Gout: Risk Prediction Tools Underestimate CV Risk

Jennifer Garcia

January 26, 2017

A new study finds that current risk assessment strategies may underestimate the cardiovascular (CV) risk for patients with gout.

"The majority of patients presenting with gout may be at very high CV risk, indicating the need for initiating optimal prevention strategies at this stage," write lead author Mariano Andrés, MD, from the Hospital General Universitario de Alicante, Spain, and colleagues.

In the study, published online January 16 in the Annals of the Rheumatic Diseases, researchers evaluated 237 new patients with crystal-proven gout being seen at a hospital-based rheumatology clinic.

All patients were seen between January 1, 2014, and June 30, 2016, and were evaluated for CV risk via physical examination, interview, review of conventional CV risk factors, anthropometry, and laboratory variables. Further, the Systematic Coronary Evaluation (SCORE) and the Framingham Heart Study were applied to all patients as risk prediction tools.

Using the 2011 European guidelines, the researchers stratified CV risk as follows: low (SCORE <1%), moderate (SCORE, 1% - 4%), high (uncomplicated diabetes mellitus, estimated glomerular filtration rate 30 - 59 mL/minute, intima-media thickness [IMT] >0.9 mm, or SCORE 5% - 9%), and very high risk (prior CV disease, carotid atheroma plaques, diabetes mellitus with complications, estimated glomerular filtration rate <30 mL/minute, SCORE >9%).

One hundred forty-two (59.9%) patients not initially placed in the very high risk category underwent carotid ultrasonography (cUS) with a trained rheumatologist after the Mannheim consensus. Patients in this group tended to be younger, have fewer CV risk factors (except for smoking), and have lower lipid levels when compared with those patients who did not undergo cUS.

Among those who underwent cUS, 64 patients (45.1%) had increased IMT and 66 patients (46.5%) had carotid atheroma plaques. Both increased IMT and atheroma plaques were seen in 44 patients (31.0%).

According to the cUS findings, 80 patients (56.3%) were upgraded to a higher risk level, indicating a significant difference from the initial risk assessment (P < .001 for trend test).

"CV preventive strategies are less costly than treating the complications, especially on subjects at risk, which support efforts to identify high-risk populations through risk prediction tools or subclinical atherosclerosis screening," write Dr Andrés and colleagues.

They go on to point out that one strength of their study was that they used "a structured CV assessment that can be easily reproduced in further studies or clinical practice" and note that incorporation of subclinical atherosclerosis screening such cUS "strengthened the CV risk stratification in patients with gout."

The majority of patients in the study were men (86.5%), and the mean age was 63.7 years. The median gout duration of participants was 4 years, whereas 30 patients (14.2%) were being evaluated at their first gout attack.

The authors hypothesize that other issues, in addition to conventional risk factors, likely play a role in the increased CV risk for patients with gout. These may include crystal-led inflammation or increased use of nonsteroidal anti-inflammatory drugs.

When asked how these study findings may alter current clinical practice, Luke Barré, MD, rheumatology fellow at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, said: "I would view it as hypothesis generating, and not something which would change routine practice."

Dr Barré noted that although these findings suggest that patients with gout may have a higher CV risk than what current tools predict, the study "does not answer the question of whether increased screening and treatment of traditional risk factors benefits this select population."

The authors acknowledge study limitations such as inclusion of more severe, refractory cases with a higher rate of comorbidities. Further, they note that the lack of a control group may have affected the results, especially with respect to the prevalence of carotid plaques identified.

The authors and independent commentator have disclosed no relevant financial relationships.

Ann Rheum Dis. Published online January 16, 2017. Abstract

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