Subclinical myocardial dysfunction and left ventricular remodeling in psoriatic arthritis: a systematic review and meta-analysis

Background

Patients with psoriatic arthritis (PsA) are at increased cardiovascular risk, yet the presence and extent of subclinical myocardial involvement remain incompletely characterized. Advanced echocardiographic parameters such as left ventricular global longitudinal strain (LV GLS) may detect early systolic dysfunction before overt changes in left ventricular ejection fraction (LVEF) occur.

Purpose of our study was to perform a systematic review and meta-analysis of published literature evaluating left ventricular systolic function and structural remodeling in patients with PsA compared with controls using conventional and advanced/deformation echocardiographic parameters.

Methods

A systematic review and meta-analysis of observational studies comparing echocardiographic parameters in PsA patients and controls was performed. Random-effects models were used to calculate standardized mean differences (SMDs) with 95% confidence intervals (CIs) for LVEF, LV GLS, left ventricular end-diastolic diameter (LVEDD), and LV mass. Heterogeneity was assessed using the I² statistic.

Results

Meta-analysis of 8 studies (11 groups) including 432 patients with PsA and 518 controls demonstrated, that LVEF was significantly lower in PsA patients compared to controls (SMD −0.36, 95% CI −0.65 to −0.07; p<0.0001, I² = 78%), corresponding to a mild but statistically significant reduction. (Fig. 1A)

Pooled analysis of 5 studies (6 groups) evaluating 174 PsA patients and 194 controls demonstrated significantly impaired LV GLS in the study group compared with controls (SMD −0.79, 95% CI −1.15 to −0.43; p < 0.0001, I² = 61%). This corresponded to a10-15% relative decrease, consistent with clinically meaningful subclinical systolic dysfunction. (Fig. 1B)

LVDD was evaluated in 6 studies (9 groups), including 311 PsA patients with and without cardiovascular risk and 374 controls. Pooled analysis demonstrated a significantly larger LVEDD in PsA patients compared with controls (SMD 0.32, 95% CI 0.09–0.55; p=0.006, I² = 53%), indicating a small but consistent increase in left ventricular cavity size. (Fig. 2A) Similarly, in the analysis of 5 studies (7 subgroups) that included 336 PsA patients and 409 controls, PsA patients exhibited significantly higher LV mass compared with controls (SMD 0.40, 95% CI 0.18–0.62; p=0.0004, I² = 52%) (Fig. 2B), consistent with mild-to-moderate adverse left ventricular remodeling. LV mass is approximately 10 g higher (or about 4–6 g/m² higher when indexed) in patients with PsA compared with controls.

Conclusions

PsA is associated with significant subclinical myocardial dysfunction and adverse left ventricular remodeling. LV GLS appears to be a more sensitive marker than LVEF for detecting early systolic impairment in PsA patients. These findings support the use of advanced echocardiographic assessment for improved cardiovascular risk stratification and earlier detection of myocardial involvement in patients with PsA.