Cardiovascular Risk in Psoriatic Arthritis in the Treat-to-Target Era: A Focused Expert Narrative Review of Epidemiology, Risk Assessment, Vascular Imaging, and Prevention

Background/Objectives: Psoriatic arthritis (PsA) is associated with excess cardiovascular (CV) morbidity, but the supporting literature spans heterogeneous observational, imaging, prediction, therapeutic, and guideline sources. This focused expert narrative review examines clinically relevant evidence for CV burden, risk markers, risk prediction, vascular imaging, treatment safety, and prevention in PsA. Methods: PubMed/MEDLINE was searched through 12 August 2026 using domain-based search blocks, supplemented by EULAR, GRAPPA, and European Society of Cardiology guidance and citation tracking. The final synthesis intentionally prioritized direct human PsA evidence; mixed psoriatic-disease or other immune-mediated evidence was used only when required for clinical context and was labeled as indirect. Embase, Scopus, and Web of Science were not searched; no formal risk-of-bias instrument or certainty-of-evidence grading framework was applied. Results: Conventional CV risk factors remain central. Direct PsA cohorts support associations between disease activity, metabolic abnormalities, and subsequent events, but do not establish incremental predictive value beyond validated risk models. Imaging studies demonstrate frequent subclinical atherosclerosis, yet plaque detection is distinct from event-prediction validation and does not establish benefit from universal screening. Therapeutic evidence is dominated by observational comparisons and low-event randomized-trial syntheses, precluding a causal cardioprotective ranking of drug classes. Conclusions: Current care should combine guideline-based CV prevention with treat-to-target PsA management for rheumatologic outcomes. PsA-specific risk modifiers, imaging-guided prevention, and treatment strategies intended to reduce hard CV outcomes require prospective validation. This article is a selective expert synthesis, not a systematic review, prediction model, or clinical pathway.