IJCS | Volume 33, Nº2, March / April 2020

116 Campos et al. Psoriatic arthritis and cardiovascular risk Int J Cardiovasc Sci. 2020; 33(2):112-118 Original Article they correspond to 41%, 31% and 28% of the patients, respectively. 33 In this study, the polyarticular form was also the most prevalent, followed by the overlap of this form with spondylitis. A 2009 retrospective cohort study using a UKdatabase, estimated to represent 5%of the population in this region, found an increased risk of stroke in PsA, whichwas higher according to the severity of the disease. 34 The presence of high levels of inflammatory biomarkers—– suggestive of increased disease activity — were predictors of clinical cardiovascular events in the study by Husted J.A. et al. 29 In our study, individuals with serum alterations of CRP and ESR presented, respectively, higher levels of LDL-C and total cholesterol, factors known to be related to the development of atherosclerosis and its consequences. However, there was no significant difference between serum levels of CRP or ESR according to the different categories of CVR — low, intermediate or high risk. Psoriatic arthritis drug therapy includes non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids and disease-modifying drugs (DMDs) — sulfasalazine, methotrexate, leflunomide and biological agents. DMDs are defined as drugs capable of preventing disease progression. 35 NSAIDs and glucocorticoids, used to alleviate PsA symptoms, are associated with an increase in unfavorable cardiovascular outcomes, such as AMI, which, in a way, may also eventually contribute to the increase of CVR. 36,37 On the other hand, in several studies, DMDs are related to reduced CVR. Risk was reduced in patients using these medications compared to those who used other systemic therapies, probably because of the greater effectiveness in reducing the disease activity, reducing inflammation and its propensity to the formation of atherosclerosis. Inflammation suppression by immunomodulatory agents represents a promising new target for themanagement of cardiovascular diseases both in the general population and among patients with chronic inflammatory conditions. 27,38 Methotrexate is the first-line DMD in PsA, due to its effectiveness in the treatment of cutaneous and joint involvement combined with its low cost. Its anti-inflammatory effect is mediated by adenosine and can neutralize neutrophils, T-cells and macrophages — the main agents in the pathogenesis of psoriasis and PsA. 33,39 Currently, the most widely used biological DMDs for PsA treatment, and approved by the Brazilian National Agency of Sanitary Surveillance (ANVISA), are the TNF- α inhibitors: etanercept, adalimumab, golimumab, infliximab, and certolizumab pegol. 40 However, in this study, there was no significant difference in cardiovascular parameters according to the different medications in use. This research presented some limitations, because, although performed in a specialized outpatient clinic, the sample obtainedwas small and there was no comparison with the control group, thus no inferences could bemade. Since it was an observational study, it was subject to memory bias. In addition, it was hampered by the lack of data in the medical records. Conclusions Most of the patients in the sample were stratified as high or intermediate CVR. Despite the high incidence of CVR factors, there was no parallel between them and the time of PsA diagnosis. It is recommended to use traditional CVR scores since there is not enough evidence to use a multiplier factor in this estimation, or to use a different calculator. Authors’ contributions Research creation and design: Campos B, Gomes G, Telis A. Data acquisition: Campos B. Data analysis and interpretation: Campos B, Telis A. Statistical analysis: Telis A. Writing: Campos B, Gomes G, Braz A, Telis A. Critical revision of themanuscript for intellectual content: Braz A, Telis A. Supervision/major investigator: Telis A. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associated with any thesis or dissertation work. Ethics approval and consent to participate This study was approved by the Ethics Committee of Universidade Federal da Paraíba under protocol number CAAE: 56336216.1.0000.5183. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study.