Gout and incidence of 12 cardiovascular diseases: a case-control study including 152 663 individuals with gout and 709 981 matched controls

Gout and rheumatoid arthritis are associated with subclinical vascular damage, reduced brachial vasoreactivity and coronary microvascular dysfunction: a case-control study

Gout and rheumatoid arthritis (RA) are distinct disorders, but both of these inflammatory arthropaties are associated with a relatively similar risk of atherosclerotic cardiovascular disease. We aimed to assess carotid intima-media thickness (CIMT), flow-mediated vasodilatation (FMD) and coronary flow reserve (CFR) in both disorders to understand and compare the extent of vascular damage. Patients with recently diagnosed gout (n = 30) and RA (n = 40) without previous cardiovascular disease were included to the present study, and 45 healthy volunteers served as controls. All participants underwent ultrasonographic examinations to measure CIMT, FMD and CFR. In unadjusted analysis, both gout and RA were associated with a significantly higher CIMT and significantly lower CFR as compared to controls, while FMD was only lower in the gout group. After adjustment, there was a significantly higher odds ratio (OR) for CIMT (OR:7.02, 95%CI:2.45-20.58 for gout and OR:2.86, 95%CI:1.27-6.57 for RA) and a lower OR for CFR (OR:0.21, 95%CI:0.08-0.55 for gout and OR:0.17, 95%CI:0.07-0.45 for RA) in both groups, while only gout patients had a lower OR for FMD (OR:0.21, 95%CI:0.08-0.55). There were no significant differences or evidence of a difference between gout and RA patients for CIMT, FMD or CFR. Gout and RA are associated with a similar degree of vascular damage, which may explain the similar incidence of atherosclerotic cardiovascular disease in both diseases.

Ceramide-based risk score: A novel laboratory tool for cardiovascular risk stratification in hyperuricemia and gout

Gout and hyperuricemia increase cardiovascular disease risk, highlighting the need for improved risk stratification. In this pilot study, we evaluated the Coronary Event Risk Test (CERT) in 94 hyperuricemic and 196 gout patients, and 53 controls. Plasma ceramides were determined by liquid chromatography-mass spectrometry. Elevated CERT scores (≥7) occurred in 11.7 % (2-fold increase) of hyperuricemic and 31.12 % (5.5-fold increase) of gout patients compared to controls. Additionally, both hyperuricemic and gout patients with increased CERT also exhibited higher levels of inflammation and atherogenic index of plasma, both of which were significantly associated with CERT. Incorporating CERT into routine care may enhance risk stratification and guide targeted interventions in this patient population.

Rheumatology: What You May Have Missed in 2024

Internal medicine physicians are frequently responsible for caring for patients with rheumatologic diseases, whether as a primary provider or in collaboration with subspecialists. This article calls attention to 8 studies published in 2024 that shed new light on the management of common rheumatologic conditions that internal medicine physicians are likely to encounter. The first study suggests that the weight loss medication semaglutide can improve pain and function in patients with painful knee osteoarthritis (OA), potentially providing a novel approach to management of this condition. The results of the second study show that methotrexate, a proven therapy for inflammatory arthritis, has promise for improving pain in patients with knee OA. The third study establishes that a trial of resistance training does not provide similar benefits as total joint replacement for patients with hip OA. The fourth study finds that platelet-rich plasma injections are no more effective than exercise in reducing pain for patients with knee OA. The fifth study underscores the importance of screening for lung cancer in patients with rheumatoid arthritis (RA), particularly in those known to have interstitial lung disease. The results of the sixth study emphasize that exercise therapy is safe and effective at improving function in patients with RA and severe activity limitations. The seventh study highlights the increased short-term risk for acute cardiovascular events in patients experiencing a new gout diagnosis. The final study suggests that supplementation with omega-3 fatty acids may provide sustained protection against developing new autoimmune diseases. Familiarity with these new studies will provide internal medicine physicians with valuable insights to enhance their care of patients with rheumatic diseases.

Predominance of Calcium Pyrophosphate Crystals in Synovial Fluid Samples of Patients at a Large Tertiary Center

Background: Crystal arthritides represent the most common inflammatory rheumatologic condition. While the prevalence of gouty arthritis by monosodium urate (MSU) is well established, the prevalences of calciumpyrophosphat (CPP) and basic calcium pyrophosphate (ARP) arthritis are less clear. We herein sought to assess the prevalence and inflammatory characteristics of crystal arthritides at our institution, the biggest tertiary center in Switzerland. Methods: A total of 5036 synovial fluid (SF) samples were analyzed with regard to crystal positivity as well as joint, age, and sex distribution in affected patients. We furthermore compared inflammatory and non-inflammatory SF samples for yields of their Polymorphonuclear (PMN) fractions. Results: About half of all samples were derived from knee joints, a male/female ratio up to 10.1:1 among the MSU-positive, and a clear shift towards elder patients with CPP-arthritis was seen. These findings were in line with previous studies and suggest good comparability of our cohort. Of note, 21.9% of all samples were CPP positive, whereas 15.3% and 9.5% were positive for MSU and ARP/alizarin-red positive, respectively. Importantly, CPP crystals were predominant in inflammatory (58.9%) and non-inflammatory (65.7%) samples. By contrast, MSU crystals were significantly more often associated with synovitis (p < 0.001). Interestingly, higher PMN fractions were found in non-inflammatory MSU-positive samples (p < 0.01), whereas a similar trend was seen in CPP-positive samples. Conclusions: CPP arthritis represented the most frequent crystal arthritis form at our center. Higher PMN fractions in non-inflammatory samples with CPP and MSU crystals suggest subclinical inflammation and provide further arguments for earlier anti-inflammatory and uric acid-lowering therapies in patients with crystal deposits.

Obesity substantially impacts rheumatic and musculoskeletal diseases: time to act

Obesity is a major health problem and risk factor for many chronic health conditions, including rheumatic and musculoskeletal diseases (RMDs). Around 7 in 10 adults with RMD live overweight or with obesity. Obesity not only increases the risk of developing RMDs. It worsens disease activity, pain, and fatigue; impairs treatment responses; and thereby reduces quality of life and physical function. Further, obesity can amplify or drive several comorbidities that are more prevalent in RMDs including hypertension, cardiovascular disease, type 2 diabetes, and metabolic dysfunction-associated steatotic liver disease. Moreover, reciprocal risk arises since RMDs make it harder to be physically active and maintain a healthy weight, especially in the context of an obesogenic environment. In this viewpoint, we review relevant evidence to suggest obesity confers distinctive, important challenges in care and daily living for many patients with RMDs. With the advent of several highly effective drugs for obesity, we also highlight research needs including that for robust clinical trials to test the efficacy and effectiveness of these therapies as part of the management of inflammatory RMDs, as primary agent or adjuvant to immune targeted therapeutics. Implementing such weight management strategies should provide a much-needed holistic approach to the care of our patients.

The changing burden of gout in adults aged 70 and above based on the global burden of disease 2019

Introduction

Gout is a significant global health issue, particularly among adults aged 70 and above. Understanding its epidemiological evolution and associated factors is crucial for guiding interventions and improving management.

Methods

This study analyzed data from the Global Burden of Disease study to assess the prevalence and trends of gout among adults aged 70 and above from 1990 to 2019. We evaluated temporal trends and regional disparities by calculating the estimated annual percentage change (EAPCs).

Results

Globally, the number of older adults individuals affected by gout increased from 5,316,210 cases in 1990 to 15,666,063 cases in 2019. It is noteworthy that the global burden of gout among the older adults continued to rise from 1990 to 2019, with an EAPC of 1.17 (95% CI: 1.02 to 1.32). In 2019, the prevalence rates among individuals aged 70-74, 75-79, 80-84, and 85 and above were 3,121.31 per 100,000, 3,437.17 per 100,000, 3,592.38 per 100,000, and 3,726.91 per 100,000, respectively. The regions with the highest prevalence rates of gout in 2019 were Australasia, High-income North America, and Southern Latin America, with rates of 8,500.73, 8,351.33, and 4,666.87 per 100,000, respectively. At the national level, some developed countries such as New Zealand, the United States of America, and Australia had the highest prevalence rates, reaching 8,893.74, 8,508.06, and 8,427.94 per 100,000, respectively. It is noteworthy that regions with higher levels of Socio-Demographic Index tended to have relatively higher burden of gout among the older adults, and the prevalence rates varied across different regions and age groups.

Conclusion

The study underscores the persistent burden of gout among the older adults, emphasizing the need for targeted interventions to address this issue and improve public health outcomes in this demographic.

Short-Term Risk of Cardiovascular Events in People Newly Diagnosed With Gout

OBJECTIVE

To investigate the temporal association between the first diagnosis of gout and cardiovascular events in the short term.

METHODS

We performed a self-controlled case series analysis and a cohort study using data from linked primary care, hospitalization, and mortality records from the United Kingdom's Clinical Practice Research Database-GOLD. We included individuals with a new diagnosis of gout either in the primary care or secondary care between January 1, 1997 and December 31, 2020. The first consultation at which gout was diagnosed was the exposure of interest. The main outcome consisted of cardiovascular events (ie, a composite of fatal and nonfatal myocardial infarction, ischemic or hemorrhagic stroke, and transient ischemic attack).

RESULTS

The 4,398 patients (66.9% male, mean age 74.6 years) had a cardiovascular event within at least two years of their first recorded diagnosis of gout. The incidence of cardiovascular events was significantly higher in the 30 days after the first diagnosis of gout compared to baseline (adjusted incidence rate ratio 1.55, 95% confidence interval [CI] 1.33-1.83). Among 76,440 patients (72.9% male, mean age 63.2 years) included in the cohort study, the incidence of cardiovascular events in the 30 days after the first gout diagnosis (31.2 events per 1,000 person-years, 95% CI 27.1-35.9) was significantly higher than in days 31 to 730 after gout diagnosis (21.6 events per 1,000 person-years, 95% CI 20.8-22.4) with a rate difference of -9.6 events per 1,000 person-years (95% CI -14.0 to -5.1).

CONCLUSION

Individuals had a short-term increased risk of cardiovascular events in the 30 days following the first consultation at which gout was diagnosed.

[Colchicine-Phoenix from the ashes]

Colchicine is an anti-inflammatory herbal medicine with a history stretching back thousands of years. It is a cornerstone in the acute and prophylactic treatment of gout and has secured a permanent place in the standard pharmacological repertoire for familial Mediterranean fever, pericarditis, neutrophilic dermatoses, Behçet's disease and severe aphthous ulcers refractory to oral treatment. The US Food and Drug Administration (FDA) has recently approved colchicine to reduce the risk of myocardial infarction, stroke, coronary revascularization and cardiovascular death in adult patients with established atherosclerotic disease or with multiple risk factors for cardiovascular diseases. The recommendation level for cardiovascular prophylaxis was raised from IIb to IIa in the current European Society of Cardiology (ESC) guidelines from 2024. Clinical studies in recent years also demonstrated an effect for acute coronary syndrome and atrial fibrillation. This review article highlights the efficacy and safety profile of colchicine and provides insights into recent and potential future evidence-based fields of application.

Influence of Uric Acid on Vascular and Cognitive Functions: Evidence for an Ambivalent Relationship

The growing recognition of the public health impact of cognitive impairment and dementia has sparked a global initiative to identify risk factors and develop strategies to prevent or slow the progression of these cognitive disorders. Uric acid, the end product of the metabolism of purine nucleotides, has been reported as a key factor of many conditions potentially involved in cognitive dysfunction/dementia. In addition, some studies support the hypothesis that elevated uric acid levels could reduce the risk of Alzheimer's disease, slow down the decline of cognition, and delay the progression of Alzheimer's disease, while other evidence achieves opposite positions. These discrepancies might reflect a biological ambivalence for uric acid depending on a very complex interplay of factors that include its concentrations achieved in biological fluids, the nature, and concentration of free radicals, the presence and concentration of other antioxidant molecules, potentially responsible for bi-directional effects of uric acid on brain health/functioning. In this narrative review, we attempt to elucidate the influential role of uric acid metabolism in cognitive functioning by discussing pathophysiological mechanisms putatively involved, being well aware that none of them can be considered one-sided due to the complexity of the human organism.

Causal association between common rheumatic diseases and arrhythmia: a Mendelian randomization study

Background

Observational studies have suggested a link between rheumatic diseases and arrhythmias. However, these studies have been limited by confounding factors and reverse causality, leaving the causal relationship between rheumatic diseases and arrhythmias uncertain. This study addresses this inquiry using genetic evidence.

Methods

Selected single nucleotide polymorphisms (SNPs) from genome-wide association study (GWAS) data were employed as instrumental variables. Inverse variance weighting (IVW), MR-Egger regression, and the weighted median method were utilized in the two-sample Mendelian randomization analysis. Horizontal pleiotropy was identified and rectified through the MR-PRESSO test and MR-Egger regression. The stability and reliability of the Mendelian randomization results were appraised using the remain-one method, Cochran Q-test, and funnel plot. Odds ratios (OR) were utilized to assess the causal relationship between six rheumatic diseases and five types of arrhythmias.

Results

The Inverse Variance Weighted (IVW) method indicated a significant association between rheumatoid arthritis (RA) and an elevated risk of right bundle branch block (RBBB) (OR: 1.10, 95% CI: 1.02-1.18, p = 0.009). Additionally, gout was significantly correlated with an augmented risk of RBBB (OR: 1.28, 95% CI: 1.09-1.51, p = 0.003). Conversely, dermatomyositis (DM) exhibited a negative association with the risk of atrioventricular block (AVB) (OR: 0.94, 95% CI: 0.90-0.99, p = 0.020). No significant associations were observed between other rheumatic diseases and arrhythmias.

Conclusion

A two-sample Mendelian Randomization (MR) study provides data indicating that in European populations, a genetically predicted gout or rheumatoid arthritis (RA) may increase the incidence of right bundle branch block (RBBB). To clarify and investigate the processes behind these causal links, more research is necessary. Because racial genetic variability exists, care should be used when interpreting our findings.

Managing Gout in Patients with Metabolic Syndrome

Gout is characterized by monosodium urate (MSU) crystal deposition secondary to hyperuricemia. Gout is associated with metabolic syndrome (MetS) and its related comorbid conditions such as cardiovascular disease (CVD). Major advances have been made in the comprehension of the link between MetS and gout. Despite observational studies suggesting an association between MetS-related conditions and hyperuricemia, there is no proof of causality. Most studies using Mendelian randomization did not find hyperuricemia as a causal factor for MetS-related conditions. In contrast, these conditions were found associated with hyperuricemia, which suggests a reverse causality. Among patients with gout, this high CVD risk profile implies the need for systematic screening for MetS-related conditions. Most international guidelines recommend systematic screening for and care of CVD and related risk factors in patients with gout. Some anti-hypertensive agents, such as losartan and calcium channel blockers, are able to decrease serum urate (SU) levels. However, there are potential interactions between gout management therapies and the treatment of metabolic diseases. Some data suggest that anti-inflammatory drugs used for gout flare treatment, such as colchicine or canakinumab, might have benefits for CVD. Regarding the impact of urate-lowering therapies on CVD risk, recent studies found a similar CVD safety profile for allopurinol and febuxostat. Finally, sodium-glucose cotransporter-2 inhibitors are promising for gout because of their ability to decrease SU levels and risk of recurrent flares. In this review, we focus on the clinical challenge of managing MetS in patients with gout, particularly older patients with co-medications.

Review: The Role of Dual-Energy Computed Tomography in Detecting Monosodium Urate Deposits in Vascular Tissues

PURPOSE OF REVIEW

To highlight novel findings in the detection of monosodium urate deposits in vessels using dual energy computed tomography, and to discuss the potential clinical implications for gout and hyperuricemia patients.

RECENT FINDINGS

Gout is an independent risk factor for cardiovascular disease. However, classical risk calculators do not take into account these hazards, and parameters to identify patients at risk are lacking. Monosodium urate measured by dual energy computed tomography is a well-established technology for the detection and quantification of monosodium urate deposits in peripheral joints and tendons. Recent findings also suggest its applicability to identify vascular urate deposits. Dual energy computed tomography is a promising tool for detection of cardiovascular monosodium urate deposits in gout patients, to better delineate individuals at increased risk for cardiovascular disease.

Trends in cardiovascular disease incidence among 22 million people in the UK over 20 years: population based study

OBJECTIVE

To investigate the incidence of cardiovascular disease (CVD) overall and by age, sex, and socioeconomic status, and its variation over time, in the UK during 2000-19.

DESIGN

Population based study.

SETTING

UK.

PARTICIPANTS

1 650 052 individuals registered with a general practice contributing to Clinical Practice Research Datalink and newly diagnosed with at least one CVD from 1 January 2000 to 30 June 2019.

MAIN OUTCOME MEASURES

The primary outcome was incident diagnosis of CVD, comprising acute coronary syndrome, aortic aneurysm, aortic stenosis, atrial fibrillation or flutter, chronic ischaemic heart disease, heart failure, peripheral artery disease, second or third degree heart block, stroke (ischaemic, haemorrhagic, and unspecified), and venous thromboembolism (deep vein thrombosis or pulmonary embolism). Disease incidence rates were calculated individually and as a composite outcome of all 10 CVDs combined and were standardised for age and sex using the 2013 European standard population. Negative binomial regression models investigated temporal trends and variation by age, sex, and socioeconomic status.

RESULTS

The mean age of the population was 70.5 years and 47.6% (n=784 904) were women. The age and sex standardised incidence of all 10 prespecified CVDs declined by 19% during 2000-19 (incidence rate ratio 2017-19 v 2000-02: 0.80, 95% confidence interval 0.73 to 0.88). The incidence of coronary heart disease and stroke decreased by about 30% (incidence rate ratios for acute coronary syndrome, chronic ischaemic heart disease, and stroke were 0.70 (0.69 to 0.70), 0.67 (0.66 to 0.67), and 0.75 (0.67 to 0.83), respectively). In parallel, an increasing number of diagnoses of cardiac arrhythmias, valve disease, and thromboembolic diseases were observed. As a result, the overall incidence of CVDs across the 10 conditions remained relatively stable from the mid-2000s. Age stratified analyses further showed that the observed decline in coronary heart disease incidence was largely restricted to age groups older than 60 years, with little or no improvement in younger age groups. Trends were generally similar between men and women. A socioeconomic gradient was observed for almost every CVD investigated. The gradient did not decrease over time and was most noticeable for peripheral artery disease (incidence rate ratio most deprived v least deprived: 1.98 (1.87 to 2.09)), acute coronary syndrome (1.55 (1.54 to 1.57)), and heart failure (1.50 (1.41 to 1.59)).

CONCLUSIONS

Despite substantial improvements in the prevention of atherosclerotic diseases in the UK, the overall burden of CVDs remained high during 2000-19. For CVDs to decrease further, future prevention strategies might need to consider a broader spectrum of conditions, including arrhythmias, valve diseases, and thromboembolism, and examine the specific needs of younger age groups and socioeconomically deprived populations.