People with gout have higher rates of heart disease and cardiovascular death than people without it. That finding is consistent across large studies.
What is not settled is why. Gout, and the high uric acid behind it, may harm blood vessels directly, or they may simply travel with the conditions that do. Either way, gout is a good reason to have your heart risk factors checked.
Key takeaways
- Gout is linked with a higher risk of dying from cardiovascular disease, even after allowing for standard risk factors.
- Heart attacks and strokes appear to be more likely in the weeks after a gout flare.
- Whether uric acid itself causes heart disease is still uncertain, and genetic studies give mixed answers.
- A large trial of a urate-lowering medicine in people without gout found no heart benefit.
What gout is
Gout is a form of inflammatory arthritis. It happens when uric acid, also called urate, builds up in the blood and forms crystals in a joint. The result is a flare: sudden pain, swelling and redness, often in the big toe.
A high uric acid level is the forerunner of gout, but many people with a high level never have a flare. That distinction matters when you read the heart research, because studies of gout and studies of uric acid are not asking the same question.
What the studies show
A pooled analysis of six studies covering 223,448 patients looked at people with gout who had no known cardiovascular disease at the start. After adjusting for traditional risk factors, gout was linked with a 29% higher risk of death from cardiovascular disease and a 42% higher risk of death from coronary heart disease.1
The same analysis had a gap worth knowing about. None of the included studies found a significant link between gout and death from heart attack specifically.1 So the overall signal is real, but the detail is less tidy than a headline suggests.
The weeks after a flare
A gout flare is a burst of intense inflammation, and inflammation plays a part in heart disease. Researchers in England tested whether the two are linked in time, using the health records of 62,574 people with gout.
They were. Patients who had a heart attack or stroke were about twice as likely to have had a gout flare in the previous 60 days as patients who did not. The odds were still raised 61 to 120 days after a flare, and were no different by 121 to 180 days.2
The authors read this as a temporary rise in cardiovascular risk after a flare. Two cautions apply. The study was observational, so it cannot prove the flare caused the event. And the patients were older, with an average age of about 76, so the size of the effect may not be the same in someone of 50.
Association or cause?
Gout rarely arrives alone. It often comes with high blood pressure, kidney disease, excess weight and type 2 diabetes, and each of these raises heart risk without any help from uric acid. That makes it hard to tell whether gout is doing damage or is a marker of the company it keeps.
Two kinds of research have tried to separate the two.
Genetic studies. Some people inherit gene variants that raise uric acid for life. If uric acid causes heart disease, those people should have more of it. One large analysis found exactly that with standard methods, but the authors warned the result might be inflated because the same genes can act through other routes. A method that corrects for this suggested there might be no causal effect at all.3
A randomized trial. The ALL-HEART trial tested the idea directly. It enrolled 5,721 people aged 60 or older who had ischemic heart disease and no history of gout, and assigned them to a urate-lowering medicine or to usual care. After an average of 4.8 years, 11.0% of the treated group and 11.3% of the usual care group had a heart attack, a stroke or a cardiovascular death.4 There was no evidence of a difference.
| Question | What the evidence shows | How firm it is |
|---|---|---|
| Do people with gout have more cardiovascular deaths? | Yes, in pooled cohort studies | Consistent, but observational |
| Does risk rise after a flare? | Yes, for about four months in one large study | Observational, older patients |
| Does uric acid itself cause heart disease? | Genetic studies disagree | Uncertain |
| Does lowering uric acid prevent heart events? | Not in people with heart disease and no gout | One large randomized trial |
One limit of ALL-HEART should be stated plainly. It excluded people with gout. So it does not tell us whether controlling gout well changes heart outcomes in people who have it. That question is still open.
What this means if you have gout
Three practical points follow from the evidence.
- Gout treatment is for gout. Medicines that lower uric acid are prescribed to prevent flares and joint damage. They have not been shown to protect the heart. Do not start, stop or change one without your prescriber.
- Treat gout as a prompt. A gout diagnosis is a sensible moment to check blood pressure, cholesterol, blood sugar and kidney function, since these are the factors that most often travel with it.
- Take symptoms seriously around a flare. Chest pain, shortness of breath or stroke symptoms during or after a flare need emergency care, not a wait-and-see approach.
If you have kidney disease as well, our guide to kidney disease and heart risk explains how the two are linked.
Your next step
If you have gout and have not had a recent look at your heart risk, start with the standard numbers. Our guide to a heart disease risk assessment explains what a preventive evaluation looks at, and the hs-CRP test guide explains how inflammation is measured for heart risk.
You can also answer the three quick questions in the screener on the Cardio Res-Q program page. Gout is on the list of inflammatory conditions the program screens for.
Are You a Candidate for Cardio Res-Q?
Three quick questions about the risk factors we screen for. Your answers stay between you and the clinic.
Frequently asked questions
Does gout cause heart disease?
It is not known. People with gout have more cardiovascular deaths than people without it, but gout also comes with high blood pressure, kidney disease, excess weight and diabetes. Researchers have not been able to show that gout itself is the cause.
Does high uric acid without gout raise heart risk?
Higher uric acid is linked with slightly more coronary heart disease in population studies. Genetic studies designed to test cause and effect give conflicting results, and one careful analysis suggested there might be no causal effect. A high level on its own is best treated as a reason to look at your other risk factors.
Will lowering my uric acid protect my heart?
There is no good evidence that it will. In the ALL-HEART trial, a urate-lowering medicine did not reduce heart attacks, strokes or cardiovascular deaths in older adults with heart disease and no gout. Whether good gout control helps the heart in people who have gout has not been settled.
Is my heart at more risk right after a gout flare?
One large English study suggests so. Heart attacks and strokes were more likely in the four months after a flare, with the strongest link in the first 60 days. It was an observational study in older adults, so treat it as a reason for extra attention to symptoms, not as a prediction.
Related reading
This article is for general education and is not medical advice. Decisions about testing and medication should be made with your clinician. If you have chest pain or other symptoms of a heart attack, call 911.
