Late-Onset PsA May Increase Risk for Cardiovascular Events 2023

Psoriatic arthritis is a complex disease with many clinical manifestations and variations that can develop over its course. In addition to the common effects on the skin, peripheral joints and spine, entheses, and areas outside the musculoskeletal system such as the eyes and bowels, individuals with psoriatic arthritis (PsA) have an increased risk of cardiovascular disease.

While diagnosis and treatment are difficult enough with younger patients, the complexities involved in PsA are multiplied in patients with late-onset disease. Patients over 60 years old often present with features that can resemble other rheumatic diseases, such as peripheral arthritis, making diagnosis tricky. In addition, older patients are likely to have more comorbidities that can pose further challenges to diagnosis and complicate treatment, including assessing for potential risk of cardiovascular events.

Study Methods

The team collected data from records of patients diagnosed with PsA in two tertiary hospitals in Athens, Greece. The data were from December 2017 to December 2022. The researchers divided the patients into two groups: those with late-onset PsA (patients diagnosed at age 60 and older) and those with earlier-onset PsA (those diagnosed before age 60). In a supplementary analysis, they compared patients who were diagnosed at age 46 or younger with those diagnosed at a later age.

A total of 281 patients with PsA were included in the study. Fifty-eight percent were female, and 14.2% had late-onset PsA. When comparing gender, family history of psoriasis or spondyloarthritis, BMI, and smoking habits, the researchers found no significant differences between participants in the late-onset and earlier-onset group.

While demographic and clinical characteristics at the time of diagnosis were similar in patients with late-onset PsA and those with earlier onset disease, over the course of the disease, older patients were less likely to manifest enthesitis, the analysis found. However, patients in the late-onset group had increased cardiovascular risk, including more dyslipidemia and more major adverse cardiovascular events, as compared with those in the earlier onset group. However, the study’s authors noted that even patients who were diagnosed when younger than 46 years of age showed an independent increased frequency of cardiac risk factors.

The researchers pointed out that the interpretation of these results is complicated. “Given the underlying inflammatory nature of PsA upon its onset, PsA could promote or exacerbate the pre-existing age-related cardiovascular risk,” they wrote. On the other hand, they added, other comorbid conditions, including pro-inflammatory factors such as adiposity, smoking, microbiome dysbiosis, and immunosenescence, have been suggested as drivers that may “lead to a break in tolerance and to the corollary initiation of autoimmune inflammatory diseases later in life.” More research, they wrote, is required to support these theories.¹

For clinicians, it is important to be aware that patients with late-onset PsA may not present with traditional symptoms. In addition, the course of the disease may not follow an expected pattern, particularly regarding enthesitis and increased cardiovascular risk.

The study is a useful addition to the literature on rheumatic disease, said Dr. Byram. “It’s very important,” he added, “to have this on your radar, to have your ears perked up and your eyes open for tricky inflammatory disease that might pose additional cardiovascular risk to your older patient.”