Comparative Stratification of Cardiovascular Risk through Framingham and Globo Risk in Patients with Psoriasis of IAHULA November 2017-May 2018.

Objectives: To know the frequency of Metabolic Syndrome in patients with Psoriasis who come to the consultation of the Dermatology Service of the Autonomous University Hospital of the Andes November 2017 to May 2018. Materials and Methods: Observational analytical descriptive study. Patients with Psoriasis diagnoses who attended the dermatology office were selected, PASI, ATP-III, Framingham and GLOBORISK were applied. Results: 55 patients, 55% men and 45% women, there was statistical correlation between older age groups and PASI index (p=0.023). The main modifiable cardiovascular risk factors were smoking, sedentary lifestyle and obesity, statistical correlation was found for sedentary lifestyle (p=0.047). The main non-modifiable cardiovascular risk factors were Hypertension and Diabetes showing both statistical significance (p=0.004), (p=0.0001). The ATP-III criteria showed statistical significance for Hypertension, glycemia, total cholesterol and low HDL (p=0.003, p=0.008, p=0.027, p=0.017). The frequency of metabolic syndrome represented 47.27% of the sample. The most affected gender was male (61.54%). Statistical correlation was found in the older age groups for the presence of Metabolic Syndrome (p=0.0001). The group with the highest frequency of metabolic syndrome was the one with 6 to 10 years of the disease (p=0.001). When applying the Framingham and GLOBORISK scores, there were higher scores in the patients as PASI was increased. Conclusion: There is a higher frequency of Metabolic Syndrome in patients with Psoriasis, so it is recommended to establish measures aimed at reducing the burden of cardiovascular disease in these patients.


Introduction
affecting between 2 and 3% of the population. World [2]. Psoriasis is estimated to affect approximately more than 125 million people worldwide, with a global prevalence of 2-3%. Being greater in those of Caucasian origin, it is variable in other races and exceptional among the indigenous people of the American continent and Australia. The white race has a prevalence of 0.1% and the incidence in the black race is low. In Germany there is a prevalence of the disease of 1.7%, in Sweden of 2.3%, the United States 2.1%, India 0.7%, Japan 0.5%. In Latin American countries it is working on it.
Studies suggest that the prevalence in South America is 1% [3].
According to the global report of psoriasis published by the WHO in 2016, people with psoriasis are at high risk of suffering from various comorbid conditions, such as cardiovascular disease, diabetes, obesity, Crohn's disease, myocardial infarction, ulcerative colitis, metabolic syndrome, strokes or liver disease. Patients with moderate/severe psoriasis, especially in the 4th decade of life, have an increased risk of having a heart attack and survival decreases 3 years for men and 4 years for women because of cardiovascular events [4]. Epidemiological studies have aroused great interest in the association of psoriasis with different cardiovascular, metabolic and immune comorbidities with which it shares inflammatory pathways or a common background [5], however, its association with metabolic syndrome has been increasingly recognized [6].
Metabolic Syndrome (MS) is a set of cardiometabolic risk factors that confer a higher risk of developing cardiovascular disease than that attributed to each component in isolation. It affects approximately 15 to 25% of the general population, its prevalence is increasing both in developed countries (United States and European countries) and in developing countries, accompanying the increase in obesity globally [7,8]. Metabolic Syndrome confers a significant burden of disease, for example, some studies show that MS confers twice the risk of coronary artery disease, [9] as well as increases the risk of cerebrovascular disease, fatty liver and certain types of malignancies such as lymphomas and squamous cell carcinomas [10].
Current recommendations suggest that patients with psoriasis should be evaluated to rule out the presence of MS, and if it is present, they should receive intensive treatment, with interventions in their lifestyle, weight loss, control of blood pressure, diabetes, and hypercholesterolemia [11]. There are multiple criteria used to define metabolic syndrome at an international Mildl, those proposed by the International Diabetes Foundation (IDF), those of the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) and others such as those of the Organization World Health Organization (WHO) and the American Association of Clinical Endocrinologists (AACE) that have in common grouping a series of abnormalities in the same individual [12][13][14].
It should be noted that most of the research papers use the ATP III criteria to compare results due to their practical utility; associating simplicity to carry out laboratory tests; and it also requires complying with three of the five parameters. There is evidence that this association (SM/PSORIASIS) is due to increased T cell immune activity, and increased production of tumor necrosis factor alpha. These classify psoriasis as the prototype of an inflammatory disease characterized by TH1 and TH17 activation, whose cytokines such as IL1, IL6, and tumor necrosis factor alpha are elevated in blood and skin mediators that could have an effect on adipogenesis, lipid metabolism, and insulin signaling. Hence, the entire inflammatory process in psoriasis has a great impact on obesity, diabetes, thrombosis, and arteriosclerosis, which, in turn, can influence the pathogenesis of psoriasis by promoting the proinflammatory state and increasing the propensity to develop the syndrome. Metabolic [15][16][17].
Given that Psoriasis is one of the main reasons for consultation in the dermatological area, and having no current data on the

Study design
Descriptive analytical observational study. e. Infectious processes in any form of presentation.

Data processing and analysis
Quantitative data were presented with measures of central tendency and dispersion (mean and standard deviation); the qualitative data were presented with absolute and relative frequencies (in percentages GraphPad Prism version 5 (GraphPad Software Inc, La Jolla, USA).

Ethical component
The ethical components of this research work will be carried out based on the international ethical standards set forth in the Declaration of Helsinki [18] and that contemplated in the Code   Table 3 shows those modifiable cardiovascular risk factors distributed in 3 categories; Hypertension, diabetes mellitus and Myocardial infarction, the first 2 were statistically significant as they were correlated with the severity of psoriasis, but the presence of Myocardial infarction was not.   Table 4 shows the ATP-III criteria, applied to our study to define metabolic syndrome. The most frequent corresponded to Arterial Hypertension, the second was hypertriglyceridemia and the third had low HDL levels. Statistical significance was not seen in the Body

Results
Mass Index, Abdominal Circumference, and Triglycerides categories.
In Table 5 it was observed that the frequency of metabolic syndrome represented 47.27% (26) of the sample. Regarding distribution, the most affected gender was male (61.54%), n=16 of the 26 patients in our study. In the distribution by age, a higher proportion could be seen for the group of those over 60 years old, n=13 (50%), finding a statistical correlation for the variables older age and the presence of metabolic syndrome in patients with Psoriasis.   Diabetes was observed in the study members, this finding from this study agrees with that found in other investigations [21].
The ATP-III criteria were applied to the study patients, since there is a high frequency of them, especially for Arterial Hypertension, hypertriglyceridemia, and low HDL levels, this finding agrees with what was found in other studies [22]. The frequency of metabolic syndrome was observed in 26 of the 55 patients, which reveals a great similarity in relation to what was found in other studies [23], where higher rates of it have been correlated compared to the general population. Additionally, it was evidenced that the evolution time of Psoriasis was decisive for the appearance of metabolic syndrome with a value of p=0.001, various studies have correlated this with the chronic activation of the immune system and the increased expression of pro-inflammatory substances that generate dysfunction. Endothelial and increased burden of cardiovascular disease [24]. The cardiovascular risk assessment when applying the Framingham and GLOBORISK scales showed a high correlation between the PASI severity index and a higher risk score for both scales. This result has been found in investigations where a greater load of cardiovascular disease and a poorer control of Psoriasis [25] have been correlated, which is also influenced by the limited availability of therapeutics at present.

1.
Extend medium and long-term follow-up, to assess cardiovascular risk in patients with Psoriasis.

2.
Measure the effects of lack of treatment in patients with Psoriasis and its repercussions regarding cardiovascular risk.

3.
Expand the sample of patients including patients with other pathologies of a rheumatological nature to characterize their cardiovascular risk profile and the frequency of metabolic syndrome.

4.
Sensitize the staff of the Dermatology service regarding the high rate of cardiovascular disease in these patients.

5.
Generate directives with the Hospital Management to acquire the necessary medications for the management of these patients. 6. Implement cardiovascular risk prevention programs in patients who come to the Psoriasis clinic.

7.
Establish in the clinical practice of the Dermatology Service tools to assess cardiovascular risk annually and request tests according to that risk.

8.
Continue with research related to cardiovascular risk and psoriasis.

Timely refer patients with Psoriasis and other
Comorbidities to the relevant service.

Use stratification tools such as Framingham and GLOBO-
RISK in the evaluation of cardiovascular risk.