Cardiovascular Imaging in Psoriasis: A Critical Review of Current Evidence, Techniques, and Therapeutic Implications.

Psoriasis is a systemic inflammatory disease increasingly recognized for its association with elevated cardiovascular risk, driven by immune-mediated endothelial dysfunction and accelerated atherosclerosis. Non-invasive cardiovascular imaging has consistently demonstrated a spectrum of subclinical abnormalities in patients with moderate-to-severe psoriasis, including coronary microvascular dysfunction, high-risk plaque burden, vascular inflammation, myocardial remodeling, and increased arterial stiffness. This critical review summarizes the role of different imaging modalities in detecting psoriasis-associated cardiovascular alterations and evaluates emerging data on the impact of systemic therapies. Imaging abnormalities in psoriasis often precede clinical events and can support early risk reclassification and referral. Biologic therapy is associated with improved coronary microvascular function and with reductions in noncalcified plaque burden and high-risk plaque features on coronary computed tomography angiography (CCTA), and statins reduce vascular 18F-fluorodeoxyglucose (FDG) uptake on positron emission tomography (PET) in psoriasis cohorts. Outcome data that link these imaging changes to reduced events remain limited. Imaging should be used selectively, with coronary calcium scoring or carotid ultrasound for risk refinement in asymptomatic adults and targeted CCTA or transthoracic echocardiography (TTE) when symptoms, examination, or screening suggest cardiovascular involvement.