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CME Released: 2/17/2010
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February 17, 2010 — A new population-based cohort study has found that women with gout but no history of ischemic heart disease had a 40% increased risk of acute myocardial infarction (AMI) over a seven-year follow-up period, compared with matched controls with no gout [1]. Authors of the study say their paper fills a knowledge gap linking gout and AMI in women; previous studies have focused on the independent impact of gout in men.
In fact, write Dr Mary A De Vera (Boston University School of Medicine, MA) and colleagues, the magnitude of risk associated with gout may actually be higher in women than in men. Speaking with heartwire , senior author on the study, Dr Hyon K Choi (Boston University School of Medicine), explained that the paper is the first to suggest that gout is an independent risk factor for coronary heart disease in women, as it has previously been shown to be in men. "This extends what we found in males and in fact seems more dramatic, more strongly associated with heart disease."
Their study appears online February 2, 2010 in the Annals of the Rheumatic Diseases.
De Vera et al reviewed incident rates of AMI in the British Columbia Linked Health Database, comparing rates between 9642 gout cases and 48 210 controls. Despite having no history of ischemic heart disease, 3268 subjects (996 women) experienced AMI over a median seven-year follow-up. Relative risk of both fatal and nonfatal MI was higher among men and women with gout than among those with no gout, particularly in women. That difference persisted even after adjustment for age, comorbidities, and prescription drug use.
Adjusted Relative Risk (99% CI) of AMI Among Men and Women With Gout
| Outcome | Women | Men |
| Nonfatal AMI | 1.41 (1.19–1.67) | 1.11 (0.98–1.25) |
| Fatal AMI | 1.33 (0.99–1.78) | 1.10 (0.88–1.38) |
| All AMI | 1.39 (1.20–1.61) | 1.11 (0.99–1.23) |
The authors point out that the increase in adjusted relative risk of AMI among women compared with men was statistically significant, a pattern also seen for nonfatal AMI (but not for fatal MI).
Gout develops from elevated levels of uric acid, which crystallizes in joints and surrounding tissue. The link between gout and coronary disease may relate to effects of hyperuricemia on vascular smooth-muscle-cell proliferation and inflammation, as well as platelet adhesiveness and aggregation, the authors note. As to why gout's relationship to AMI might be more powerful in women than in men, De Vera and colleagues point out that serum uric-acid levels are typically higher in men but start climbing in women around menopause. As Choi explained, even though the absolute level of uric acid in men and women might be similar, the "relative worsening" in women is typically greater, and this may have a more powerful physiological disruption on women than on men.
"These findings provide support for the aggressive management of cardiovascular risk factors for male and female patients with gout," the authors conclude.
To heartwire , Choi observed that cardiologists may already be thinking of gout as a heart disease risk factor in men; they should now do the same for female patients. He also emphasized that while the manifestation of gout is major joint discomfort and disability, it is fundamentally an inflammatory/metabolic condition, like diabetes. As such, "it's not surprising" that this would have cardiovascular effects. "That part is less well acknowledged by physicians," he noted.
References
Gout affects up to 9% and 6% of elderly men and women, respectively. In men, gout has been linked with a higher risk for coronary artery disease, but the risk has not been well studied in women. The mechanism may be related to hyperuricemia affecting smooth muscle proliferation and the inflammation associated with gout.
This is a prospective, population-based cohort study conducted in 1 province of Canada to examine the association between gout and the risk for AMI in elderly women.
