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Abstract
Background Autoimmune disease such as systemic lupus erythematosus (SLE) and psoriasis have been previously associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD), though whether similar increased ASCVD risk is seen with cutaneous lupus (CLE) remains unclear. Thus, we sought to evaluate the prevalence and incidence of ASCVD among those with CLE, SLE, and psoriasis compared with disease-free controls.
Methods We performed a retrospective, longitudinal cohort study using outpatient and inpatient encounters claims data from the IBM® MarketScan® Commercial Claims database from January 2018 to December 2020. Our inclusion criteria included adults age ≥18 years with at least 1 year of continuous enrollment in the dataset. Within this population, we identified adults with CLE, SLE, and psoriasis based on the following International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes: CLE using L93, SLE using M32, and psoriasis using L40. CLE was further classified by subtypes: DLE (L93.0), SCLE (L93.1) and other CLE (L93.2). The control population included persons free of CLE, SLE, and psoriasis, matched 10:1 with the CLE population on age, sex, insurance type, and enrollment duration. Prevalent ASCVD was defined as coronary artery disease (CAD, I20 and I25), prior myocardial infarction (MI, I21 and I22), or cerebrovascular accident (CVA, I63 and select G43). Incident ASCVD (hospitalization for CAD, MI, or CVA) was assessed through the end of follow up (up to 2 years and 11 months) in each group. Multivariable logistic regression and Cox- proportional hazards modeling was performed to compare prevalence and incidence of ASCVD between groups adjusting for age, sex, and cardiovascular risk factors.
Results We identified 8,138 persons with CLE (median age 49, 81% women), 24,675 persons with SLE, 192,577 persons with psoriasis, and 81,380 controls (figure 1, table 1). The prevalence of ASCVD was 2.24% (95% CI, 1.93–2.59%) for CLE, 2.06% (1.89–2.25 %) for SLE, 1.44% (1.39–1.50%) for psoriasis, and 0.19% (0.16–0.22%) for controls. In multivariable analysis, the odds of ASCVD were higher than control for CLE (OR 1.72, 1.45–2.02) and SLE (OR 2.41, 95% CI 2.14–2.70), but not psoriasis (OR 1.03, 95% CI 0.95–1.11) (figure 2). At median 36 months follow-up, the incidence of ASCVD in CLE was 15.2 (13.1–17.7) per 1000 person-years (HR vs control 1.32, 95% CI 1.13–1.55), 24.8 (23.3–26.4) per 1000 person-years for SLE (HR vs control 2.23, 95% CI 2.05–2.43), and 14.0 (13.5–14.4) per 1000 person years for psoriasis (HR 1.06, 0.99–1.13) (figure 3).
Conclusions and Relevance We found that the prevalence of ASCVD in persons with CLE was similar to that seen in SLE, and higher than that observed in persons with psoriasis. Similarly, after controlling for traditional risk factors for ASCVD, in comparison with a control population, the incidence of newly diagnosed ASCVD was similar in those with CLE and SLE, and higher in those with CLE compared with those with psoriasis. Combined, these data suggest that CLE should be considered as a risk-enhancer for ASCVD and persons with CLE should be targeted for comprehensive cardiovascular risk reduction strategies. Clinicians treating patients with CLE should consider them at increased ASCVD risk and institute appropriate preventive therapies.
Study population cohort demographics and co-morbidities traditionally associated with cardiovascular disease
Study population flow chart for prevalent and incident ASCVD analysis. The flow chart shows application of inclusion/exclusion criteria for both the prevalent and incident ASCVD analytic populations. Flowchart generated in Biorender.com. aAmong persons with CLE, 234 had concurrent SLE and psoriasis, 3,404 had concurrent SLE, and 621 had concurrent psoriasis. bAmong persons with SLE, 234 had concurrent CLE and psoriasis, 3,404 had concurrent CLE, and 414 had concurrent psoriasis. cAmong persons with psoriasis, 234 had concurrent CLE and SLE, 621 had concurrent CLE, and 414 had concurrent SLE. Abbreviations: ASCVD: atherosclerotic cardiovascular disease, CLE: cutaneous lupus erythematosus, ICD-10-CM: International Classification of Diseases, Tenth Revision, Clinical Modification, SLE: systemic lupus erythematosus
Time course incidence of ASCVD in persons with CLE, SLE, and psoriasis compared with controls. Kaplan-Meier survival curves stratified by persons with CLE, SLE, psoriasis, and controls. Persons were censored after the first instance of ASCVD or if no further follow-up is available. 95% confidence intervals are denoted by the shaded portions. The number at risk and cumulative number censored in 120-day increments is shown in the tables beneath the survival curves. Abbreviations: ASCVD: atherosclerotic cardiovascular disease, CLE: cutaneous lupus erythematosus, SLE: systemic lupus erythematosus
Multivariable adjusted hazards ratios of ASCVD in persons with CLE, SLE, and psoriasis compared with controls. Multivariable Cox proportional hazards regression and adjusted hazards ratios are presented in a forest plot. Models are adjusted for traditional comorbidities associated with ASCVD, including age, sex, hypertension, diabetes mellitus, obesity, chronic kidney disease, and dyslipidemia. The primary outcome was composite ASCVD as defined by any one of the following: myocardial infarction, cerebrovascular accident, and coronary artery disease. Each component of composite outcome is presented separately. The control group served as the reference group and is not shown. P<0.05 was considered significant. Abbreviations: ASCVD: atherosclerotic cardiovascular disease, CLE: cutaneous lupus erythematosus, CAD: coronary artery disease, CI: confidence interval, CVA: cerebrovascular accident, HR: hazards ratio, MI: myocardial infarction, SLE: systemic lupus erythematosus
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