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Gout and Cardiovascular Disease: The lesser known impact

01 October 2024 - A/Prof Helen Keen

Gout, a common yet preventable condition in Australia, is not as benign as once thought. While it has long been suggested that people with gout are at increased risk of cardiovascular disease and mortality, the association has been complex and unclear. Recent evidence has improved our understanding of this link, confirming it is not dependent on the traditionally implicated comorbidities such as hypertension, dyslipidaemia, chronic kidney disease, type 2 diabetes and obesity.

As primary care health providers what do these findings mean for our patients and what are the implications for their care?

Recent Findings 

Recent evidence suggests that gout flares are associated with a short-term increase in the risk of major adverse cardiovascular events and that in people with gout, normalising serum urate levels is linked to a reduced risk of cardiovascular disease.

  • A 2022 UK observational study, involving over 62,500 patients newly diagnosed with gout, revealed a nearly doubled risk of cardiovascular events within the two months following a gout flare. This heightened risk remained even after excluding those with pre-existing cardiovascular diseases, and appeared to subside and return to baseline after four months. These findings highlight the importance of preventing gout flares to reduce cardiovascular risk, and monitoring for cardiovascular signs and symptoms during the critical post-flare period (1).

  • Further supporting the need to prevent gout flares to reduce cardiovascular risk, a 2023 study from Western Australia found that people had a 70% higher risk of experiencing a major adverse cardiovascular event in the 30 days after hospital admission for acute gout than in the year before or year after the admissions (2).  

  • A recent New Zealand study identified an increased risk of cardiovascular events in people with gout, even after adjusting for multiple cardiovascular risk factors, (adjusted hazard ratio 1.34 (95% confidence interval 1.23 to 1.45) in women; 1.18 (1.12 to 1.24) in men). They also observed that among men with gout but without a history of cardiovascular disease, regular allopurinol use and maintaining target serum urate levels were linked to reduced cardiovascular risk. In contrast, men who were not dispensed regular allopurinol and those with a serum urate ≥ 0.36 mmol/L had increased cardiovascular risks. 

These findings reinforce the need for clinicians to adopt a treat-to-target approach when managing gout, as well as ensuring that flares are prevented, to improve cardiovascular outcomes. 

Understanding the link between gout and heart disease

“The association between gout and cardiovascular disease is complex and much is still unknown. The research suggests multifactorial causes likely play a role, including hyperuricaemia, the effect of acute inflammation on plaque stability and chronic low-grade inflammation. The important take-home point here is that regardless of possible cause, all of these factors can be controlled by lowering serum urate. Patients with complex needs and multimorbidities often view gout as an acute issue involving a few days of pain and so it tends to be put to the bottom of the pile in terms of issues needing attention. However, recent studies have highlighted that having flares of gout is not OK. In fact, the consequences of gout flare are a significantly raised risk of a heart attack in the short-term.”

Dr Helen Keen MB BS W.Aust., FRACP

Take home messages 

It is important that clinicians recognise gout is not just acute flares, but rather a chronic condition, which is potentially disabling and affecting kidney and heart health. 

Australian healthcare practitioners can enhance care by:

  • Ensuring gout patients reach target serum urate levels. 

  • Regularly assessing cardiovascular risk and optimising the management of comorbidities i.e. obesity, hypertension, hyperlipidaemia, chronic kidney disease and type 2 diabetes. 

  • Educating patients on the chronic nature of gout and its potential complications (e.g. joint damage and deformity, increased risk of chronic kidney disease and kidney stones and the associated increased cardiovascular risk). 

  • Emphasising the importance of adherence to prescribed urate-lowering therapy and lifestyle modifications.

“When we are talking with our patients, we need to keep our messaging simple. The best thing they can do for their ongoing health is to not have a flare. This is achievable because, compared to many other conditions, gout is easy to treat. It is just a tablet every day.”

Dr Helen Keen MB BS W.Aust., FRACP

Learn more about the management of gout

Use the Gout Treatment Algorithm from the Quality Use of Medicines Alliance for at-a-glance guidance on best practice management for gout and gout flares. The Algorithm reflects current Australian recommendations and is endorsed by the ARA, ANZMUSC and Cochrane Musculoskeletal.

Earn 2.5 hours of Measuring Outcomes CPD and reflect on your management of patients with gout by completing our mini-audit.

If you are looking for an opportunity to update about gout at a whole of practice level and earn 1 hour of reviewing performance CPD, book a virtual education visit. 

References

1. Cipolletta E, Tata LJ, Nakafero G, et al. Association Between Gout Flare and Subsequent Cardiovascular Events Among Patients With Gout. JAMA. 2022; 328(5): 440–450. https://doi.org/10.1001/jama.2022.11390

2. Lopez D, Dwivedi G, Nossent J, et al. Risk of Major Adverse Cardiovascular Event Following Incident Hospitalization for Acute Gout: A Western Australian Population-Level Linked Data Study. ACR Open Rheumatology. 2023; 5(6): 298–304. https://doi.org/10.1002/acr2.11540

3. Cai K, Wu B, Mehta S, et al. Association between gout and cardiovascular outcomes in adults with no history of cardiovascular disease: Large data linkage study in New Zealand. BMJ Medicine. 2022; 1(1): e000081. https://doi.org/10.1136/bmjmed-2021-000081

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For more free Quality Use of Medicines education, check out QHUB on Medcast

 

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A/Prof Helen Keen
A/Prof Helen Keen

Associate Professor Helen Keen, MBBS FRACP PhD CCPU, Vice-President Australian Rheumatology Association

A/Prof Helen Keen is a clinical rheumatologist and mid-career researcher, having been awarded a PhD (Leeds) in 2011. She is the head of both the South Metropolitan Health Service Rheumatology service and holds a conjoint position as a Consultant in Rheumatology at Fiona Stanley Hospital and as a Clinical Associate Professor in the School of Medicine and Pharmacology, University of Western Australia. Dr Keen is an Adjunct Professor at Murdoch University. She is the Western Australian lead for A3BC – The Australian Arthritis and Autoimmune Registry and Biobank Collaborative.

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