1/8 ORIGINAL ARTICLE Cardiovascular Screening Practices and Statin Prescription Habits ActaDV in Patients with Psoriasis among Dermatologists, Rheumatologists and Primary Care Physicians Emilio BERNA-RICO1#, Carlota ABBAD-JAIME DE ARAGON1#, Ángel GARCIA-APARICIO2, David PALACIOS-MARTINEZ3, Asunción BALLESTER-MARTÍNEZ1, Jose-M CARRASCOSA4, Pablo DE LA CUEVA5, Cristina ANTON6, Carlos AZCARRAGA- LLOBET1, Emilio GARCIA-MOURONTE1, Belén DE NICOLAS-RUANES1, Lluis PUIG7, Pedro JAEN1, Nehal N. MEHTA8, Joel M. GELFAND9 and Álvaro GONZALEZ-CANTERO1,6 1 Department of Dermatology, Hospital Universitario Ramon y Cajal, IRYCIS, Madrid, 2Department of Rheumatology, Hospital Universitario Acta Dermato-Venereologica de Toledo, Toledo, 3Centro de Salud Universitario Isabel II, Parla, Madrid, 4Department of Dermatology, Hospital Universitari Germans Trias i Pujol. Universitat Autònoma de Barcelona, IGTP, Badalona, 5Department of Dermatology, Infanta Leonor Hospital, Madrid, 6Faculty of Medicine, Universidad Francisco de Vitoria, Madrid, 7Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain, 8Laboratory of Inflammation & Cardiometabolic diseases, Cardiovascular Branch, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD and 9Department of Dermatology and Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA. # These authors contributed equally. Patients with psoriasis have a higher prevalence of car­ diovascular risk factors. This study evaluated cardio­ SIGNIFICANCE vascular screening practices and statin prescribing Patients with psoriasis have an increased risk of cardio- habits among dermatologists, rheumatologists and pri­ vascular events. This is partly due to a higher prevalence mary care physicians (PCPs) through an online ques­ of smoking, hypertension, diabetes mellitus and dyslipi- tionnaire, which was distributed through the Spanish daemia. This study found that less than 30% of the phy- scientific societies of the above-mentioned specialties. sicians evaluated (dermatologists, rheumatologists and A total of 299 physicians (103 dermatologists, 94 rheu­ primary care physicians) performed global screening, defi- matologists and 102 PCPs) responded to the questionn­ ned as screening for hypertension, dyslipidaemia, smoking aire. Of these, 74.6% reported screening for smoking, and diabetes mellitus by the same physician. In addition, 37.8% for hypertension, 80.3% for dyslipidaemia, more than 60% of the primary care physicians stated that ActaDV and 79.6% for diabetes mellitus. Notably, only 28.4% they were unaware of the association between psoriasis performed global screening, defined as screening for and cardiovascular disease. Regarding treatment, 50% of smoking, hypertension, dyslipidaemia, and diabetes dermatologists and rheumatologists who do not prescribe mellitus by the same physician, and 24.4% reported statins would be willing to start prescribing them. calculating 10-year cardiovascular disease (CVD) risk, probably reflecting a lack of comprehensive cardiovas­ cular risk assessment in these patients. This study also sis (1, 2) and an increased risk of major cardiovascular identified unmet needs for awareness of cardiovascular events (3–6). Myocardial infarction occurs, on average, 5 comorbidities in psoriasis and corresponding screening years earlier in people with psoriasis than in the general Advances in dermatology and venereology and treatment recommendations among PCPs. Of PCPs, population (7). This elevated cardiovascular risk could be 61.2% reported not being aware of the association bet­ driven by both systemic inflammation in moderate-to-se- ween psoriasis and CVD and/or not being aware of its vere forms of the disease (8–10) and a higher prevalence screening recommendations, and 67.6% did not con­ of modifiable cardiovascular risk factors (CVRF), such sider psoriasis as a risk-enhancing factor when deci­ as obesity, smoking, hypertension, diabetes mellitus, ding on statin prescription. Thirteen dermatologists (12.6%) and 35 rheumatologists (37.2%) reported dyslipidaemia, metabolic syndrome or sedentary lifestyle prescribing statins. Among those who do not prescribe, (11–14). Interestingly, disease severity is associated with 49.7% would be willing to start their prescription. an increased likelihood of having CVRFs (15, 16), and with poorer control of hypertension in a dose-dependent manner Key words: cardiovascular disease; diagnosis; hearth disease risk factor; psoriasis. (17). Primary care-based and dermatologist-based scree- ning studies have shown that CVRFs are underdiagnosed Accepted Jan 31, 2023; Published Mar 28, 2023 in these patients, with 27.5–48% of patients with psoriasis Acta Derm Venereol 2023; 103: adv5087. having at least 1 undetected CVRF (18, 19). Moreover, DOI: 10.2340/actadv.v103.5087 an international cross-sectional study that included 2,254 Corr: Alvaro Gonzalez-Cantero, Dermatology Department, Ramon y Cajal patients with psoriasis and/or psoriatic arthritis found that University Hospital, IRYCIS, Colmenar Viejo km 9.100, ES-28034 Madrid, 65.6% of those with dyslipidaemia were not adequately Spain. E-mail: alvarogc261893@hotmail.com treated with statins (20). On this basis, a European working group and the P soriasis is a chronic immune-mediated skin disease, which is associated with accelerated atherosclero- National Psoriasis Foundation (NPF)/American Academy of Dermatology (AAD) have independently developed Published by Medical Journals Sweden, on behalf of the Society for Publication of Acta Dermato-Venereologica. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/) 2/8 E. Berna-Rico et al. “Cardiovascular screening and statin prescription in patients with psoriasis” position statements for the diagnosis and treatment of and factors that could affect the screening ratio. Questions related psoriasis comorbidities, including CVRFs screening to statin prescription habits were included in the dermatologists’ ActaDV and rheumatologists’ questionnaires. For PCPs, a final question recommendations (21, 22). Both documents recommend was included, assessing whether they consider psoriasis as a risk- following national guidelines, considering earlier and more enhancing factor when prescribing statins. frequent assessment in those patients with moderate-to-se- Questions were designed according to recommendations from vere forms of the disease. The most followed guidelines the most relevant CVD primary prevention guidelines (23, 24), for primary cardiovascular disease (CVD) prevention are guidelines for the diagnosis and management of individual CVRFs those from the European Society of Cardiology (ESC) (25–30) and position statements for the management of comorbi- dities in psoriasis (21, 22). Table SI summarizes baseline screening and the American Heart Association/American College recommendations and their periodicity for each CVRF. of Cardiology (AHA/ACC) (23, 24), which recommend a The questionnaire is provided in Appendix S1. Acta Dermato-Venereologica global approach based on the estimation of 10-year CVD The study followed the relevant portions of the Strengthening the risk with different scores, rather than an approximation Reporting of Observational Studies in Epidemiology (STROBE) based on individual CVRFs. These scores are easily reporting guideline (31) and the American Association for Public Opinion Research (AAPOR) reporting guideline (32). calculated through free online or mobile applications in which demographic information, smoking status, blood Outcomes and study covariates pressure, cholesterol values and diabetes mellitus status must be entered. Statins are usually indicated when blood The primary outcome of this study was to evaluate the screening cholesterol levels are above treatment goals, which are rates of smoking, obesity, hypertension, dyslipidaemia and dia- betes mellitus among dermatologists, rheumatologists and PCPs defined according to 10-year risk of CVD. Psoriasis is not in patients with psoriasis. Global screening (GS) was defined as quantitatively included in these tools, but it is considered screening for smoking, hypertension, dyslipidaemia and diabetes as a risk-enhancing factor that can tip the balance towards mellitus by the same physician, since these are the 4 CVRFs needed more proactive treatment in borderline cases (23). to estimate 10-year CVD risk. This study also assessed if the 10- Despite the screening recommendations for comorbi- year CVD risk estimation via the SCORE Risk Charts or the Pooled Cohort ASCVD Risk Equation was calculated in these patients. dities in patients with psoriasis, the extent to which these Secondary outcomes were: (i) to compare screening rates among guidelines are implemented in clinical practice is unclear, the above-mentioned specialties; (ii) to identify factors associated and which specialist should assume the burden of this CVD with a higher or lower frequency of screening; and (iii) to explore prevention remains controversial. Although a primary statin prescribing habits among dermatologists and rheumatologists care-based management of CVRFs is recommended, scree- and factors that could help their implementation. ActaDV ning measures are usually shared by both specialists and primary care physicians (PCP), and NPF/AAD guidelines Statistical analysis open the door to hypertension and dyslipidaemia treatment In the descriptive analysis, categorical variables were described by the dermatologists (21). using absolute frequencies and percentages. Exact 95% confidence The principal aim of this study was to evaluate scree- intervals (95% CI) were provided for selected parameters. ning practices among dermatologists, rheumatologists and Univariable logistic regression was used to evaluate differences in screening rates between dermatologists, rheumatologists and PCPs regarding CVRFs, especially focusing on a global PCPs. A multivariable logistic regression model was built to approach through calculation of 10-year risk of CVD. This identify predictors (independent variables) of GS, 10-year CVD study also examined statin prescribing habits among the Advances in dermatology and venereology risk calculation and statin prescription. Medical specialty, sex, above-mentioned specialties, exploring whether derma- practice setting (public, private or both), years since completing tologists and rheumatologists viewed statin prescription residency training, number of patients with psoriasis treated per month, participation in a specialized psoriasis outpatient clinic, feasible. participation in research projects related to psoriasis and univer- sity teaching were evaluated. As a first step, a univariable logistic regression was performed between each of the aforementioned MATERIALS AND METHODS variables and the dependent variables GS, 10-year CVD risk calculation and statin prescription. Variables with p < 0.20 were Study setting and instrument included in the multivariable model (33). Variables with p > 0.20, From September 2021 to February 2022, an online questionnaire but which were identified as potential confounders, were also was distributed via e-mail to dermatologists from the Spanish included. A p-value of < 0.05 was considered significant for all Academy of Dermatology and Venereology (AEDV) and from analyses. Statistical analyses were completed using SPSS v.25.0 the Spanish Group of Psoriasis (GPS), to rheumatologists from (SPSS, Chicago, IL, USA). the Spanish Society of Rheumatology (SER) and to PCPs from the Spanish Society of Primary Care Physicians (SEMERGEN). Each of the above-mentioned societies sent the survey to all their RESULTS members via their institutional e-mail list. The Institutional Review Board of the Hospital Universitario Ramon y Cajal considered A total of 103 out of 1,930 dermatologists (response rate that the study protocol was exempt from review given its design. 5.3%), 94 out of 1,879 rheumatologists (response rate Survey questions were developed and reviewed by an expert panel of clinicians (EBR, AGC, ABM, IGD, JMG) and a survey 5.0%) and 102 out of 412 PCPs surveyed (response rate methodology expert (CAR). Questions included: demographic 24.8%) responded to the questionnaire. Table I shows data, degree of training and specialization, CVRF screening habits the baseline characteristics of the participants. Baseline Acta Derm Venereol 2023 3/8 E. Berna-Rico et al. “Cardiovascular screening and statin prescription in patients with psoriasis” Table I. Baseline characteristics of the respondents Dermatologists (n=103) Rheumatologists (n=94) PCPs (n=102) Total (n=299) p-value* ActaDV Female, n (%) 65 (63.1) 63 (67.0) 61 (59.8) 189 (63.2) 0.467 Practice setting, n (%) < 0.001 Public hospital/clinic 43 (41.7) 72 (76.6) 96 (94.1) 212 (70.9) Private hospital/clinic 18 (17.5) 9 (9.6) 4 (3.9) 30 (10.0) Both 42 (40.8) 12 (12.8) 2 (2.0) 56 (18.8) Years since completing residency training, n (%) 0.621 Fellow 9 (8.7) 3 (3.2) 10 (9.8) 22 (7.4) 1–10 25 (24.3) 29 (30.9) 21 (20.6) 75 (25.3) 11–20 24 (23.3) 22 (23.4) 20 (19.6) 66 (22.2) 21–30 27 (26.2) 22 (23.4) 29 (28.4) 78 (26.3) > 30 17 (16.5) 17 (18.1) 22 (21.6) 56 (18.9) Acta Dermato-Venereologica Psoriasis patients treated per month, n (%) < 0.001 <5 7 (6.8) 4 (4.3) 62 (60.8) 73 (24.4) 5–20 32 (31.1) 46 (48.9) 40 (39.2) 118 (39.5) > 20 64 (62.1) 44 (46.8) 0 (0) 108 (36.1) Specialization, n (%) Specialized psoriasis outpatient clinic 41 (39.8) 8 (8.5) 2 (2.0) 41 (17.3) < 0.001 Research projects 47 (45.6) 30 (30.5) 0 (0) 77 (26.1) < 0.001 University teaching 25 (24.3) 17 (18.1) 1 (1) 43 (14.6) < 0.001 PCPs: primary care physician. *χ2 test. characteristics of dermatologists and rheumatologists less likely than PCPs to calculate 10-year CVD risk (OR were similar in terms of sex, percentage of fellows and 0.05, 95% CI 0.02–0.20, p < 0.001). private practice to those of the AEDV and SER members, Among those who do not perform GS, 42 dermatolo- respectively (Tables SII and SIII). gists (51.2%) and 32 rheumatologists (49.2%) reported referring the patient to a PCP and/or cardiologist (OR Screening practices for cardiovascular risk factors 1.08, 95% CI 0.57–2.08, p = 0.811). Overall, 223 physicians (74.6%, 95% CI 69.9–79.8) Predictors and factors reported as stimuli or obstacles reported screening for smoking, 136 (45.5%, 95% CI for cardiovascular risk factors screening ActaDV 39.8–51.2) for obesity, 113 (37.8%, 95% CI 32.3–43.3) for hypertension, 240 (80.3%, 95% CI 75.7–84.8) for Among physician characteristics, the participation in a dyslipidaemia and 238 (79.6%, 95% CI 75.0–84.2) for specialized psoriasis outpatient clinic was independently diabetes mellitus. Eighty-five physicians (28.4%, 95% associated with an increased likelihood of performing GS CI 23.3–33.6) performed GS and 73 physicians (24.4%, (OR 2.59, 95% CI 1.01–6.69, p = 0.049). Participation in 95% CI 19.5–29.3) reported calculating 10-year CVD risk. research projects related to psoriasis was independently Table II summarizes the screening rates for each cardio- associated with an increased likelihood of both GS (OR vascular risk factor among dermatologists, rheumatolo- 2.32, 95% CI 1.03–5.24, p = 0.044) and 10-year CVD risk gists and PCPs and the univariable comparative analysis. (OR 3.30, 95% CI 1.17–9.34, p = 0.024). Male physicians Advances in dermatology and venereology On multivariable analysis (Table III), dermatologists were less likely to perform GS than females (OR 0.53, were less likely to perform GS compared with rheumato- 95% CI 0.28–0.97, p = 0.040). The adjusted values for logists (OR 0.33, 95% CI 0.15–0.74, p = 0.007) and PCPs each predictor of GS and 10-year CVD risk calculation (OR 0.14, 95% CI 0.05–0.38, p < 0.001); they were also in multivariable analysis are detailed in Table III. Table II. Screening practices among the specialists evaluated with univariable logistic regression results ORγ (95% CI) Dermatologists (n=103) Rheumatologists (n=94) PCPs (n=102) Total (n=299) *D vs R; **D vs PCPs Smoking, n (%) 81 (78.6 86 (91.5) 56 (54.9) 223 (74.6) *OR 0.34 (0.14–0.81) **OR 3.02 (1.64–5.58) Obesity, n (%) 56 (54.4) 47 (50.0) 33 (32.4) 136 (45.5) *OR 1.19 (0.68–2.09) **OR 2.49 (1.41–4.40) HTN, n (%) 22 (21.4) 34 (36.2) 57 (55.9 113 (37.8) *OR 0.48 (0.26–0.902) **OR 0.21 (0.12–0.40) Dyslipidaemia, n (%) 80 (77.7) 92 (97.9) 68 (66.7) 240 (80.3) *OR 0.08 (0.02–0.33) **OR 1.74 (0.94–3.23) DM, n (%) 77 (74.8) 87 (92.6) 74 (72.6) 238 (79.6) *OR 0.24 (0.01–0.58) **OR 1.12 (0.60–2.09) Global screening, n (%) 21 (20.6) 29 (30.9) 35 (34.3) 85 (28.4) *OR 0.57 (0.3–1.1) **OR 0.49 (0.26–0.92) 10-year cardiovascular risk 12 (11.7) 12 (12.8) 49 (48.0) 73 (24.4) *OR 0.90 (0.38–2.12) calculation, n (%) **OR 0.14 (0.07–0.29) D: dermatologists; 95% CI: 95% confidence interval; DM: diabetes mellitus; HTN: hypertension; OR: odds ratio; PCP: primary care physician; R: rheumatologists; γ: univariable logistic regression. Acta Derm Venereol 2023 4/8 E. Berna-Rico et al. “Cardiovascular screening and statin prescription in patients with psoriasis” Table III. Multivariable regression models for global screening and 10-year and 3.7% of dermatologists, 4.6% of rheu- CVD risk calculation matologists and 38.8% of PCPs, p < 0,001, ActaDV Global screening* 10-year CVD risk calculation a a respectively). Figs 1 and 2 summarize the OR 95% CI p-value ORa 95% CIa p-value reasons reported. Specialty 0.001 0.001 Dermatologists vs rheumatologists 0.33 0.15–0.74 0.007 0.53 0.18–1.54 0.241 Dermatologists vs PCPs 0.14 0.05–0.38 < 0.001 0.05 0.02–0.20 < 0.001 Sex Statin prescription Men vs women 0.53 0.28–0.97 0.040 — — — Practice setting 0.533 When PCPs were asked whether they con- Private vs public — — — 2.01 0.59–6.91 0.266 sidered psoriasis as a risk-enhancing factor Private + public vs only public — — — 1.22 0.43–3.45 0.704 Years of experience 0.027 0.047 when prescribing statins, 69 physicians Acta Dermato-Venereologica 1–10 years vs resident 0.52 0.15–1.80 0.304 0.68 0.20–2.29 0.534 (67.6%) answered that they did not. 10–20 years vs resident 20–30 years vs resident 0.46 1.44 0.13–1.66 0.43–4.78 0.235 0.28 0.08–1.03 0.552 0.92 0.27–3.14 0.056 0.898 Thirteen dermatologists (12.6%, 95% CI > 20 years vs resident 1.24 0.37–4.14 0.732 0.35 0.10–1.27 0.111 6.1–19.1) and 35 rheumatologists (37.2%, Patients with psoriasis treated per month 0.426 0.662 95% CI 27.3–47.2) reported statin prescrip- 5–20 vs < 5 1.71 0.76–3.83 0.193 0.72 0.33–1.57 0.406 > 20 vs < 5 1.75 0.57–5.42 0.33 0.60 1.61–2.22 0.442 tion according to ESC/AHA guidelines. The Specialized psoriasis outpatient clinic difference was significant (OR 0.04, 95% Yes vs no Research projects related to psoriasis 2.59 1.01–6.69 0.049 1.95 0.61–6.25 0.264 CI 0.01–0.16, p < 0.001) after adjustment for Yes vs no 2.32 1.03–5.24 0.044 3.30 1.17–9.34 0.024 years since completing residence, number University teaching including psoriasis of psoriasis patients seen per month, parti- Yes vs no 1.50 0.65–3.48 0.344 1.47 0.51–4.23 0.475 cipation in a specialized psoriasis outpatient clinic, participation in research projects a Variables with no value in any of the columns are those with a p-value > 0.20 in a first univariable logistic regression and which were not identified as potential confounders, as detailed in methods. 95% CI: 95% confidence interval; CVD: cardiovascular disease; OR: odds ratio; PCP: primary related to psoriasis and university teaching care physician. including psoriasis lectures (Table SIV). *Defined as screening for smoking, hypertension, dyslipidaemia and diabetes mellitus by the same physician. Those who do not routinely prescribe statins were asked if they would be willing When asked about factors that prompt physicians to to start prescribing them. Forty-seven out of 90 derma- screen for CVRFs in psoriasis (more than 1 answer was tologists (52.2%) and 27/59 rheumatologists (45.8%) possible), 33 dermatologists (32.0%), 9 rheumatologists would start prescribing statins. ActaDV (9.6%) and 16 PCPs (15.5%) answered the severity of Table IV summarizes the statin prescription habits and the disease, whereas 40 dermatologists (40.8%), 27 the reasons for initiating or not initiating their prescrip- rheumatologists (28.7%) and 22 PCPs (21.4%) answe- tion among dermatologists and rheumatologists. red a personal or family history suggestive of increased cardiovascular risk. DISCUSSION Regarding the reasons for not screening for CVRFs (more than 1 answer was possible), the most frequent The most relevant findings of this survey study are: (i) a response among those who did not perform GS was lack comprehensive approach to cardiovascular risk in patients Advances in dermatology and venereology of time, reported by 105 physicians (65.9% of derma- with psoriasis is apparently lacking. Overall, only 28.4% tologists, 63.1% of rheumatologist and 14.9% of PCPs, of the specialists surveyed performed GS, and 24.4% p < 0.001). Interestingly, unawareness of the association reported calculating 10-year CVD risk. (ii) PCPs were between psoriasis and increased CVR and unawareness insufficiently aware of the increased cardiovascular risk of screening recommendations in psoriasis patients were experienced by patients with psoriasis and the implica- answered essentially by PCPs (0.0% of dermatologists, tions that this entity has on CVRFs screening and mana- 0.0% of rheumatologists and 32.8% of PCPs, p < 0.001, gement. The fact that almost 70% of them did not consider Fig. 1. Factors that prompt cardiovascular risk factor (CVRF) screening. Bars indicate percentage of physicians within each specialty that marked every option. PCP: primary care physician. Acta Derm Venereol 2023 5/8 E. Berna-Rico et al. “Cardiovascular screening and statin prescription in patients with psoriasis” ActaDV Acta Dermato-Venereologica Fig. 2. Reasons for not screening for cardiovascular risk factors (CVRFs). Bars indicate percentage of physicians within each specialty that marked every option. PCP: primary care physician. psoriasis as a risk-enhancing factor when deciding on The gap between elevated screening rates for most statin prescription is noteworthy. (iii) Dermatologists CVRFs included in 10-year CVD risk scores and low and rheumatologists reported a high predisposition to frequency of GS could indicate a fractional approach to start prescribing statins. cardiovascular risk assessment in these patients and the Parsi et al. (34) studied the cardiovascular screening absence of a strategy that integrates all aspects of their practices in patients with psoriasis among PCPs and cardiometabolic map. It is essential to identify the barriers cardiologists launching a questionnaire based on 2008 behind these gaps, since the absence of a comprehensive NPF and American Journal of Cardiology recommen- cardiovascular approach could preclude not only the co- dations. Manalo et al. (35) explored the same topic rrect assessment of these patients, but also their adequate among dermatologists. Both studies showed less than management. Serum lipid profile and blood glucose deter- half of the above-mentioned specialists screened for minations are easily ordered and integrated in blood tests hypertension, dyslipidaemia and diabetes mellitus ac- that dermatologists and rheumatologists usually request cording to guidelines. In this regard, 2 studies analyse before starting systemic medication or in their controls. data from the National Ambulatory Medical Care Survey However, blood pressure measurement is time-consuming ActaDV (NAMCS), a cross-sectional ongoing survey of non- and requires specific (albeit cheap and accessible) equip- federally employed, office-based physician practices ment. In this regard, lack of time and lack of facilities were in the USA. Blood pressure values were included in the reasons for not screening most commonly reported 32.2–36.4% of psoriasis outpatient visits, glucose levels among dermatologists and rheumatologists. Interestingly, in 4.9–5.9%, cholesterol levels in 9–9.2% and body mass the GS rate among these specialists is twice the rate of index (BMI) values in 26–29.9% (36, 37). In the current 10-year CVD risk calculation. Therefore, there appear to study, although hypertension was screened by only 21.4% be dermatologists and rheumatologists who are collecting of dermatologists, 36.2% of rheumatologists and 55.9% all the required information, but who are not calculating of PCPs, screening rates for dyslipidaemia (80.3%) and the scores, even though this can be done through free, fast Advances in dermatology and venereology diabetes mellitus (79.6%) were higher compared with and easy-to-use apps (ESC CVD Risk Calculation App® those previously reported, especially among dermatolo- or ASCVD Risk Estimator Plus®) or web pages (38, 39). gists and rheumatologists. Screening rates for smoking A lack of confidence in these prediction systems could were also acceptable (74.6%). be behind this discrepancy. Several studies have pointed Table IV. Statin prescription habits and predisposition to start prescribing them Dermatologists Rheumatologists (n = 103) (n = 94) OR (95% CI) Current prescription of statins, n (%) 13 (12.6) 35 (37.2) *OR 0.24 (0.12–0.50) **OR 0.04 (0.01–0.16) Would you be willing to start prescribing statins?a Yes (%) 47 (52.2) 27 (45.8) I would start prescribing after attending specific training courses for dermatologists or 43 (91.5) 27 (100) rheumatologists Others motivesb 4 (8.5) 0 (0.0) No (%) 43 (47.8) 32 (54.2) This exceeds the role of a dermatologists 15 (35.0) 9 (28.1) I do not have enough time to determine the need for statins 23 (53.5) 19 (59.4) I do not have the necessary material means to determine the need for statins 14 (32.6) 4 (12.5) a More than 1 answer was possible. bRespondents could provide free text: “I would prescribe if the prescription of statins was included in protocols developed for dermatologists” was answered by 1 dermatologist and “Clearer criteria for prescribing statins” by another. Two respondents marked the free-text option, but did not provide any text. 95% CI: 95% confidence interval; OR: odds ratio. *Univariable logistic regression; **multivariable logistic regression, adjusted for years since completing residence, number of psoriasis patients seen per month, participation in a specialized psoriasis outpatient clinic, participation in research project related with psoriasis and university teaching including psoriasis lessons. Acta Derm Venereol 2023 6/8 E. Berna-Rico et al. “Cardiovascular screening and statin prescription in patients with psoriasis” out that they may underestimate the actual CVD risk in (69.3%) agreed that screening for CVRFs was doable, patients with chronic inflammatory states such as psoriasis, and 36.1% considered that prescribing statins was feasi- ActaDV especially in moderate-to-severe forms of the disease (40, ble. To facilitate the lipid management in specialty care 41). However, clinical practice guidelines still consider the clinics, they propose the use of a care coordinator. The calculation of 10-year CVD risk as the basis for preventive specialists measure or identify individual CVRFs and the measures, considering psoriasis as a risk-enhancing factor care coordinators review test results and other sociodemo- that may guide primary preventive measures in interme- graphic information to calculate 10-year CVD risk score. diate risk patient (23, 24). Lack of familiarity with CVD Finally, a protocolized clinician decision support system prediction systems, usually outside the scope of practice of would help them to determine whether statin therapy or dermatologists and rheumatologists, could also contribute blood pressure management are indicated. The current Acta Dermato-Venereologica to this gap. study also shows that, although current prescription rates Conversely, blood pressure measurement and calcula- of statins by dermatologists and rheumatologists were tion of 10-year CVD risk scores are integrated in routine low, nearly 50% of those who did not prescribe statins workup performed by PCPs. This may explain a higher would be willing to start prescribing them after attending rate of that variable, despite the fact that screening for specific training courses. However, PCPs have greater most individual CVRFs was less frequent among PCPs expertise in the management of statins and antihyper- than among dermatologists and rheumatologists. However, tensives and can offer a more comprehensive view of the reported rate of 10-year CVD risk calculation was still the patient. Allocating more resources to training PCPs less than 50%. In this regard, 61.2% of PCPs reported in the cardiovascular comorbidities of psoriasis could not being aware of the association between psoriasis and be a more reasonable and efficient measure in settings increased cardiovascular risk and/or not being aware of where patients with psoriasis are properly engaged with its screening recommendations, and 67.7% of them did them, always ensuring good communication with hospital not consider the presence of psoriasis when deciding specialists. on statin prescription, despite ESC and AHA guideline recommendation (23, 24). This is especially relevant Study limitations considering that patients with psoriasis are nowadays Limitations of the study should be considered in the referred to their PCPs for screening and management context of its design. Response and sampling bias are ActaDV of CVRFs. both inherent to questionnaire-based studies. To mitigate The severity of the disease may influence the screening the sampling bias, the online survey was distributed th- rates among different specialists. Patients with moderate- rough national email lists; hence we could assume a wide to-severe psoriasis have a higher risk of cardiovascular geographical distribution of the questionnaire. Although events, and may also be more involved with dermatolo- the response rate among PCPs was acceptable, the low gists and rheumatologists. However, the questionnaire response rate among dermatologists and rheumatologists asked about factors that prompt screening, and less than severely limits our ability to generalize the results. The 30% of the specialists surveyed answered the severity response rate among dermatologists in the study by Bar- of the disease. This could reflect the lack of clear recom- bieri et al. was, surprisingly, very similar (5.2%) to that Advances in dermatology and venereology mendations from clinical practice guidelines. The AAD/ of the current study, with considerably fewer responses NPF guidelines recommends earlier and more frequent from rheumatologists (42). Both survey respondents screening for CVRFs in patients with moderate-to-severe and members of the AEDV and SER showed relatively forms of the disease, but without providing concrete ages similar demographic characteristics in terms of sex, pri- of onset or intervals (21). In the coming years, more vate practice and percentage of fellows, which would studies and clearer positions may be needed to define support that the respondents might adequately represent the best screening strategy in this particularly high-risk the population from which they were sampled. Parsi et subgroup of patients. al. (34) reported a response rate of 21% among PCPs and The strategy chosen to try to improve cardiovascular cardiologists, similar to that observed among PCPs in the outcomes of patients with psoriasis should be adapted current study. Cardiologists were not asked, as they are according to available resources and the structure of each more involved in the treatment of established cardiovas- healthcare system. In the US, 16.9% of women and 21.6% cular diseases than in screening practices in our setting. of men with psoriasis had no encounters with a PCP in Finally, a considerable proportion of dermatologists and the year following their first visit to a dermatologist (42), rheumatologists who responded to the questionnaire came whereas in Spain psoriatic patients seem to be more en- from an academic setting. They may be more likely to be gaged with their PCPs, with a mean of 8.7 visits per year aware of new scientific publications and to consider the (43). Barbieri et al. (44) explore dermatologists’ perspecti- patient’s comorbidities compared with their colleagues, ves on a specialist-led model of cardiovascular screening which may bias these results. Actual screening rates could and management. More than two-thirds of dermatologists therefore be lower than reported. Acta Derm Venereol 2023 7/8 E. Berna-Rico et al. “Cardiovascular screening and statin prescription in patients with psoriasis” Conclusion consultant for Abbie, Janssen, Novartis, Lilly, Almirall, Celgene, and Leo Pharma, receiving grants/other payments. ActaDV The deficit of a comprehensive approach to cardiovas- cular risk in patients with psoriasis highlighted by the current study could hinder the adequate treatment of REFERENCES their modifiable CVRFs, which is of utmost importance 1. Lerman JB, Joshi AA, Chaturvedi A, Aberra TM, Dey AK, Ro- given their increased risk of CVD. Obstacles behind the dante JA, et al. 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