Acta Dermato-Venereologica 99-10CompleteContent | Page 9
CLINICAL REPORT
865
Association Between Atopic Dermatitis and Cardiovascular Disease:
A Nationwide Register-based Case-control Study from Sweden
Lina U. IVERT 1,2 , Emma K. JOHANSSON 1,3 , Henrik DAL 4,5 , Bernt LINDELÖF 1,2 , Carl-Fredrik WAHLGREN 1,2 and Maria BRADLEY 1,2
Dermatology and Venereology Unit, Department of Medicine Solna, Karolinska Institutet, 2 Department of Dermatology, Karolinska University
Hospital Solna, 3 Dermatological and Venereal Clinic, Södersjukhuset, 4 Department of Public Health Sciences, Karolinska Institutet, and
5
Centre for Epidemiology and Community Medicine, Stockholm County Council, Stockholm, Sweden
1
The associations between atopic dermatitis (AD) and
cardiovascular disease (CVD) are debated. The aim of
this study was to investigate the association between
AD and coronary artery disease or ischaemic stroke
in a nationwide, register-based, case-control study
(104,832 AD cases, 1,022,435 controls) based on link
age of Swedish national register data between 1968
and 2016. Patients were classified as having severe
AD if they had received systemic pharmacotherapy for
AD or had been treated in a dermatological ward with
AD as the main diagnosis. Other AD was classified as
non-severe. After multivariable adjustments for co-
morbidities and socioeconomic status, overall AD was
associated with angina pectoris (adjusted odds ratio
(aOR) 1.13, 95% confidence interval (CI) 1.08–1.19),
but among males with severe AD this association was
not found, compared with the general population. Male
non-severe AD was associated with myocardial infarc-
tion (OR 1.15, 95% CI 1.07–1.23). Severe AD was as-
sociated with ischaemic stroke, with similar estimates
in men and women (aOR 1.19, 95% CI 1.07–1.33).
Subgroup analyses among women indicated smoking
as an important risk factor among severe cases. Dia
betes mellitus, hyperlipidaemia, and hypertension
were more prevalent in severe AD than in controls,
and hyperlipidaemia and hypertension were also more
prevalent in non-severe AD than in controls. In conclu-
sion, in this study, AD was associated with CVD, and
this should be kept in mind, especially when managing
patients with severe AD.
Key words: angina pectoris; atopic dermatitis; coronary artery
disease; comorbidity, eczema; myocardial infarction; stroke.
Accepted Jun 13, 2019; E-published Jun 14, 2019
Acta Derm Venereol 2019; 99: 865–870.
Corr: Lina U. Ivert, Department of Dermatology, Karolinska University
Hospital Solna, SE-171 76 Stockholm, Sweden. E-mail: [email protected]
A
topic dermatitis (AD) is a common chronic inflam-
matory skin disorder with a lifetime prevalence of
10–20% in developed countries (1, 2). The pathogenesis
of AD is complex, with interactions of multiple genetic,
biological and environmental factors leading to skin
barrier dysfunction and altered immunological response.
AD can have a severely negative impact on health-related
quality of life, including self-confidence and sleep, and it
also implies a socioeconomic burden, with loss of work
ing days and extensive use of healthcare resources (3).
SIGNIFICANCE
Studies show conflicting results regarding the association
between atopic dermatitis and cardiovascular disease. The
aim of this study was to investigate the association bet-
ween atopic dermatitis and angina pectoris, myocardial
infarction, or ischaemic stroke in a nationwide, register-
based, case-control study among Swedish patients aged 15
years or older. Adult patients with atopic dermatitis were
found to have a positive association with angina pectoris,
myocardial infarction, and ischaemic stroke, compared with
the general population. The association between atopic
dermatitis and cardiovascular disease was attenuated after
adjustment for cardiovascular comorbidities and education.
Associations between AD and atopic comorbidities,
such as asthma, allergic rhinitis, and food allergies, are
well-established (1). In recent years, several studies
have explored associations between AD and non-atopic
comorbidities; for example, cardiovascular disease. It
has been suggested that the chronic systemic inflam-
mation in patients with AD may trigger arteriosclerosis
and cardiovascular disease, in line with the observed
risks among patients with psoriasis (4, 5). However, a
meta-analysis using adjusted effect estimates reported no
association between AD and myocardial infarction, hy-
pertension, diabetes mellitus, or stroke, although a modest
association with angina pectoris was found. The authors
concluded that variations in risk factors, such as obesity
and smoking, might explain positive associations in dif-
ferent populations, and that AD is unlikely to represent
an independent risk factor for cardiometabolic disease
(6). On the other hand, most of the studies included were
cross-sectional and, in some, the AD diagnosis was based
on questionnaires not specific for AD. Furthermore, in a
large population-based study from the UK, patients with
severe AD had a significantly higher risk of stroke and
cardiac outcomes (7). Also, a recent systematic review
and meta-analysis found that significant associations
between AD and cardiovascular outcomes were more
common in cohort studies, but with between-study hete-
rogeneity, and that increasing AD severity was associated
with cardiovascular outcomes (8). Thus, in summary,
epidemiological studies have shown conflicting results.
The aims of this study, using well-established nation-
wide Swedish healthcare registries, were to assess the
association between AD at age 15 years or older and
This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta
Journal Compilation © 2019 Acta Dermato-Venereologica.
doi: 10.2340/00015555-3235
Acta Derm Venereol 2019; 99: 865–870