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J Rheum Dis 2023; 30(4): 209-210

Published online October 1, 2023

© Korean College of Rheumatology

Administrative regional variation in cardiovascular risk among patients with gout: implications for the management of cardiovascular complications

Sang Tae Choi , M.D., Ph.D.

Division of Rheumatology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea

Correspondence to : Sang Tae Choi, https://orcid.org/0000-0002-2074-1733
Division of Rheumatology, Department of Internal Medicine, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul 06973, Korea. E-mail: beconst@cau.ac.kr

Received: August 11, 2023; Revised: August 28, 2023; Accepted: August 28, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

The incidence and prevalence of gout have been rapidly increasing in Korea and worldwide [1,2]. Accordingly, the importance of gout treatment and disease management for the comorbidities accompanying gout is on the rise. Gout is significant associated with cardiovascular (CV) diseases both epidemiologically and pathophysiologically [3]. Moreover, gout has been identified as an independent risk factor for CV diseases, resulting in higher CV mortality than that in the general population [4,5]. Therefore, addressing gout flare prevention and CV disease risk reduction is crucial when managing patients with gout.

Investigating the risk factors of CV diseases in patients with gout is critical aspect to consider managing CV risk factors. Well-known risk factors for CV diseases include age, hypertension, diabetes mellitus, obesity, dyslipidemia, and chronic kidney disease [6]. Certain gout-related factors have been suggested as risk factors for CV diseases. These factors include disease duration ≥2 years, oligo- or polyarthritis, serum urate acid levels >9.1 mg/dL, joint damage, and tophi [5,7]. Another study conducted in Korea with National Health Insurance Service Database suggested old age, current smoking, frequent alcohol intake, high low-density lipoprotein, and diabetes mellitus were risk factors for CV diseases in patients with gout [8]. Geographical disparities, particularly the distinction between rural and urban locations, may also play a role in influence the risk of CV disease. Residents in urban areas tend to have lower CV morbidity and mortality rates than rural residents [9]. However, research on how regional factors specifically affect the occurrence of CV diseases in patients with gout is limited and remains unclear.

A recent study by Kim et al. [10], published in the previous issue of the Journal of Rheumatic Diseases, has provided valuable insights into regional variations in CV risk among patients with gout. This study investigated the variation based on extensive data from nearly all patients newly diagnosed with gout in Korea between August 2019 and January 2021. This study is particularly noteworthy for its focus on geographic differences according to administrative divisions, rather than rural-urban disparities.

The findings indicate that patients with gout in Jeolla/Gwangju had a significantly high risk of myocardial infarction. As for cerebral infarction in patients with gout, residing in Gangwon, Jeolla/Gwangju, and Gyeongsang/Busan/Daegu/Ulsan was associated with a significantly increased risk. Korea has a relatively high racial similarity and minor climate differences. Nevertheless, the findings of this study that the CV risk of patients with gout differs depending on the administrative region have significant implications for the management of patients with gout not only in Korea but also in other countries or regions. These results are expected to serve as valuable data for assessing the CV risk of patients with gout in the regions and devising appropriate treatment plans accordingly.

Several factors must be considered when evaluating this study. First, the distinction based on administrative divisions rather than rural-urban differences is a unique aspect of this research and a point that requires careful interpretation. This is because various factors, such as access to health care services and lifestyle habits, could contribute to differences in CV morbidity and mortality between rural and urban areas [9,11], as was shown the incidence of myocardial infarction or cerebral infarction tended to be low overall in Seoul than other regions in this study. Second, the CV risk was notably high in the Jeolla/Gwangju region, and the cause needs to be identified. The difference in CV risk between the Jeolla/Gwangju region and the Gangwon, Chungcheong/Daejeon/Sejong, and Gyeongsang/Busan/Daegu/Ulsan regions cannot be solely explained by rural-urban disparities. Factors such as healthcare utilization, the number of tertiary hospitals and islands, and socioeconomic status may have had an impact. Further research is required to clarify these effects. Third, the potential impact of differences in the management of traditional CV risk factors, such as diabetes mellitus, hypertension, and dyslipidemia, in addition to gout, is worth considering. For instance, fasting blood sugar levels in Jeolla/Gwangju appeared to be higher than those in other regions, and these differences may contribute to CV morbidity. Finally, medications for the treatment of gout could be considered. Since the publication of the CARES study on the CV safety of febuxostat or allopurinol in patients with gout [12], various research findings on the effect of gout treatment drugs have been reported. However, the relationship between CV safety and the drugs used for gout treatment, including febuxostat and allopurinol, remains controversial. Differences in the prescription of gout medication based on region and their potential impact on CV risk cannot be excluded.

In conclusion, patients with gout exhibited different risks of myocardial infarction and cerebral infarction depending on the administrative region. Further evaluation is required to better understand the regional disparities in CV events among patients with gout, considering the aforementioned factors.

No potential conflict of interest relevant to this article was reported.

  1. Kim JW, Kwak SG, Lee H, Kim SK, Choe JY, Park SH. Prevalence and incidence of gout in Korea: data from the national health claims database 2007-2015. Rheumatol Int 2017;37:1499-506.
    Pubmed CrossRef
  2. Jeong YJ, Park S, Yon DK, Lee SW, Tizaoui K, Koyanagi A, et al. Global burden of gout in 1990-2019: a systematic analysis of the Global Burden of Disease study 2019. Eur J Clin Invest 2023;53:e13937.
    Pubmed CrossRef
  3. Kuo CF, Grainge MJ, Zhang W, Doherty M. Global epidemiology of gout: prevalence, incidence and risk factors. Nat Rev Rheumatol 2015;11:649-62.
    Pubmed CrossRef
  4. Abeles AM, Pillinger MH. Gout and cardiovascular disease: crystallized confusion. Curr Opin Rheumatol 2019;31:118-24.
    Pubmed CrossRef
  5. Hansildaar R, Vedder D, Baniaamam M, Tausche AK, Gerritsen M, Nurmohamed MT. Cardiovascular risk in inflammatory arthritis: rheumatoid arthritis and gout. Lancet Rheumatol 2021;3:e58-70.
    Pubmed KoreaMed CrossRef
  6. Flora GD, Nayak MK. A brief review of cardiovascular diseases, associated risk factors and current treatment regimes. Curr Pharm Des 2019;25:4063-84.
    Pubmed CrossRef
  7. Disveld IJM, Fransen J, Rongen GA, Kienhorst LBE, Zoakman S, Janssens HJEM, et al. Crystal-proven gout and characteristic gout severity factors are associated with cardiovascular disease. J Rheumatol 2018;45:858-63.
    Pubmed CrossRef
  8. Moon KW, Kim MJ, Choi IA, Shin K. Cardiovascular risks in Korean patients with gout: analysis using a National Health Insurance Service database. J Clin Med 2022;11:2124.
    Pubmed KoreaMed CrossRef
  9. Singh GK, Siahpush M. Widening rural-urban disparities in all-cause mortality and mortality from major causes of death in the USA, 1969-2009. J Urban Health 2014;91:272-92.
    Pubmed KoreaMed CrossRef
  10. Kim HJ, Ghang B, Kim J, Ahn HS. Regional variations of cardiovascular risk in gout patients: a nationwide cohort study in Korea. J Rheum Dis 2023;30:185-97.
    Pubmed KoreaMed CrossRef
  11. Abrams LR, Myrskylä M, Mehta NK. The growing rural-urban divide in US life expectancy: contribution of cardiovascular disease and other major causes of death. Int J Epidemiol 2022;50:1970-8.
    Pubmed KoreaMed CrossRef
  12. White WB, Saag KG, Becker MA, Borer JS, Gorelick PB, Whelton A, et al. Cardiovascular safety of febuxostat or allopurinol in patients with gout. N Engl J Med 2018;378:1200-10.
    Pubmed CrossRef

Article

Editorial

J Rheum Dis 2023; 30(4): 209-210

Published online October 1, 2023 https://doi.org/10.4078/jrd.2023.0047

Copyright © Korean College of Rheumatology.

Administrative regional variation in cardiovascular risk among patients with gout: implications for the management of cardiovascular complications

Sang Tae Choi , M.D., Ph.D.

Division of Rheumatology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea

Correspondence to:Sang Tae Choi, https://orcid.org/0000-0002-2074-1733
Division of Rheumatology, Department of Internal Medicine, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul 06973, Korea. E-mail: beconst@cau.ac.kr

Received: August 11, 2023; Revised: August 28, 2023; Accepted: August 28, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body

The incidence and prevalence of gout have been rapidly increasing in Korea and worldwide [1,2]. Accordingly, the importance of gout treatment and disease management for the comorbidities accompanying gout is on the rise. Gout is significant associated with cardiovascular (CV) diseases both epidemiologically and pathophysiologically [3]. Moreover, gout has been identified as an independent risk factor for CV diseases, resulting in higher CV mortality than that in the general population [4,5]. Therefore, addressing gout flare prevention and CV disease risk reduction is crucial when managing patients with gout.

Investigating the risk factors of CV diseases in patients with gout is critical aspect to consider managing CV risk factors. Well-known risk factors for CV diseases include age, hypertension, diabetes mellitus, obesity, dyslipidemia, and chronic kidney disease [6]. Certain gout-related factors have been suggested as risk factors for CV diseases. These factors include disease duration ≥2 years, oligo- or polyarthritis, serum urate acid levels >9.1 mg/dL, joint damage, and tophi [5,7]. Another study conducted in Korea with National Health Insurance Service Database suggested old age, current smoking, frequent alcohol intake, high low-density lipoprotein, and diabetes mellitus were risk factors for CV diseases in patients with gout [8]. Geographical disparities, particularly the distinction between rural and urban locations, may also play a role in influence the risk of CV disease. Residents in urban areas tend to have lower CV morbidity and mortality rates than rural residents [9]. However, research on how regional factors specifically affect the occurrence of CV diseases in patients with gout is limited and remains unclear.

A recent study by Kim et al. [10], published in the previous issue of the Journal of Rheumatic Diseases, has provided valuable insights into regional variations in CV risk among patients with gout. This study investigated the variation based on extensive data from nearly all patients newly diagnosed with gout in Korea between August 2019 and January 2021. This study is particularly noteworthy for its focus on geographic differences according to administrative divisions, rather than rural-urban disparities.

The findings indicate that patients with gout in Jeolla/Gwangju had a significantly high risk of myocardial infarction. As for cerebral infarction in patients with gout, residing in Gangwon, Jeolla/Gwangju, and Gyeongsang/Busan/Daegu/Ulsan was associated with a significantly increased risk. Korea has a relatively high racial similarity and minor climate differences. Nevertheless, the findings of this study that the CV risk of patients with gout differs depending on the administrative region have significant implications for the management of patients with gout not only in Korea but also in other countries or regions. These results are expected to serve as valuable data for assessing the CV risk of patients with gout in the regions and devising appropriate treatment plans accordingly.

Several factors must be considered when evaluating this study. First, the distinction based on administrative divisions rather than rural-urban differences is a unique aspect of this research and a point that requires careful interpretation. This is because various factors, such as access to health care services and lifestyle habits, could contribute to differences in CV morbidity and mortality between rural and urban areas [9,11], as was shown the incidence of myocardial infarction or cerebral infarction tended to be low overall in Seoul than other regions in this study. Second, the CV risk was notably high in the Jeolla/Gwangju region, and the cause needs to be identified. The difference in CV risk between the Jeolla/Gwangju region and the Gangwon, Chungcheong/Daejeon/Sejong, and Gyeongsang/Busan/Daegu/Ulsan regions cannot be solely explained by rural-urban disparities. Factors such as healthcare utilization, the number of tertiary hospitals and islands, and socioeconomic status may have had an impact. Further research is required to clarify these effects. Third, the potential impact of differences in the management of traditional CV risk factors, such as diabetes mellitus, hypertension, and dyslipidemia, in addition to gout, is worth considering. For instance, fasting blood sugar levels in Jeolla/Gwangju appeared to be higher than those in other regions, and these differences may contribute to CV morbidity. Finally, medications for the treatment of gout could be considered. Since the publication of the CARES study on the CV safety of febuxostat or allopurinol in patients with gout [12], various research findings on the effect of gout treatment drugs have been reported. However, the relationship between CV safety and the drugs used for gout treatment, including febuxostat and allopurinol, remains controversial. Differences in the prescription of gout medication based on region and their potential impact on CV risk cannot be excluded.

In conclusion, patients with gout exhibited different risks of myocardial infarction and cerebral infarction depending on the administrative region. Further evaluation is required to better understand the regional disparities in CV events among patients with gout, considering the aforementioned factors.

ACKNOWLEDGMENTS

None.

FUNDING

None.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

References

  1. Kim JW, Kwak SG, Lee H, Kim SK, Choe JY, Park SH. Prevalence and incidence of gout in Korea: data from the national health claims database 2007-2015. Rheumatol Int 2017;37:1499-506.
    Pubmed CrossRef
  2. Jeong YJ, Park S, Yon DK, Lee SW, Tizaoui K, Koyanagi A, et al. Global burden of gout in 1990-2019: a systematic analysis of the Global Burden of Disease study 2019. Eur J Clin Invest 2023;53:e13937.
    Pubmed CrossRef
  3. Kuo CF, Grainge MJ, Zhang W, Doherty M. Global epidemiology of gout: prevalence, incidence and risk factors. Nat Rev Rheumatol 2015;11:649-62.
    Pubmed CrossRef
  4. Abeles AM, Pillinger MH. Gout and cardiovascular disease: crystallized confusion. Curr Opin Rheumatol 2019;31:118-24.
    Pubmed CrossRef
  5. Hansildaar R, Vedder D, Baniaamam M, Tausche AK, Gerritsen M, Nurmohamed MT. Cardiovascular risk in inflammatory arthritis: rheumatoid arthritis and gout. Lancet Rheumatol 2021;3:e58-70.
    Pubmed KoreaMed CrossRef
  6. Flora GD, Nayak MK. A brief review of cardiovascular diseases, associated risk factors and current treatment regimes. Curr Pharm Des 2019;25:4063-84.
    Pubmed CrossRef
  7. Disveld IJM, Fransen J, Rongen GA, Kienhorst LBE, Zoakman S, Janssens HJEM, et al. Crystal-proven gout and characteristic gout severity factors are associated with cardiovascular disease. J Rheumatol 2018;45:858-63.
    Pubmed CrossRef
  8. Moon KW, Kim MJ, Choi IA, Shin K. Cardiovascular risks in Korean patients with gout: analysis using a National Health Insurance Service database. J Clin Med 2022;11:2124.
    Pubmed KoreaMed CrossRef
  9. Singh GK, Siahpush M. Widening rural-urban disparities in all-cause mortality and mortality from major causes of death in the USA, 1969-2009. J Urban Health 2014;91:272-92.
    Pubmed KoreaMed CrossRef
  10. Kim HJ, Ghang B, Kim J, Ahn HS. Regional variations of cardiovascular risk in gout patients: a nationwide cohort study in Korea. J Rheum Dis 2023;30:185-97.
    Pubmed KoreaMed CrossRef
  11. Abrams LR, Myrskylä M, Mehta NK. The growing rural-urban divide in US life expectancy: contribution of cardiovascular disease and other major causes of death. Int J Epidemiol 2022;50:1970-8.
    Pubmed KoreaMed CrossRef
  12. White WB, Saag KG, Becker MA, Borer JS, Gorelick PB, Whelton A, et al. Cardiovascular safety of febuxostat or allopurinol in patients with gout. N Engl J Med 2018;378:1200-10.
    Pubmed CrossRef
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Schematic diagram for mechanism of botanical drugs and ingredients for health functional food for treatment of OA. OA: osteoarthritis, IL: interleukin, TNF-α: tumor necrosis factor-alpha, PGE2: prostaglandin E2, MMP: matrix metalloproteinase, VAS: visual analogue scale. (J Rheum Dis 2024;31:68-78)

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