Reviews/Psoriasis Psoriatic Arthritis/Psoriasis as independent cardiovascular risk factor
Psa CVD · PSA-CVD-01 · v2
Borderline: within 4 points of the Likely/Uncertain boundary, so a re-grade could land either side.
Several large studies that followed patients over time found that people with severe psoriasis had more heart attacks, cardiovascular deaths and major heart events than expected, even after accounting for the usual risks like smoking, diabetes, high blood pressure and cholesterol [1][2][3][4]. The extra risk tended to rise with more severe skin disease. But the picture is not uniform: one very large UK study found the extra risk shrank until it was no longer clear once all the standard risk factors were accounted for [7], and a Japanese study found no extra risk at all [8]. Because these are observational studies, they cannot rule out that some unmeasured difference between patients, such as weight or activity level, explains part of the association. The panel judged that the weight of the adjusted evidence supports an independent link for severe disease, while the contrary studies and this uncertainty kept it from the highest tier.
Four large adjusted cohorts report that severe psoriasis is independently associated with heart events after adjusting for traditional risk factors: MI relative risk 1.36 (1.13-1.64) at age 60 [1], cardiovascular mortality HR 1.57 (1.26-1.96) [2], major adverse cardiac events HR 1.53 (1.26-1.85) [3], and MACE HR 1.42 (1.17-1.73) in severe DMARD-treated patients [4]. A severity gradient recurs across these and the heart-failure cohort, where risk rose from HR 1.22 in mild to 1.53 (1.34-1.74) in severe disease [5]. A cross-sectional NHANES analysis adds adjusted MI odds of 2.24 (1.27-3.95) [6]. Against this, the CPRD cohort [7] saw its severe-psoriasis HR fall from 1.40 (1.07-1.84) to a non-significant 1.28 (0.96-1.69) on full adjustment, and the Japanese cohort [8] found a null MACE HR of 0.96 (0.67-1.38). The contested point: The evidence divides on whether the independent association survives full adjustment and generalises across populations: the positive cohorts [1][2][3][4] retain significance, but the CPRD cohort [7] attenuates to non-significance and the Japanese cohort [8] is null and flat across severity. Much of the positive signal also derives from the shared GPRD/CPRD data source, so the studies are not fully independent replications.
All 10 papers behind this claim with their DOIs and what each does to it, the panel’s arbitration, the evidence gap map and the open research questions. Free, and sent to your inbox.
We’ll also send you other claims from Psoriasis Psoriatic Arthritis, one at a time, and tell you when a release or a pivotal trial changes a grade. Unsubscribe by replying.
One reviewer's only job is to attack the finding. The challenges below were weighed before the grade was set.
The largest CPRD cohort [7] found severe-psoriasis MACE HR 1.28 with CI crossing 1 (0.96-1.69) after full adjustment, directly contradicting the positive cohorts and suggesting residual confounding drives the association.
The Japanese cohort [8] reports a null MACE HR 0.96 (0.67-1.38) flat across severity, showing the effect is population-dependent rather than a universal independent risk.
Where it remains uncertain. The CPRD cohort [7] attenuates to a non-significant severe HR 1.28 (0.96-1.69) on full adjustment and the Japanese cohort [8] is null at HR 0.96 (0.67-1.38), while much positive evidence shares GPRD/CPRD data.
Aleatory
The severe-psoriasis estimate in [7], 1.28 (0.96-1.69), and the null in [8], 0.96 (0.67-1.38), have intervals wide enough that chance alone leaves the direction of effect unsettled.
Epistemic
Positive cohorts are UK/US [1][2][3][4][6] while the null [8] is Japanese, so it is not known whether the association holds across populations.
Inferential
[9] (GLS) and [10] (coronary calcium) measure subclinical imaging endpoints and [5] measures heart failure; inferring MACE risk from these requires an unverified leap.
The load-bearing papers from a corpus of 10, each classified by what it does to the claim. Every DOI is taken from the corpus the claim was graded on.
Independent MI risk in severe psoriasis after adjustment.
“Psoriasis may confer an independent risk of MI; the RR was greatest in young patients with severe psoriasis, after adjusting for major cardiovascular risk factors.”
Panel auditInternal validity: medium · scope of inference: MI risk in psoriasis patients (by severity and age) relative to the general population, adjusted for traditional risk factors.Key limitations: no sample size in abstract · MI only, not full MACE composite · residual confounding possible
Independent CV mortality risk after adjustment for traditional factors.
“Severe psoriasis was an independent risk factor for CV mortality (HR 1.57; 95% CI 1.26, 1.96) when adjusting for age, sex, smoking, diabetes, hypertension, and hyperlipidaemia.”
Panel auditInternal validity: medium · scope of inference: CV mortality in severe psoriasis relative to comparators in a UK general-practice cohort, adjusted for traditional risk factors.Key limitations: CV mortality only, not the MI/stroke MACE composite · no sample size in abstract · severe psoriasis only
Direct MACE association after full adjustment.
“Severe psoriasis was a risk factor for major adverse cardiac events (hazard ratio 1.53; 95% CI 1.26-1.85) after adjusting for age, gender, diabetes, hypertension, tobacco use, and hyperlipidemia.”
Panel auditInternal validity: medium · scope of inference: 10-year MACE risk in severe psoriasis vs the general population, adjusted for traditional risk factors.Key limitations: no sample size in abstract · severe psoriasis only · residual confounding possible
Counter-evidence: association attenuates to non-significance on full adjustment.
“Neither psoriasis nor severe psoriasis were associated with the short-to-medium term risk of major CV events after adjusting for known cardiovascular disease risk factors.”
Panel auditInternal validity: medium · scope of inference: Short-to-medium term MACE risk in psoriasis and severe psoriasis in a UK cohort, after full adjustment for known CV risk factors.Key limitations: short-to-medium term follow-up only · no sample size in abstract · severe-psoriasis CI wide (0.96-1.69)
4 of 10 papers shown. The full review lists all of them, with the panel’s arbitration →
Claims are graded at each quarterly release, and re-graded between releases only when a pivotal trial lands. Every change is a new version of the claim.
The preponderance of adjusted cohort evidence supports an independent association for severe disease, but credible null studies and unresolvable residual confounding hold it below the Established tier.
Release 2026-q4 re-graded every claim from its corpus under protocol v0.19. An earlier release's grade is shown for the record; it came from an earlier protocol and is not a movement.
Assumptions that carry weight but are not themselves established.
The panel records the gap that would most move the claim, and the study that would close it.
Independent replication outside the GPRD/CPRD lineage. Much positive evidence [1][2][3][7] shares one UK data source, so the association is not confirmed in fully independent cohorts. The panel rates this the highest-importance open gap for the claim, and names the study design that would close it: Large adjusted cohort studies in separate national databases with harmonised severity and MACE definitions.
Open question: Does the independent association between severe psoriasis and MACE survive full adjustment in cohorts drawn from data sources other than the GPRD/CPRD? Why it is still open: The positive cohorts [1][2][3] and the attenuating null [7] share one UK lineage, and [7] loses significance on full adjustment.
Priors is a sceptical first reader, not peer review, and not medical advice.
Release 2026-q4 · graded 18 Sep 2026 · protocol v0.19