Hitting urate goal links to fewer heart events
Among adults with gout starting urate-lowering medicine, reaching a blood urate level under 6 mg/dL within 12 months was linked to fewer serious heart and stroke events over 5 years.
*Emulated target trial using new-user cohort; Level 2b (OCEBM).

Citation

Cipolletta E, Zverkova Sandström T, Rozza D, et al. Treat-to-target urate-lowering treatment and cardiovascular outcomes in patients with gout. JAMA Internal Medicine. 2026;186(3):332-342. doi:10.1001/jamainternmed.2025.7453

Background

Gout is linked to higher risk of heart disease and stroke. It is unclear whether getting blood urate to recommended targets after starting urate-lowering medicine improves cardiovascular outcomes.

Patients

109,504 adults (≥18 years) in England with newly diagnosed gout, pre-treatment blood urate >6 mg/dL, and a first prescription for urate-lowering medicine; required linked hospital and death records.

Intervention

Achieved blood urate <6 mg/dL within 12 months after starting urate-lowering medicine.

Control

Did not achieve <6 mg/dL within 12 months (including no urate test recorded in that period).

Outcome

First serious heart or stroke event (heart attack, stroke, or cardiovascular death) within 5 years.

Follow-up Period

Up to 5 years.

Results

Outcome Absolute change in 5-year event-free survival Relative risk over follow-up NNT (5 years)
Serious heart or stroke event (primary) +1.0% (0.5% to 1.6%) 0.91 (0.89 to 0.92) 100
Heart attack +0.5% (0.2% to 0.9%) 0.88 (0.85 to 0.90) 200
Stroke +0.5% (0.2% to 0.8%) 0.86 (0.83 to 0.90) 200
Serious heart or stroke event when urate <5 mg/dL achieved +2.6% (0.9% to 3.6%) 0.77 (0.72 to 0.81) 39
Patients who reached the target also had fewer gout flares; no differences were seen in several “negative control” outcomes.
The main analysis was “as-treated” (grouped by whether the urate goal was achieved).

Limitations

Because this was not a randomized trial, unmeasured differences (such as overall quality of care) could partly explain the findings. The absolute benefit was small (about 1 fewer event per 100 people over 5 years). Some patients lacked urate testing, which may misclassify groups.

Funding

UK public research funding (National Institute for Health and Care Research).

Clinical Application

In primary care gout management, monitor urate and adjust therapy to reach <6 mg/dL; benefits may be greatest in patients with high cardiovascular risk.