Gout and cardiovascular disease: the lesser known impact

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 

Three recent studies suggest 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.

1. A 2022 UK observational study, of  over 62,500 patients newly diagnosed with gout, revealed a nearly doubled risk of cardiovascular events within the two months following a gout flare (even after excluding those with pre-existing cardiovascular disease), 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).

2. 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).  

3. 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) (3). The authors 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 risk. 

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. 

Regardless of possible cause, it is important to understand that all of these factors can be controlled by lowering serum urate.

Take home messages 

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. The best thing for a patient’s ongoing health is to avoid flares. Health professionals can support this by:

• ensuring patients with gout reach target serum urate levels 

• evaluating 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

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 (MO) CPD and reflect on your management of patients with gout by completing our mini-audit.

Book a virtual education visit for your whole practice, or join as an individual alongside peers Australia-wide. Update your knowledge on gout management and earn 1 hour of Reviewing Performance (RP) CPD. 

References

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