By Leo Robert

	Findings surrounding the possible role of gout as a risk factor for heart disease are mixed. The evidence for an association between inflammatory diseases such as rheumatoid arthritis and cardiovascular disease (CVD) is more robust, yet there are data that link hyperuricemia, the primary metabolic abnormality in gout, with higher risk of CVD. Elevated serum urate leads to acute joint inflammation and is associated with endothelial dysfunction, a known precursor to atherogenic disease. Hyperuricemia has also been identified as a risk factor for peripheral vascular disease, another manifestation of atherosclerosis.

	The following short slide show reviews several recent studies that also suggest a link between the crystal-induced arthropathy and heart disease. What do you see in your practice?

Both High and Low Uric Acid Boost Cardiovascular Risk.

 A recent study evaluated relationships between serum uric acid level and newly emergent acute myocardial infarction, congestive heart failure, coronary artery disease, composite cardiovascular (CV) events, hypertension, hyperlipidemia, and renal disease in patients with gout. Both hyperuricemia and hypouricemia were linked with increased risk of CV events.

MI Risk is High in Gout and Other Arthritis.

 A systematic search was performed to evaluate the risk of incident myocardial infarction (MI) across 5 major types of arthritis. MI risk was significantly increased in gout, rheumatoid arthritis, psoriatic arthritis, and osteoarthritis and tended toward increased risk in ankylosing spondylitis. Traditional risk factors were more prevalent in all types of arthritis.

Uric Acid Level Runs Low With DASH Diet. 

The Dietary Approaches to Stop Hypertension (DASH) Diet, designed to lower high blood pressure, also may lower uric acid (UA) levels. The effect was greater among patients with hyperuricemia. In addition, higher sodium intake decreased serum UA levels.

The low-carb, high-fat ketogenic diet prevents inflammation and joint pathology during gout flares. The ketone β-hydroxybutyrate, a known alternate metabolic fuel, is an anti-inflammatory molecule that may serve as a treatment for gout.

Putting Primary Care on the Gout Care Map.

 A new “roadmap” for improving gout care in all clinical practices calls on primary care to play a bigger role: “Major improvements in gout outcomes at a population level will require much deeper engagement of primary care and affiliated health professionals, and will require careful validation, particularly in populations with differing cultural and socioeconomic backgrounds.”

Both High and Low Uric Acid Boost Cardiovascular Risk (

MI Risk is High in Gout and Other Arthritis (

Uric Acid Level Runs Low With DASH Diet (

Putting Primary Care on the Gout Care Map (

Articles

Slide show: Evidence for gout's role as a risk factor for heart disease is mixed. New studies add support.

Gout and Heart Disease News Roundup

	Cutting-edge advances and updates in cardiovascular care was the promise from ACC.16, the 

American College of Cardiology’s 65th Annual Scientific Session

	Here are highlights of the clinical findings presented at the meeting.

Study: Use More Statins in Intermediate Risk Patients

Lowering cholesterol with statins significantly reduced adverse CV events in persons with average cholesterol and blood pressure levels who were considered to be at intermediate risk for heart disease.

The use of blood pressure-lowering medications was beneficial only in those with higher blood pressure levels.

The trial, HOPE-3, is the first to assess outcomes of preventative treatment with cholesterol and blood pressure-lowering drugs in a large, globally diverse population at intermediate risk for CVD.

The researchers concluded that statins are safe and effective and recommended more widespread use, particularly for patients with hypertension.

“Statin Re-challenge” for Muscle Related Adverse Effects

A blinded, placebo-controlled “statin re-challenge” in patients with a history of muscle-related adverse effects investigated statin-associated muscle symptoms.

Of 491 participants, 42.6% reported muscle-related adverse effects while taking atorvastatin but not while taking placebo.

Patients with confirmed statin intolerance given evolocumab showed a 52.8% reduction in LDL cholesterol vs a 16.7% reduction for patients who received ezetimibe.

For average change in LDL cholesterol for weeks 22 and 24, patients taking evolocumab and ezetimibe showed 54.5% and 16.7% reductions, respectively.

Evolocumab substantially lowered LDL cholesterol, with few patients experiencing muscle symptoms.

Just before the meeting, the ACC released expert consensus guidance for using non-statin therapies to lower cholesterol in high-risk patients.

The new document provides practical guidance for clinicians and patients in situations not covered by the evidence-based 2013 guideline. Looking first at lifestyle issues (eg, diet, exercise, and smoking) and then at statin therapy is recommended as in the earlier document.

The writing committee supports consideration of adding ezetimibe, 10 mg/d, as the first non-statin agent for many higher-risk patient groups.

The writing committee chair noted that evidence-based statin therapy remains the first-line standard of care for patients at risk for atherosclerotic CVD.

Discussion of disease risk-reduction benefits and potential harms between clinicians and patients before the start of combination therapy was recommended.

Cholesterol Gene Mutation Elevates Coronary Artery Disease Risk

Few persons who have very high cholesterol can attribute it to a genetic mutation related to familial hypercholesterolemia, but those who do are at high risk for early-onset coronary artery disease.

Persons with LDL ≥ 190 but no familial hypercholesterolemia mutation have a 6X higher risk of early-onset CAD than those with LDL < 130. The risk for persons who have the mutation: 22X higher.

Genetic screening could help identify and prevent early CVD in affected persons-and their relatives.

Death and Stroke Rates Equal for Surgery and Valve Replacement

The rates of death and disabling strokes after 2 years in intermediate-risk patients with severe aortic stenosis are similar with minimally invasive transcatheter aortic valve replacement (TAVR) and with standard open heart surgical replacement.

Patients who received TAVR had shorter hospital stays and a lower incidence of some major complications than those who underwent surgery.

TAVR yielded significantly lower rates of acute kidney injury, severe bleeding events, and new onset atrial fibrillation. The surgery group had fewer major vascular complications and leakage around the valve.

Conclusion: TAVR is at least as safe and effective as surgery in these patients.

Chest Pain Tool Facilitates Shared Decision-making

Patients who visited a hospital ED with chest pain and engaged with their physician in shared decision-making with the Chest Pain Choice tool showed better knowledge of their health status and follow-up care options than patients who received only standard counseling.

The tool, the first to facilitate shared decision-making between patients who have chest pain and their physicians, uses a 1-page printable information sheet that depicts a patient’s specific risk profile and health management options.

The decision aid substantially improved patient engagement and reduced the use of stress tests, with no adverse effects.

Researchers presented several new findings about statins and non-statins at ACC.16. This brief roundup summarizes these and other noteworthy reports.

6 Cardiology Meeting Highlights

	About that apple-a-day keeping the doctor away-is there proof? Find out in this slide-show summary of some well-known, and lesser-known, facts about apples and good health.

 Americans eat more bananas than any other fresh fruit (average, 25 lb, or 100 average-sized fruits/yr).

			Other widely consumed fruits: watermelon, cantaloupe, oranges, grapes, strawberries.

 Apples contain plenty of vitamins and minerals.

			Rich in phytonutrients acting as antioxidants

			In US, apples are the largest source of phenolics consumed from fruits (22%)

			Particularly high in the flavonoid quercetin

			Apple consumption shown to reduce “LDL oxidation lag time”

Apples, Gut Microbes, and Cardiovascular Health:

 Apples and their components may modulate cardiovascular disease (CVD) risk factors.

			Strongest effects are related to lipid metabolism but also impact vascular function, inflammation.

			Consumption shown to reduce total cholesterol.

			Microbiota-derived metabolites could contribute to the beneficial effects.

			Prebiotic impact of eating apples may be important mechanism of CVD risk marker reduction.

 Antioxidant power in apples ranks among the highest in fruits.

			Antioxidants may protect cells from cancer-inducing oxidative damage, prevent the start of cancer growth, stop continued tumor growth, and promote cancer cell death.

			Apples may suppress breast cancer tumor growth.

			Eating ≥1 apples/d associated with lower risk of lung & colon cancer.

			Adding 3 apples/d to women’s diets helps lower calorie intake & contributes to weight loss, very important for cancer prevention.

Study: Apples Lower Type 2 Diabetes Risk:

 Participants from the Nurses’ Health Study, Nurses’ Health Study II, and Health Professionals Follow-up Study.

			Greater consumption of specific whole fruits, including apples-significantly associated with a lower risk of type 2 diabetes.

			Associations with risk of type 2 diabetes differed significantly among individual fruits.

			Greater consumption of fruit juice is associated with a higher risk.

Potassium Protects Heart, Bones, and Muscles:

 Apples rank among the best sources of K.

 helps relax blood vessels, decrease stroke risk, reduce blood pressure.

 K-rich foods produce alkali in the body to maintain acid-base balance.

 K needed for muscle contraction, muscle-nerve communication, and overall muscular function.

About that apple-a-day keeping the doctor away-is there proof? Find out in this slide-show summary of some well-known, and lesser-known, facts about apples and good health.

By Leo Robert

Articles

Gout and Heart Disease News Roundup

6 Cardiology Meeting Highlights

10 Juicy Facts About Apples