Incidence of cardiovascular disease in individuals with psoriasis: a systematic review and meta-analysis.

The relationship between psoriasis and increased risk of cardiovascular disease (CVD) is controversial. We critically evaluate 14 cohorts and meta-analyze the magnitude of CVD risk for the primary outcomes of CVD mortality, stroke, and myocardial infarction (MI), and establish subgroup risk for different psoriasis severities and age groups. Increased CVD risk was identified only in individuals with severe psoriasis (defined as requiring systemic therapy or hospital admission): the risk ratio relative to the general population was 1.37 (95% confidence interval (CI) 1.17-1.60) for CVD mortality, 3.04 (95% CI 0.65-14.35) for MI, and 1.59 (95% CI 1.34-1.89) for stroke. The relative risks of CVD were highest in the younger, severe psoriasis population (e.g., 3.10 (95% CI 1.98-4.86) for MI at 30 years), and absolute risks were greatest in older individuals with severe psoriasis (e.g., 23.2 excess MIs per 10,000 person-years at 60 years). Uncertainty remains about whether CVD risk is directly attributable to psoriasis, as the majority of studies failed to adequately adjust for key traditional risk factors.

Making clinical governance work.

This paper summarises a conference that took place at the Royal College of Physicians about the work of the Clinical Effectiveness and Evaluation Unit (CEEu) and the National Collaborating Centre for Chronic Conditions (NCC-CC). The importance of the clinical standards, audit, and evidence-based guidelines and their contribution to the clinical governance arena was acknowledged. In addition, consideration was given to the fact that information provision alone does not change clinician behaviour. Multifaceted strategies are discussed and lessons learnt examined. The CEEu and NCC-CC have made significant contributions at a national level in the development of clinical governance.