ABC | Volume 113, Nº2, August 2019

Original Article Oliveira et al Cardiovascular risk in psoriasis patients Arq Bras Cardiol. 2019; 113(2):242-249 Methods Type of study This was a cross-sectional, analytical, observational study conducted between May 2016 and March 2018. Participants Psoriasis group (PG) was composed of 11 male volunteers, without evidence of CVD, aged between 40 and 65 years, with Psoriasis Area and Severity Index (PASI) > 7. 16 All patients were consecutively included during their medical visit at a public health care center in Belo Horizonte, Brazil. All patients were classified as PASI > 10, indicating severe skin manifestations of the disease. For the control group (CG), we selected 33 healthy men, without evidence of CVD or psoriasis, matched by age, recruited from the same health care center and from a private clinic in the same city. For theCG, patients seen for dermatological assessment due to conditions other than psoriasis. The number of subjects recruited was obtained by specific sample calculation proposed by Siqueira et al. 17 Sample sizewas calculated assuming that variations in AS between PG and CG were similar. We also considered a proportion of three controls to one case, due to the low prevalence of severe psoriasis. Exclusion criteria for both groups were: chronic diseases requiring nonsteroidal anti-inflammatory drugs (NSAIDs) or systemic corticosteroids, treatment for neoplasms or diagnosis of neoplasms less than five years, severe chronic kidney failure (glomerular filtration rate < 30 mL/min), liver failure or previous coronary diseases, peripheral vascular disease and HF with reduced ejection fraction. We also excluded from the study psoriasis patients with PASI < 7. All patients were seen by a cardiologist and assessed for smoking habit (smokers were considered those patients who smoked at least one cigarette per day in the last 12 months), 18 alcohol consumption (15 doses/week in the last 12 months – 1 dose corresponded to one can of beer), 19 systemic arterial hypertension (according to the 2017 Brazilian Guidelines on Dyslipidemias and Prevention of Atherosclerosis), 12 diabetes mellitus (according to the 2018 American Diabetes Association guidelines), 20 use of medications, and any other factor that may be related to the exclusion criteria of the study. All volunteers had their body weight and height measured for body mass index (BMI) calculation, body surface area (BSA) measured, and waist and hip circumferences measured for waist-to-hip ratio (WHR) calculation. These measurements were obtained using calibrated and certified (by INMETRO/ ANVISA) equipment. Blood samples were collected for laboratory tests and measurement of C-reactive protein (CRP), LDL cholesterol, HDL cholesterol, and total cholesterol (TC). Patients of the PG were classified according to the PASI, developed by Fredriksson and Pettersson in 1978 to assess the extent of the psoriatic plaques. 21 This is the method of choice for the classification of the disease severity, 16 and was applied by a dermatologist. Analysis of the severity and extent of the disease was made in four anatomical regions: head, trunk and upper and lower limbs. Measurements of blood pressure (both peripheral/arm and central) and AS were obtained non-invasively using the monitor Mobil-O-Graph NG (IEM, Stolberg, Germany), with ARC Solver algorithm (the ARC Solver method, Austrian Institute of Technology). This is an oscillometric, 24-hour ambulatory blood pressure monitoring device, approved by the USA Food and Drug Administration and the Conformité Européenne. Themethod was validated according to the British Hypertension Society and recently by the American Heart Association’s Council on Hypertension. 22-24 After the measurement of the arm circumference and selection of the arm cuff, the device was positioned as proposed by the Brazilian Society of Cardiology. 12 Three consecutive readings were taken automatically and the results were expressed as the mean of these three measurements. AS was estimated using the variables pulse wave velocity (PWV) and augmentation index (AIx) adjusted for a heart rate (HR) of 75 beats per minute (Alx@75). The monitor also provided the measurements of HR, systolic blood pressure (SBP), diastolic blood pressure (DBP) and peripheral and central pulse pressure (PP). The analysis of IMT was performed by duplex scanning of the carotid arteries using the two-dimensional mode, and linear probe 10-MHZ Vivid S6 (GE healthcare, Telaviv, Israel), according to the recommendations of the Department of Cardiovascular Imaging of the Brazilian Society of Cardiology. 25 The measurement of IMT was semi-automatically obtained one centimeter from the posterior wall of the common carotid artery. To determine the IMT percentile, the mean IMT (without including the plaque) of each segment was compared with those of the reference tables. The highest percentile for age of each participant was obtained. We used the tables obtained from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), 26 that evaluates chronic diseases in the Brazilian population aged from 40 to 65 years, of white, mulatto and black ethnicity, and from the Multi Ethnic Study of Atherosclerosis (MESA). 27 Measures above the 75 th percentile were considered as significant increases. A two-dimensional echocardiography with Doppler and tissue Doppler was performed following the American Society of Echocardiography (ASE) recommendations. 28 We analyzed the electrocardiographic images of three cardiac cycles for the dimensions of the left ventricle, left atrial volume (LAV), parietal thickness, left ventricular mass index, left ventricular ejection fraction and color Doppler images of all valves. Analysis of the left ventricular diastolic function (LVDF) was performed according to the 2016 recommendations of the American Society of Echocardiography and the EuropeanAssociationof Cardiovascular Imaging. 29 The following parameters were obtained: early left ventricular filling (E-wave), peak atrial filling wave (A-wave), E/A ratio, E-wave deceleration time, and isovolumic relaxation time. TissueDoppler velocitymeasurementswereobtained in themedial and in the lateral mitral annulus, in the four-chamber view, for the measurement of the peak early diastolic velocity (e’). The 2016, 29 American Society of Echocardiography recommendations were also used for classification of diastolic function – normal function, diastolic dysfunction grade II (pseudonormal pattern), anddiastolic dysfunction grade III (restrictive pattern). Subclinical dysfunction (i.e., asymptomatic condition) was diagnosed by left ventricular systolic and/or diastolic dysfunction. 243