How gout attacks lead to heart attacks
Not only are gout flares excruciatingly painful and highly disruptive, they also increase the chances of you having a heart attack or stroke over the next few months.
These disturbing findings come from a study by Edoardo Cipolletta of the Polytechnic University of Marche in Ancona, Italy, just published in the American medical journal JAMA.
Dr Cipolletta and his collaborators reviewed the case files of more than sixty-two thousand British gout patients. They found that more than ten thousand of those patients had suffered a heart attack or stroke. That’s about 17%, or 1 in 6. When they compared those patients with the remaining fifty-two thousand who hadn’t had a heart attack or stroke, they found those with a heart attack were twice as likely to have had a gout attack over the preceding two months. This effect persisted after adjusting for differences between the groups for obesity, smoking, alcohol intake, socio-economic status and other factors that may have caused a difference.
What this suggests is that having a gout flare-up increases your risk of having a heart attack or stroke over the following few months. This effect persisted up to four months after the gout flare-up.
We have known for some time that having gout increases the risk of heart attacks and strokes. A review of more than eight and a half million people in 2015 showed that having gout makes you one and a half times more likely to have a heart attack than someone who does not have gout. That risk was almost three times higher for people whose gout had started before they were forty-five. Having poorly controlled gout also increases the risk: the higher your uric acid level, the higher your risk. Other risk factors for heart attacks, such as high blood pressure, diabetes, or high cholesterol, raise this risk even further.
Soberingly, one Dutch study found that someone with gout has a risk of dying from cardiovascular disease that is seven times higher than a similar person without gout.
How might gout attacks lead to heart attacks?
The answer is inflammation, the body’s response to irritants or foreign material. The plaques of atheroma that cause narrowing of the coronary arteries often cause inflammation of the arterial wall, and inflammation can cause these plaques to break off and cause a heart attack by blocking a coronary artery. We also know that people with heart attacks often show increased levels of chemicals in the blood that indicate inflammation. Inflammation in one part of the body can lead to effects elsewhere. This is how gum disease increases the risk of heart attacks.
Gout is a form of arthritis characterised by inflammation. You can tell that as soon as you look at the hot, red, painful, swollen big toe of someone suffering a typical gout attack. The inflammation of joints in a gout flare-up may trigger a worsening of inflammation in the coronary artery walls and lead to the break off of a plaque or blood clot. It is this that blocks the coronary artery and causes a heart attack.
Your medication may increase the risk even further
The medication used to treat gout can compound the problem. Non-steroidal anti-inflammatory drugs (NSAIDs) such as indomethacin increase the risk of heart attacks and strokes. Doctors use NSAIDs both to treat gout flare-ups and long-term to prevent future attacks.
Febuxostat, which like allopurinol, blocks the production of uric acid, has been shown to raise the risk of death from cardiovascular events. Consequently, doctors only prescribe it for people who can’t take allopurinol or another alternative.
In contrast, colchicine and allopurinol may offer some protection. Colchicine is an anti-inflammatory drug used to treat gout attacks and prevent future flare-ups. Canadian researchers found that giving colchicine to patients who had just had a heart attack reduced the risk of severe cardiovascular events (such as another heart attack or cardiac arrest) by almost a third. Other large studies support this figure, prompting doctors to explore the possibility of using colchicine in patients who have had or are at risk of a heart attack.
Allopurinol, the most widely used drug to reduce uric acid levels in people with gout, appears to reduce the risk of a heart attack by about 20%. The effect is greater with higher doses and a longer time on treatment with allopurinol.
If you have gout, what does this mean for you?
Given how painful most gout flare-ups are, you probably don’t need much convincing that you should reduce the risk of future attacks. This new information just makes that even more urgent.
Most people with gout will have other risks factors for heart attacks and strokes, such as:
- Being overweight
- Having high blood pressure
- Having abnormal blood lipids (cholesterol)
- Smoking
You need to take this risk very seriously. The good news is that you can simultaneously reduce the chances of gout attacks, heart attacks and strokes by making the same lifestyle changes and checking with your doctor to ensure you are on optimal treatment.
What can you do to reduce your risk?
There are several steps you can take to reduce your chances of gout flare-ups, heart attacks and strokes:
- Stop smoking.
- Get down to a healthy weight.
- Eat a diet rich in fruits and vegetables.
- Take any medicines prescribed for gout correctly and regularly.
- See your doctor and get the following measurements checked. If they are high, talk to your doctor about treatment:
- Your blood pressure
- Your blood lipids (cholesterol)
- Your blood uric acid level
- Follow all the usual recommendations to avoid a gout flare-up:
- Avoid purine-rich foods
- Drink lots of fluids
- Minimise your alcohol consumption
You’ve seen all these recommendations before, and it’s easy to become complacent, but your future really is in your hands.
Take action today. Add these recommendations to your to-do list or diary, post them on your fridge door, and make an appointment to see your doctor. Choose a healthier future today!
If you found this information useful, please have a look at The Gout & Pseudogout Handbook which is packed with similar information.
The Pocket Doctor Handbooks are designed to give you the knowledge and facts you need to talk confidently with your doctor to ensure you get the best treatment.
Really interesting. I have gout flares and try and manage with colchine but it soon starts to upset me. I have been prescribed allupurinol for long term use so after reading this article I feel prompted to take it when gout flare has subsided.
You’re right, Diana. Colchicine has what we call a narrow therapeutic window. There’s very little room between an effective dose and one that causes side effects.
If you’ve been prescribed allopurinol, you’re lucky. Only about a third of people with gout in the UK get a medicine like allopurinol to lower the uric acid in their body. Without it, although colchicine or non-steroidal anti-inflammatories treat an acute attack, the uric acid keeps building up in the joints and other tissues, causing damage and storing up problems for the future.
Ask your doctor to check your uric acid levels at intervals once you start. In a US study, only 20% of people on allopurinol ever reached their target uric acid level. Another 20% didn’t achieve their target level, and fully 60% never had their uric acid level measured! It’s not for no reason that gout has been described as one of the worst-treated chronic diseases. It’s important to push for the best care.
If you like, send me your email address (ben@thepocketdoctor.og), and I’ll shoot you the treatment chapter from The Gout and Pseudogout Handbook.