Risk of Aortic Valve Stenosis in Patients With Psoriasis
The study included a total of 5 107 624 Danish citizens, aged ≥18 years from 1 January 1997 to 31 December 2011. Subjects with a history of psoriasis (n = 14 061) and AS (n = 4166) were excluded from the analysis at study baseline. In the course of the study period, 58 747 subjects with mild psoriasis and 11 918 with severe psoriasis were identified. A flowchart of the study population selection is shown in Figure 1. Compared with the reference population, patients who developed psoriasis had similar use of cardiovascular medications and comparable comorbidity at baseline (Table 1). The mean duration from psoriasis diagnosis (according to our study criteria) to new-onset AS was 10.2, 6.7, and 5.7 years for the reference population, mild psoriasis, and severe psoriasis, respectively.
(Enlarge Image)
Figure 1.
Flow chart of selection of study population.
The overall incidence rates for AS were 8.09 (CI 8.02–8.17), 16.07 (CI 14.73–17.52), and 20.08 (CI 16.50–24.45) per 10 000 person-years for the reference population (48 539 cases [mean follow-up 12.3 years]), mild psoriasis (509 cases [mean follow-up 6.2 years]) and severe psoriasis (99 cases [mean follow-up 5.4 years]), respectively. The multivariable Poisson regression analyses, adjusted for age, gender, and calendar year confirmed psoriasis severity-dependent elevated IRRs for AS in patients with psoriasis compared with the reference population, i.e. IRRs 1.31 (CI 1.20–1.43) and 1.74 (CI 1.43–2.13) for mild and severe psoriasis, respectively. The significantly increased risk of AS associated with psoriasis persisted in the fully adjusted statistical models controlling for age, gender, calendar year, comorbidity, concomitant medications, and socioeconomic status (Table 2, Figure 2).
(Enlarge Image)
Figure 2.
Forest plot showing incidence rate ratios for aortic valve stenosis in psoriasis with 95% confidence intervals. *Estimates adjusted for: age, gender, and calendar year. **Estimates adjusted for: age, gender, calendar year, comorbidity, medications, and socioeconomic status.
Exclusion of patients with atherosclerotic disease prior to study start together with censoring of patients who developed atherosclerotic disease during study period did not attenuate the observed association between psoriasis and risk of AS (Table 2). Indeed, in these analyses patients with psoriasis had markedly increased age-, gender-, and calendar year-adjusted IRRs for AS, that were comparable with the results of the primary analyses. When we altered the criteria for definition of psoriasis and psoriasis severity, we identified 90 900 patients with mild psoriasis and 25 094 patients with severe psoriasis. Again the results were similar to the primary analyses, with increased age-, gender-, and calendar year-adjusted IRRs for AS in patients with mild (IRR 1.26 [CI 1.17–1.36]) and severe (IRR 1.54 [CI 1.34–1.77]) psoriasis, respectively. The age-stratified rates of AS per 10 000 person-years were increased for individuals with psoriasis in all age strata, and were highest for patients aged ≥65 years with severe psoriasis compared with the reference population (Table 3).
Results
Baseline Characteristics
The study included a total of 5 107 624 Danish citizens, aged ≥18 years from 1 January 1997 to 31 December 2011. Subjects with a history of psoriasis (n = 14 061) and AS (n = 4166) were excluded from the analysis at study baseline. In the course of the study period, 58 747 subjects with mild psoriasis and 11 918 with severe psoriasis were identified. A flowchart of the study population selection is shown in Figure 1. Compared with the reference population, patients who developed psoriasis had similar use of cardiovascular medications and comparable comorbidity at baseline (Table 1). The mean duration from psoriasis diagnosis (according to our study criteria) to new-onset AS was 10.2, 6.7, and 5.7 years for the reference population, mild psoriasis, and severe psoriasis, respectively.
(Enlarge Image)
Figure 1.
Flow chart of selection of study population.
Risk of Aortic Valve Stenosis
The overall incidence rates for AS were 8.09 (CI 8.02–8.17), 16.07 (CI 14.73–17.52), and 20.08 (CI 16.50–24.45) per 10 000 person-years for the reference population (48 539 cases [mean follow-up 12.3 years]), mild psoriasis (509 cases [mean follow-up 6.2 years]) and severe psoriasis (99 cases [mean follow-up 5.4 years]), respectively. The multivariable Poisson regression analyses, adjusted for age, gender, and calendar year confirmed psoriasis severity-dependent elevated IRRs for AS in patients with psoriasis compared with the reference population, i.e. IRRs 1.31 (CI 1.20–1.43) and 1.74 (CI 1.43–2.13) for mild and severe psoriasis, respectively. The significantly increased risk of AS associated with psoriasis persisted in the fully adjusted statistical models controlling for age, gender, calendar year, comorbidity, concomitant medications, and socioeconomic status (Table 2, Figure 2).
(Enlarge Image)
Figure 2.
Forest plot showing incidence rate ratios for aortic valve stenosis in psoriasis with 95% confidence intervals. *Estimates adjusted for: age, gender, and calendar year. **Estimates adjusted for: age, gender, calendar year, comorbidity, medications, and socioeconomic status.
Sensitivity Analyses
Exclusion of patients with atherosclerotic disease prior to study start together with censoring of patients who developed atherosclerotic disease during study period did not attenuate the observed association between psoriasis and risk of AS (Table 2). Indeed, in these analyses patients with psoriasis had markedly increased age-, gender-, and calendar year-adjusted IRRs for AS, that were comparable with the results of the primary analyses. When we altered the criteria for definition of psoriasis and psoriasis severity, we identified 90 900 patients with mild psoriasis and 25 094 patients with severe psoriasis. Again the results were similar to the primary analyses, with increased age-, gender-, and calendar year-adjusted IRRs for AS in patients with mild (IRR 1.26 [CI 1.17–1.36]) and severe (IRR 1.54 [CI 1.34–1.77]) psoriasis, respectively. The age-stratified rates of AS per 10 000 person-years were increased for individuals with psoriasis in all age strata, and were highest for patients aged ≥65 years with severe psoriasis compared with the reference population (Table 3).
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