Having inflammatory types of rheumatic disease means that your risk of having a heart attack, stroke, or other serious cardiovascular issue is far higher than average. That’s certainly not great news, but take heart: You have the power to lower your risk and protect your ticker and blood vessels — and it starts with patient education.
In honor of American Heart Month this February, we’re taking a closer look at how gout, axSpA, and lupus affect your heart — and what you can do to keep your heart healthy. You can also check out A Patient’s Guide to Understanding Rheumatoid Arthritis and Heart Disease for more information on this topic.
Gout is the most common type of inflammatory arthritis worldwide, yet it’s also one of the most likely to cause a lot of confusion. Many people wrongly assume that gout causes severe pain only in the big toe, or that only wealthy people who consume decadent foods and alcohol get it.
In reality, gout often tends to strike in the big toe, but it can also commonly cause excruciating pain in many different joints. And while gout was erroneously known as the “disease of kings,” nowadays we know genetics or another underlying condition such as kidney disease play a major role in having gout. In people who are genetically susceptible to the condition, gout can be exacerbated by overindulging in high-fat, high-sugar foods, drinking too much, and being overweight or obese.
Perhaps the biggest misconception, however, is that gout is merely about joint pain. Although your joints might bear the brunt of the pain, gout is an inflammatory disease that is associated with a variety of health problems throughout your body — including in your heart and blood vessels.
A study published in Annals of the Rheumatic Disease found that more than half of gout patients are at “very high risk” for heart disease, thanks to factors including a buildup of fatty plaque in their carotid arteries (major vessels that provide blood flow to the brain). If your carotid arteries are clogged with plaque, it could lead to a stroke.
Other research from the University of Oxford has shown that people with gout are twice as likely as members of the general public to have a heart attack or stroke. Meanwhile, a study from the Journal of the American Heart Association determined that coronary artery disease patients (being treated for damage or blockages in the major vessels of the heart) who have gout are 15 percent more likely than others with coronary artery disease to die from cardiovascular disease or suffer a heart attack or stroke.
Why Gout Might Harm Your Heart
Although researchers are still teasing out the exact mechanism that ties gout to cardiovascular disease, they already know that there are several reasons why these diseases often overlap.
In people with gout, high levels of urate (uric acid) build up in the bloodstream, form crystals, and get deposited in one or more joints. That sets off an inflammatory response characterized by redness, swelling, and major pain. But it’s also a sign that your body might have too much inflammation in general, which can predispose you to blood clots, stroke, heart attack, and other cardiovascular problems.
Studies have shown that people with high levels of an inflammatory marker called interleukin-1 (IL-1) are more prone to frequent gout flares. This same substance has been linked to an elevated risk of heart failure, a chronic disease in which the heart becomes too weak to efficiently pump blood throughout the body.
High blood pressure
The relationship between gout and high blood pressure is complicated, but there’s little doubt that the two are related. More than 70 percent of people with gout have hypertension (chronic high blood pressure), which raises the risk of heart attack and stroke. While some of these individuals certainly had high blood pressure before developing gout, there’s also evidence that the high uric acid levels associated with gout makes it more likely that someone with pre-hypertension (borderline high blood pressure) will eventually end up with the full-fledged problem.
What’s more, many common blood pressure medications are in the diuretic class — they make you urinate more often. That can make you slightly dehydrated and make your blood more concentrated, which increases the odds of uric acid in your blood forming crystals that may lead to gout or worsen it.
Obesity and diabetes
Although anyone can get gout, people with a high body mass index (BMI) face a higher risk because obesity tends to increase uric acid levels in the bloodstream. Obesity is also strongly associated with heart disease: Excess levels of fat often raise LDL (“bad”) cholesterol and triglycerides while lowering HDL (“good”) cholesterol. Obesity also increases the odds of higher blood pressure and type 2 diabetes.
Diabetes is a major risk factor for heart disease. Having diabetes makes you two to four times more likely to develop cardiovascular disease. Even pre-diabetes (borderline) can be problematic, because it’s usually characterized by insulin resistance. When you don’t use insulin efficiently or make enough of it, your blood sugar stays too high. That, in turn, may damage your blood vessels and cause inflammation that leaves you prone to cardiovascular disease.
Also concerning: Preliminary research shows that high uric acid levels may contribute to insulin resistance. Some large-scale studies, including the Framingham Heart Study, found that patients with high uric acid levels have a higher chance of developing type 2 diabetes. Read more about the link between gout and type 2 diabetes.
How to Lower Your Heart Disease Risk
While it’s clear that having gout may increase your risk of cardiovascular disease, there are several things you can do to help protect yourself:
Take your gout medication as prescribed
Recent research has shown that more than a third of gout patients stop taking their uric acid-lowering medication or use it inconsistently. This can leave you vulnerable to gout flares as well as cardiovascular disease. That’s because high uric acid levels may contribute to a variety of heart-related problems, including atherosclerosis (hardening of the arteries).
“For people with gout, there is some evidence that controlling their uric acid level — most commonly with allopurinol — can reduce cardiac risk,” says rheumatologist Theodore R. Fields, MD, Professor of Clinical medicine at Weill-Cornell Medical College and Attending Physician at Hospital for Special Surgery. “Also, another medication commonly used in gout, colchicine, has been shown to have some ability to decrease heart attack risk.”
Keep close tabs on your heart health
Your rheumatologist (or an internist or a cardiologist) should be regularly checking your blood pressure, cholesterol, and blood sugar. Depending on your personal overall cardiovascular disease risk, you might also be a candidate for additional tests like an EKG (electrocardiogram), stress test, or a cardiac CT.
Ask your doctor if you might benefit from taking a statin (cholesterol-lowering medication). Research has found that gout patients who are treated with statins are less likely to die prematurely.
“The main issue is the fact that many patients with gout have obesity, high blood pressure, diabetes, and abnormal cholesterol,” says Joshua F. Baker, MD, Associate Professor of Rheumatology and Epidemiology at the University of Pennsylvania and the Corporal Michael J. Crescenz VA Medical Center. “It is important that these are identified and treated to prevent the risk of cardiovascular disease. Patients with gout area also at higher risk of developing these conditions over time, so they should be continually monitored for their development.”
Lose weight if you’re overweight
Losing excess pounds can be challenging, but even losing a small amount of weight if you’re overweight may help protect your heart. “There is an increased incidence of being overweight in gout patients, so weight loss can be important as a cardiac-preventive strategy in gout patients,” says Dr. Fields.
If you cut calories enough to lose weight, you may reduce your risk of future gout attacks. Plus, if you cut back on purines (substances found in organ meats, certain seafood, soda, and alcohol that your body breaks down into uric acid), you may also help reduce gout flares.
The bottom line: There’s no better time than now to take steps to manage your gout and protect your ticker. Talk to your health care provider about your personal risk factors, medications, and lifestyle changes you can make to reduce your risk of heart disease.
Andrés M, et al. Cardiovascular risk of patients with gout seen at rheumatology clinics following a structured assessment. Annals of the Rheumatic Diseases. 2017. doi: https://doi.org/10.1136/annrheumdis-2016-210357.
Bardin T, et al. Impact of comorbidities on gout and hyperuricaemia: an update on prevalence and treatment options. BMC Medicine. April. 2017. doi: https://doi.org/10.1186/s12916-017-0890-9.
Colantonio, LD, et al. Gout is associated with an increased risk for incident heart failure among older adults: the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort study. Arthritis Research & Therapy. 2020. doi: https://doi.org/10.1186/s13075-020-02175-2.
Choi HK, et al. Obesity, weight change, hypertension, diuretic use, and risk of gout in men: the health professionals follow-up study. Arch Intern Med. April 2005. doi: https://doi.org/10.1001/archinte.165.7.742.
Interview with Joshua F. Baker, MD, associate professor of rheumatology and epidemiology at the University of Pennsylvania and the Corporal Michael J. Crescenz VA Medical Center
Interview with Theodore R. Fields, MD, rheumatologist and professor of clinical medicine at Weill-Cornell Medical College
Keller SF, et al. Statin use and mortality in gout: A general population-based cohort study. Seminars in Arthritis and Rheumatism. December 2018. doi: https://doi.org/10.1016/j.semarthrit.2018.03.007.
Kuwabara M, et al. Uric acid is a strong risk marker for developing hypertension from prehypertension: a 5-year japanese cohort study. Hypertension. December 2018. doi: https://doi.org/10.1161/HYPERTENSIONAHA.117.10370.
Framingham Heart Study (FHS). National Institutes of Health/National Institute of Arthritis, Musculoskeletal, and Skin Diseases. https://www.nhlbi.nih.gov/science/framingham-heart-study-fhs.
Seminog OO, et al. Gout as a risk factor for myocardial infarction and stroke in England: evidence from record linkage studies. Rheumatology. September 2013. doi: https://doi.org/10.1093/rheumatology/ket293.
Pagidipati NJ, et al. Association of gout with long‐term cardiovascular outcomes among patients with obstructive coronary artery disease. Journal of the American Heart Association. August 2018. doi: https://doi.org/10.1161/JAHA.118.009328.
Yu W, et al. Uric acid and cardiovascular disease: an update from molecular mechanism to clinical perspective. Frontiers in Pharmacology. November 2020. doi: https://doi.org/10.3389/fphar.2020.582680.
Zhi L, et al. High uric acid induces insulin resistance in cardiomyocytes in vitro and in vivo. Bertrand L, ed. PLoS ONE. February 2016. doi: https://doi.org/10.1371/journal.pone.0147737.