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Incidence of Myocardial Infarction and Cerebrovascular Accident in Patients With Hidradenitis Suppurativa

Educational Objective:
To discuss the associations of hidradenitis suppurativa with myocardial infarction and cerebrovascular accident.
1 Credit CME
Key Points

Question  Is hidradenitis suppurativa associated with an increased risk of myocardial infarction and cerebrovascular accident?

Findings  In this cohort study of 49 862 patients with hidradenitis suppurativa, significantly increased risk of myocardial infarction or cerebrovascular accident was noted among patients with hidradenitis suppurativa compared with controls. Increased risks were also noted for myocardial infarction alone and cerebrovascular accident alone.

Meaning  Hidradenitis suppurativa appears to be an independent risk factor for cardiovascular events, including myocardial infarction and cerebrovascular accident; patients with hidradenitis suppurativa may benefit from screening and early management of risk mediators.

Abstract

Importance  Although hidradenitis suppurativa (HS) is associated with several cardiovascular risk mediators, information on the risk of myocardial infarction (MI) and cerebrovascular accident (CVA) in this population is sparse.

Objective  To compare risk of MI, CVA, and composite disease (MI or CVA) in patients with HS, stratified by use of biologic agents, with controls without HS.

Design, Setting, and Participants  A retrospective cohort analysis was conducted between January 1, 1999, and April 1, 2019, using a demographically heterogeneous population-based sample of over 56 million unique patients. Individuals with HS (n = 49 862) and without HS (n = 1 421 223) were identified using electronic health records data.

Main Outcomes and Measures  The primary outcome was incidence of composite MI or CVA.

Results  Of the 49 862 patients with HS, 37 981 were women (76.2%), 29 711 were white (59.6%), and mean (SD) age was 38.3 (13.3) years. Crude incidence rate of composite disease was 6.6 (95% CI, 6.3-7.0) per 1000 person-years in patients with HS compared with 6.8 (95% CI, 6.7-6.8) per 1000 person-years in controls. In patients with HS, crude incidence rates were 2.9 (95% CI, 2.6-3.1) per 1000 person-years for MI alone and 4.1 (95% CI, 3.9-4.4) per 1000 person-years for CVA alone compared with 3.2 (95% CI, 3.18-3.25) per 1000 person-years for MI alone in control patients and 4.1 (95% CI, 4.0-4.1) per 1000 person-years for CVA alone in control patients. In adjusted analysis, patients with HS had a 23% increased risk of composite disease (hazard ratio [HR], 1.23; 95% CI, 1.17-1.30; P < .001) and a similar increase in the risk of MI alone (HR, 1.21; 95% CI, 1.12-1.32; P < .001) and CVA alone (HR, 1.22; 95% CI, 1.14-1.31; P < .001) compared with control patients. The relative difference in composite MI or CVA risk between patients with HS and controls was highest among younger patients HR in subgroup aged 18-29 years: 1.67; 95% CI, 1.37-2.03).

Conclusions and Relevance  Patients with HS appear to have an increased risk of MI and CVA. Early management of modifiable cardiovascular risk mediators may be warranted in patients with HS.

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Article Information

Accepted for Publication: September 11, 2019.

Corresponding Author: Amit Garg, MD, Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 1991 Marcus Ave, Ste 300, New Hyde Park, NY, 11042 (amgarg@northwell.edu).

Published Online: November 13, 2019. doi:10.1001/jamadermatol.2019.3412

Author Contributions: Mr Strunk and Dr Garg had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Strunk, Garg.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Reddy, Garg.

Critical revision of the manuscript for important intellectual content: Strunk, Gregor, Garg.

Statistical analysis: Strunk, Garg.

Obtained funding: Garg.

Administrative, technical, or material support: Reddy.

Supervision: Garg.

Conflict of Interest Disclosures: Dr Gregor reported receiving grants from AbbVie, InflaRx, Janssen Pharma, and UCB; and personal fees from AbbVie, Chemocentryx, InflasRx, Incyte, and personal fees from UCB outside the submitted work. Dr Garg reported receiving grants and personal fees from AbbVie, personal fees from Amgen, Asana Biosciences, Pfizer, UCB, and Janssen during the conduct of the study. No other disclosures were reported.

Funding/ Support: This study was supported in part by an education grant from AbbVie.

Role of the Funder/Sponsor: AbbVie had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Jemec  GB.  Clinical practice. hidradenitis suppurativa.  N Engl J Med. 2012;366(2):158-164. doi:10.1056/NEJMcp1014163PubMedGoogle ScholarCrossref
2.
Tzellos  T, Zouboulis  CC, Gulliver  W, Cohen  AD, Wolkenstein  P, Jemec  GB.  Cardiovascular disease risk factors in patients with hidradenitis suppurativa: a systematic review and meta-analysis of observational studies.  Br J Dermatol. 2015;173(5):1142-1155. doi:10.1111/bjd.14024PubMedGoogle ScholarCrossref
3.
Gold  DA, Reeder  VJ, Mahan  MG, Hamzavi  IH.  The prevalence of metabolic syndrome in patients with hidradenitis suppurativa.  J Am Acad Dermatol. 2014;70(4):699-703. doi:10.1016/j.jaad.2013.11.014PubMedGoogle ScholarCrossref
4.
Garg  A, Papagermanos  V, Midura  M, Strunk  A.  Incidence of hidradenitis suppurativa among tobacco smokers: a population-based retrospective analysis in the USA.  Br J Dermatol. 2018;178(3):709-714. doi:10.1111/bjd.15939PubMedGoogle ScholarCrossref
5.
Garg  A, Birabaharan  M, Strunk  A.  Prevalence of type 2 diabetes mellitus among patients with hidradenitis suppurativa in the United States.  J Am Acad Dermatol. 2018;79(1):71-76. doi:10.1016/j.jaad.2018.01.014PubMedGoogle ScholarCrossref
6.
Miller  IM, Ellervik  C, Vinding  GR,  et al.  Association of metabolic syndrome and hidradenitis suppurativa.  JAMA Dermatol. 2014;150(12):1273-1280. doi:10.1001/jamadermatol.2014.1165PubMedGoogle ScholarCrossref
7.
Shalom  G, Freud  T, Harman-Boehm  I, Polishchuk  I, Cohen  AD.  Hidradenitis suppurativa and metabolic syndrome: a comparative cross-sectional study of 3207 patients.  Br J Dermatol. 2015;173(2):464-470. doi:10.1111/bjd.13777PubMedGoogle ScholarCrossref
8.
IBM. The data curation process. Watson health informatics overview of mapping, standardization, and indexing. https://www.ibm.com/downloads/cas/JBNOXQK4. Accessed October 9, 2019.
9.
US National Library of Medicine. Unified Medical Language System (UMLS). SNOMED CT. https://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html. Accessed July 25, 2019.
10.
Nelson  SJ, Zeng  K, Kilbourne  J, Powell  T, Moore  R.  Normalized names for clinical drugs: RxNorm at 6 years.  J Am Med Inform Assoc. 2011;18(4):441-448. doi:10.1136/amiajnl-2011-000116PubMedGoogle ScholarCrossref
11.
McDonald  CJ, Huff  SM, Suico  JG,  et al.  LOINC, a universal standard for identifying laboratory observations: a 5-year update.  Clin Chem. 2003;49(4):624-633. doi:10.1373/49.4.624PubMedGoogle ScholarCrossref
12.
Shen  JJ, Wan  TT, Perlin  JB.  An exploration of the complex relationship of socioecologic factors in the treatment and outcomes of acute myocardial infarction in disadvantaged populations.  Health Serv Res. 2001;36(4):711-732.PubMedGoogle Scholar
13.
Foraker  RE, Rose  KM, Whitsel  EA, Suchindran  CM, Wood  JL, Rosamond  WD.  Neighborhood socioeconomic status, Medicaid coverage and medical management of myocardial infarction: atherosclerosis risk in communities (ARIC) community surveillance.  BMC Public Health. 2010;10:632. doi:10.1186/1471-2458-10-632PubMedGoogle ScholarCrossref
14.
Strunk  A, Midura  M, Papagermanos  V, Alloo  A, Garg  A.  Validation of a case-finding algorithm for hidradenitis suppurativa using administrative coding from a clinical database.  Dermatology. 2017;233(1):53-57. doi:10.1159/000468148PubMedGoogle ScholarCrossref
15.
McCormick  N, Lacaille  D, Bhole  V, Avina-Zubieta  JA.  Validity of myocardial infarction diagnoses in administrative databases: a systematic review.  PLoS One. 2014;9(3):e92286. doi:10.1371/journal.pone.0092286PubMedGoogle Scholar
16.
Andrade  SE, Harrold  LR, Tjia  J,  et al.  A systematic review of validated methods for identifying cerebrovascular accident or transient ischemic attack using administrative data.  Pharmacoepidemiol Drug Saf. 2012;21(21)(suppl 1):100-128. doi:10.1002/pds.2312PubMedGoogle ScholarCrossref
17.
McCormick  N, Bhole  V, Lacaille  D, Avina-Zubieta  JA.  Validity of diagnostic codes for acute stroke in administrative databases: a systematic review.  PLoS One. 2015;10(8):e0135834. doi:10.1371/journal.pone.0135834PubMedGoogle Scholar
18.
Navaneethan  SD, Jolly  SE, Schold  JD,  et al.  Development and validation of an electronic health record-based chronic kidney disease registry.  Clin J Am Soc Nephrol. 2011;6(1):40-49. doi:10.2215/CJN.04230510PubMedGoogle ScholarCrossref
19.
Egeberg  A, Gislason  GH, Hansen  PR.  Risk of major adverse cardiovascular events and all-cause mortality in patients with hidradenitis suppurativa.  JAMA Dermatol. 2016;152(4):429-434. doi:10.1001/jamadermatol.2015.6264PubMedGoogle ScholarCrossref
20.
Garg  A, Kirby  JS, Lavian  J, Lin  G, Strunk  A.  Sex- and age-adjusted population analysis of prevalence estimates for hidradenitis suppurativa in the United States.  JAMA Dermatol. 2017;153(8):760-764. doi:10.1001/jamadermatol.2017.0201PubMedGoogle ScholarCrossref
21.
Laslett  LJ, Alagona  P  Jr, Clark  BA  III,  et al.  The worldwide environment of cardiovascular disease: prevalence, diagnosis, therapy, and policy issues: a report from the American College of Cardiology.  J Am Coll Cardiol. 2012;60(25)(suppl):S1-S49. doi:10.1016/j.jacc.2012.11.002PubMedGoogle ScholarCrossref
22.
Reddy  S, Strunk  A, Garg  A.  Comparative overall comorbidity burden among patients with hidradenitis suppurativa.  JAMA Dermatol. 2019;155(7):797-802. doi:10.1001/jamadermatol.2019.0164PubMedGoogle ScholarCrossref
23.
Egeberg  A, Skov  L, Joshi  AA,  et al.  The relationship between duration of psoriasis, vascular inflammation, and cardiovascular events.  J Am Acad Dermatol. 2017;77(4):650-656.e3. doi:10.1016/j.jaad.2017.06.028PubMedGoogle ScholarCrossref
24.
Davidovici  BB, Sattar  N, Prinz  J,  et al.  Psoriasis and systemic inflammatory diseases: potential mechanistic links between skin disease and co-morbid conditions.  J Invest Dermatol. 2010;130(7):1785-1796. doi:10.1038/jid.2010.103PubMedGoogle ScholarCrossref
25.
Wang  Y, Gao  H, Loyd  CM,  et al.  Chronic skin-specific inflammation promotes vascular inflammation and thrombosis.  J Invest Dermatol. 2012;132(8):2067-2075. doi:10.1038/jid.2012.112PubMedGoogle ScholarCrossref
26.
Matusiak  L, Bieniek  A, Szepietowski  JC.  Increased serum tumour necrosis factor-alpha in hidradenitis suppurativa patients: is there a basis for treatment with anti-tumour necrosis factor-alpha agents?  Acta Derm Venereol. 2009;89(6):601-603. doi:10.2340/00015555-0749PubMedGoogle ScholarCrossref
27.
Matusiak  Ł, Szczęch  J, Bieniek  A, Nowicka-Suszko  D, Szepietowski  JC.  Increased interleukin (IL)-17 serum levels in patients with hidradenitis suppurativa: implications for treatment with anti-IL-17 agents.  J Am Acad Dermatol. 2017;76(4):670-675. doi:10.1016/j.jaad.2016.10.042PubMedGoogle ScholarCrossref
28.
Jiménez-Gallo  D, de la Varga-Martínez  R, Ossorio-García  L, Albarrán-Planelles  C, Rodríguez  C, Linares-Barrios  M.  The clinical significance of increased serum proinflammatory cytokines, C-reactive protein, and erythrocyte sedimentation rate in patients with hidradenitis suppurativa.  Mediators Inflamm. 2017;2017:2450401. doi:10.1155/2017/2450401PubMedGoogle Scholar
29.
Libby  P, Ridker  PM, Maseri  A.  Inflammation and atherosclerosis.  Circulation. 2002;105(9):1135-1143. doi:10.1161/hc0902.104353PubMedGoogle ScholarCrossref
30.
Libby  P.  Inflammation and cardiovascular disease mechanisms.  Am J Clin Nutr. 2006;83(2):456S-460S. doi:10.1093/ajcn/83.2.456SPubMedGoogle ScholarCrossref
31.
Ahlehoff  O, Gislason  GH, Charlot  M,  et al.  Psoriasis is associated with clinically significant cardiovascular risk: a Danish nationwide cohort study.  J Intern Med. 2011;270(2):147-157. doi:10.1111/j.1365-2796.2010.02310.xPubMedGoogle ScholarCrossref
32.
Dowlatshahi  EA, van der Voort  EA, Arends  LR, Nijsten  T.  Markers of systemic inflammation in psoriasis: a systematic review and meta-analysis.  Br J Dermatol. 2013;169(2):266-282. doi:10.1111/bjd.12355PubMedGoogle ScholarCrossref
33.
Ogdie  A, Yu  Y, Haynes  K,  et al.  Risk of major cardiovascular events in patients with psoriatic arthritis, psoriasis and rheumatoid arthritis: a population-based cohort study.  Ann Rheum Dis. 2015;74(2):326-332. doi:10.1136/annrheumdis-2014-205675PubMedGoogle ScholarCrossref
34.
Dessein  PH, Joffe  BI, Singh  S.  Biomarkers of endothelial dysfunction, cardiovascular risk factors and atherosclerosis in rheumatoid arthritis.  Arthritis Res Ther. 2005;7(3):R634-R643. doi:10.1186/ar1717PubMedGoogle ScholarCrossref
35.
Feng  W, Chen  G, Cai  D, Zhao  S, Cheng  J, Shen  H.  Inflammatory bowel disease and risk of ischemic heart disease: an updated meta-analysis of cohort studies.  J Am Heart Assoc. 2017;6(8):e005892. doi:10.1161/JAHA.117.005892PubMedGoogle Scholar
36.
Nancey  S, Hamzaoui  N, Moussata  D, Graber  I, Bienvenu  J, Flourie  B.  Serum interleukin-6, soluble interleukin-6 receptor and Crohn’s disease activity.  Dig Dis Sci. 2008;53(1):242-247. doi:10.1007/s10620-007-9849-6PubMedGoogle ScholarCrossref
37.
Rydén  L, Buhlin  K, Ekstrand  E,  et al.  Periodontitis increases the risk of a first myocardial infarction: a report from the PAROKRANK study.  Circulation. 2016;133(6):576-583.PubMedGoogle Scholar
38.
Loos  BG, Craandijk  J, Hoek  FJ, Wertheim-van Dillen  PM, van der Velden  U.  Elevation of systemic markers related to cardiovascular diseases in the peripheral blood of periodontitis patients.  J Periodontol. 2000;71(10):1528-1534. doi:10.1902/jop.2000.71.10.1528PubMedGoogle ScholarCrossref
39.
Gelfand  JM, Neimann  AL, Shin  DB, Wang  X, Margolis  DJ, Troxel  AB.  Risk of myocardial infarction in patients with psoriasis.  JAMA. 2006;296(14):1735-1741. doi:10.1001/jama.296.14.1735PubMedGoogle ScholarCrossref
40.
Mehta  NN, Yu  Y, Pinnelas  R,  et al.  Attributable risk estimate of severe psoriasis on major cardiovascular events.  Am J Med. 2011;124(8):775.e1-775.e6. doi:10.1016/j.amjmed.2011.03.028PubMedGoogle ScholarCrossref
41.
Wu  JJ, Choi  YM, Bebchuk  JD.  Risk of myocardial infarction in psoriasis patients: a retrospective cohort study.  J Dermatolog Treat. 2015;26(3):230-234. doi:10.3109/09546634.2014.952609PubMedGoogle ScholarCrossref
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