We did not observe any statistically significant differences in the time domain HRV. Measured values were (mean ± SD): SDNN: 128 ± 28 msec and 131 ± 35 msec, rMSSD: 26 ± 13

Discussion

The examined group of psoriatic patients did not report any cardiovascular symptoms, were not under cardiologic follow-up and were not on any cardiologic drugs. None of the examined patients demonstrated any abnormalities in heart rate based on routinely performed ECG examination. Predisposition to sinusal tachycardia and more frequent occurrence of supraventricular beats in psoriatic patients were demonstrated only by Holter 24-h ECG monitoring.

There are scarce data in the literature on

Acknowledgments

This work was supported by grants from the Medical University of Lodz (no. 503-1019-1 and 502-11-353).

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Cited by (41)

Frequency of Electrocardiographic Abnormalities in Patients With Psoriasis
2018, American Journal of Cardiology
Citation Excerpt :
In view of the prognostic importance of electrocardiographic abnormalities and the general availability of the ECG, it is surprising that only limited previous reports with conflicting results are available on the ECG in psoriasis. For example, heart rate was similar17,20,21 or increased19 in subjects with psoriasis compared with controls, but in these studies, adjustments for smoking and BMI were not performed. It is well established that psoriasis is associated with smoking and obesity, which are linked to increased heart rate and sympathetic activation.16,23
Psoriasis is a chronic inflammatory disease associated with cardiovascular disease, for example, myocardial infarction, stroke, cardiovascular death, and arrhythmias. The resting electrocardiogram may carry prognostic information, but limited evidence is available of electrocardiographic findings in subjects with psoriasis. The electrocardiographic results were compared between 1,131 subjects with self-reported psoriasis and 18,397 controls participating in the Danish General Suburban Population Study (GESUS). The mean heart rate was marginally increased in patients with psoriasis (66 ± 11 vs 65 ± 11 beats/min, p = 0.007), but not after adjustment for smoking and body mass index. All other examined electrocardiographic variables, including QT interval corrected for heart rate with the Fridericia formula, PR interval, QRS duration, R axis, P-wave duration in lead V1, P-terminal force, J point elevation in lead V1, electrocardiographic criteria for left ventricular hypertrophy, electrocardiographic signs of previous myocardial infarction, and premature ventricular or supraventricular complexes, respectively, were comparable between the 2 groups. In conclusion, psoriasis was associated with a marginal increase in resting heart rate, which was driven by smoking and increased body mass index. All other examined electrocardiographic variables were similar between the 2 groups. The results suggest that psoriasis per se is not associated with significant abnormalities of the electrocardiogram.
Cardiovascular Involvement in Psoriatic Arthritis
2017, Handbook of Systemic Autoimmune Diseases
Citation Excerpt :
However, in comparison with healthy controls, heart rate is significantly higher in patients with psoriasis (p < .0001), and there is a positive correlation between this and the severity of cutaneous involvement. Single supraventricular beats are also significantly more frequent in PsA patients than in healthy controls (p < .0001) (Markuszeski et al., 2007). Another study found decreased heart rate variability in PsA patients in comparison with healthy controls, as verified by the decrease in the standard deviation of normal R-R intervals (65.1 ± 66.8 vs. 83.2 ± 43.3 ms; p = .011), the percentage of normal R-R intervals differing by more than 50 ms (12.9 ± 15.4% vs. 20.6 ± 17.1%; p = .035), and total power (2069.4 ± 1537.8 vs. 2942.5 ± 1734.2 ms(2); p = .006).
Psoriatic arthritis is a chronic inflammatory condition in which unbalanced inflammatory pathways act as key drivers of a wide range of articular and extraarticular manifestations. It is associated with a high prevalence of cardiovascular (CV) disease and risk factors. The precise pathogenetic mechanism of CV involvement has still to be clarified, but certain inflammatory cytokines play a key role in the atherosclerotic process. Studies have shown the potentially beneficial role of disease-modifying antirheumatic drug–induced immunosuppression and also anti–tumor necrosis factor drugs on CV diseases.
Cardiogoniometry in psoriatic patients and its comparison with a control group
2017, Indian Heart Journal
Citation Excerpt :
We did not use ECG Holter monitoring in our study. The heart rate in ECG was higher compared with the controls, showing positive correlation with PASI but not with the disease duration.16 QT dispersion (QTd) can be used to assess the homogeneity of cardiac repolarization and autonomic function denoting the increased heterogeneity of repolarization could be associated with increased risk of ventricular tachyarrhythmias.17,18
Cardiogoniometry (CGM), a spatiotemporal electrocardiologic method may be useful as a cardiovascular diagnostic tool. Increased incidence of coronary artery or myocardial involvement and defects in automatic setting of heart activity have been reported in psoriasis which could be related to the presence of systemic inflammation. Cardiogoniometry and the related parameters have been used in this study as a diagnostic technique in psoriasis patients.
Thirty patients with psoriasis and 30 healthy, age and sex-matched individuals with no history of cardiovascular diseases or traditional coronary risk factors were enrolled. Duration and severity of the disease, using psoriasis severity and area index (PASI) score were recorded. Electrocardiography and cardiogoniometry were performed. Heart rate, QT interval and QT dispersion (QTD) were measured. SDNN (standard deviation of normal R-R interval) and myocardial ischemia score were determined by cardiogoniometry.
There was significant difference between the psoriasis patients and the controls in terms of heart rate (76.37 ± 14.41 vs 72.53 ± 9.684, p = 0.02), myocardial ischemia score (−1.53 ± 2.63 vs −0.46 ± 0.73, p = 0.037), corrected QT interval (392.64 ± 26.00 vs 377.26 ± 22.34, p = 0.017) and QTD (32.00 ± 17.88 vs 6.67 ± 15.16, p < 0.001). No statistically significant difference was found in SDNN (36.37 ± 21.01 vs 26.90 ± 14.88, p = .29). There were moderate correlation between PASI and SDNN (r = 0.427, p = 0.009), heart rate (r = 0.427, p = .009) and score (r = 0.481, p = .004).
Abnormalities in resting ECG and CGM and their correlation with disease severity raises concerns about the need for cardiovascular follow-ups of psoriatic patients, especially those with severe disease.
Increased risk of arrhythmia in patients with psoriatic disease: A nationwide population-based matched cohort study
2015, Journal of the American Academy of Dermatology
Citation Excerpt :
These findings suggested the associations between cardiac conduction abnormalities and psoriasis. However, most of these studies were small and cross-sectional,25,26 focused on specific ECG indicators or predictors as a surrogate for arrhythmia, and did not investigate the true incidence and types of arrhythmia. A study reporting that psoriasis independently predicts new-onset atrial fibrillation only included hypertensive patients with psoriasis and left ventricular hypertrophy, who are not representative of all patients with psoriasis.27
Psoriasis is associated with cardiovascular morbidity and mortality. However, the association between psoriasis and arrhythmia has not been adequately studied.
We sought to investigate whether patients with psoriasis have an increased risk of arrhythmia.
This population-based cohort study identified 40,637 patients with psoriasis and 162,548 subjects without psoriasis matched by age, sex, history of coronary artery disease, hypertension, and diabetes in the Taiwan National Health Insurance Research Database during 2004 through 2006.
After adjusting for medical history and medication use, patients with psoriasis were at increased risk of overall arrhythmia (adjusted hazard ratio [aHR] 1.34; 95% confidence interval [CI] 1.29-1.39). The risks of arrhythmia were higher in all subgroups, including patients with severe (aHR 1.25; 95% CI 1.12-1.39) and mild (aHR 1.35; 95% CI 1.30-1.41) psoriasis, and in patients with (aHR 1.46; 95% CI 1.22-1.74) and without (aHR 1.33; 95% CI 1.28-1.39) psoriatic arthritis.
The National Health Insurance Research Database did not contain information regarding Psoriasis Area and Severity Index, cigarette smoking, or alcohol consumption.
Patients with psoriasis were at higher risk of developing arrhythmia, particularly for those with psoriatic arthritis, independent of traditional cardiovascular risk factors.
Psoriasis and its relationship with the metabolic syndrome
2013, Revista Colombiana de Reumatologia
La psoriasis es una enfermedad crónica con un gran impacto en la calidad de vida de quienes la padecen.
En numerosos estudios se ha demostrado que, a pesar de contar con múltiples opciones terapéuticas, los pacientes con psoriasis no siempre reciben el tratamiento óptimo necesario para mejorar sus manifestaciones clínicas y prevenir el efecto que tienen las enfermedades concomitantes asociadas sobre su calidad de vida. Es considerable el uso insuficiente de tratamientos efectivos y es probable que existan vacíos en el conocimiento de la enfermedad que impiden tomar mejores decisiones en el manejo de la psoriasis.
El entendimiento de la psoriasis como una condición compleja y multifactorial tiene un gran impacto en la disminución de la morbimortalidad asociada y ofrece a los pacientes la oportunidad de recibir una atención integral, que abarque los fenómenos biológicos propios de la enfermedad, pero que pueden ser vistos en el contexto que implica la asociación con numerosas enfermedades que se traducen en un deterioro de la capacidad física y el desarrollo personal y, por ende, afectan el bienestar de los individuos con psoriasis.
Este artículo pretende explorar las implicaciones fisiopatogénicas que explican las relaciones de causalidad entre la psoriasis y el síndrome metabólico y, de esta forma, argumentar con suficiente información la necesidad real que tienen los pacientes con psoriasis de ser contemplados dentro del espectro de una enfermedad sistémica y la oportunidad de que sean adecuadamente tratados por un grupo multidisciplinario que garantice el más completo abordaje diagnóstico y terapéutico.
Psoriasis is a chronic disease with a major impact on patient quality of life.
Despite there being multiple treatment options, numerous studies have shown that patients with psoriasis do not always receive the optimal treatment necessary to improve their clinical manifestations, and to prevent the associated comorbidities that impact on quality of life. The gaps in knowledge and the underuse of effective treatments prevent better decisions to be made in the management of psoriasis.
The understanding of psoriasis as a complex and multifactorial condition has a major impact on reducing associated morbidity and mortality, and offers patients the opportunity to receive comprehensive care that encompasses the biological phenomena characteristics of the disease, which can be observed in the context of the psoriasis, its association with multiple diseases, the deterioration in physical and personal abilities, thus affecting the well-being of the patient.
This article examines the physiopathogenic implications, explaining the causal relation ships between psoriasis and the metabolic syndrome, and argues the real need for psoriasis patients to be considered within the spectrum of a systemic disease, and to have the opportunity to be properly treated by a multidisciplinary team to ensure the most comprehensive diagnostic and therapeutic approach.
P wave dispersion, Tpeak-Tend interval, and Tp-e/QT ratio in children with psoriasis
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Original articleClinicalHeart Rate and Arrhythmia in Patients with Psoriasis Vulgaris

Background

Methods

Results

Conclusions

Introduction

Section snippets

Patients

Results

Discussion

Acknowledgments

Clin Chim Acta

J Am Acad Dermatol

Lancet

Am J Med

Int J Immunopharmacol

Clin Dermatol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

The natural history of psoriasis in 5,600 patients

Dermatologica

Psoriasis—recent advances on understanding its pathogenesis and treatment

J Am Acad Dermatol

Psoriasis

N Engl J Med

Psoriasis: dysregulation of innate immunity

Br J Dermatol

Immunopathogenic mechanisms in psoriasis

Clin Exp Immunol

Cytokines in psoriasis

Int J Dermatol

Interleukin-1 and interleukin-6 in psoriasis

J Invest Dermatol

Interleukin-6 in normal skin and psoriasis

Acta Dermatol Venereol (Stockh)

Cellular localization of interleukin-8 and its inducer, tumor necrosis factor-alpha in psoriasis

Am J Pathol

In situ expression of mRNA of IL-1 and IL-6 in psoriasis: IL-6 involved in formation of psoriatic lesions

Arch Dermatol Res

Correlation between psoriasis and cardiovascular diseases (authors' translation)

Z Hautkr

High prevalence of cardiovascular diseases and enhanced activity of the renin-angiotensin system in psoriatic patients

Acta Cardiol

Mitral valve prolapse (MVP) in psoriatic arthritis (PA)

Arch Intern Med

Psoriatic arthritis and aortic regurgitation

JAMA

Inflammation of the myocardium as an arrhythmia trigger

Z Kardiol

Original article
Clinical
Heart Rate and Arrhythmia in Patients with Psoriasis Vulgaris