Urate Crystals and Inflammation. Cardiovascular Impact of Gout.

After reading with interest the article by Borghi et al. about the relationship between uric acid and cardiovascular risk (CVR) score [ [1] Borghi C. Rodriguez-Artalejo F. De Backer G. Dallongeville J. Medina J. Nuevo J. et al. Serum uric acid levels are associated with cardiovascular risk score: a post hoc analysis of the EURIKA study. Int. J. Cardiol. 2018; 253: 167-173 Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar ], we would also like to emphasize the importance of gout. Atherosclerosis has been linked to different inflammatory diseases, such as rheumatoid and psoriatic arthritis [ [2] Libby P. Role of inflammation in atherosclerosis associated with rheumatoid arthritis. Am. J. Med. 2008; 121: S21-S31 Abstract Full Text Full Text PDF PubMed Scopus (345) Google Scholar ]. Nevertheless, unlike improvements in comprehensive approaches and patient survival that these pathologies have undergone in recent decades, the management of patients with gout continues to be suboptimal. Its significant cardiovascular morbidity remains underestimated and there is too little knowledge about its nature both among medical professionals and in society. When causing persistent inflammation and pro-oxidative state, gout induces accelerated atherosclerosis, which more than doubles cardiovascular mortality compared to the general population, and it is responsible for 40% of all-cause mortality [ [3] Perez-Ruiz F. Martinez-Indart L. Carmona L. Herrero-Beites A.M. Pijoan J.I. Krishnan E. Tophaceous gout and high level of hyperuricaemia are both associated with increased risk of mortality in patients with gout. Ann. Rheum. Dis. 2014; 73: 177-182 Crossref PubMed Scopus (146) Google Scholar ]. Several articles confirm its role as an independent risk factor for all forms of cardiovascular disease (CVD), with an overall impact similar to that of diabetes. In Spain, two independent studies of patients with gout have reported shocking data regarding CVR: carotid atheromatous plaques in 38–47% (bilateral in up to 50%), pathologic intima-media thickness in 45–66%, altered flow-mediated vasodilation in 81% (severe in 52%), and electrocardiogram/echocardiogram alterations in more than 50% [ [4] Andres M. Bernal J.A. Sivera F. Quilis N. Carmona L. Vela P. et al. Cardiovascular risk of patients with gout seen at rheumatology clinics following a structured assessment. Ann. Rheum. Dis. 2017; 76: 1263-1268 Crossref PubMed Scopus (32) Google Scholar , [5] Calvo Aranda E. Estudio de riesgo cardiovascular y disfunción endotelial en pacientes con gota. Experiencia de un grupo multi-hospitalario español. Universidad CEU San Pablo. Facultad de Medicina, Madrid2017 Google Scholar ]. Therefore, ultrasound and dynamic vascular analyses studies can optimize CVR stratification in gout, since tools such as SCORE and Framingham do not include inflammatory parameters. Optimization of co-management among rheumatologists, cardiologists, general practitioners and other specialties would certainly lead to improvements in the morbimortality and prognosis of these patients.