What is the risk of developing gout after cardiac (heart) surgery?

Postsurgical Gout After Heart Surgery

Gout flares occur in approximately 17% of patients with a history of gout who undergo cardiac surgery, typically developing within 4 days postoperatively. 1

Incidence and Timing

• Postsurgical gout develops at a mean of 4.2 days after cardiac surgery, with most attacks occurring within the first 8 days postoperatively. 1, 2

• Among patients with pre-existing gout who undergo any type of surgery, approximately 17% (52 of 302 patients) will experience a postoperative gout flare. 2

• Endovascular interventional procedures carry a particularly high risk, with 38.74% of patients with gout history experiencing flares after these procedures compared to 13.48% in controls. 3

Clinical Presentation After Cardiac Surgery

• Attacks predominantly affect lower extremity joints (97%), most commonly the first metatarsophalangeal joint (63%), though classic podagra is less common than expected. 1, 2

• Polyarticular involvement occurs in approximately 50% of cases, with the number of affected joints correlating with the total number of previously involved joints. 1

• Fever is nearly universal (mean 100.7°F) and accompanied by leukocytosis, which can mislead clinicians to pursue infectious workup unnecessarily. 2

• Heart transplant recipients face accelerated disease progression, with unusually rapid development of chronic polyarticular disease and tophi within months of transplantation. 4

Specific Risk Factors for Cardiac Surgery Patients

Three major risk factors significantly increase postsurgical gout risk:

• Presurgical serum uric acid ≥9 mg/dL (or ≥7 mg/dL in some studies) increases risk substantially. 1, 3

• Failure to administer prophylactic colchicine before surgery significantly increases flare risk (HR 0.264 for those receiving prophylaxis). 1, 3

• History of cancer surgery is an independent risk factor. 1

Additional cardiac-specific risk factors include:

• Cyclosporine use in heart transplant recipients causes nephrotoxicity and appears to be the major driver of hyperuricemia, with peak serum uric acid levels reaching 11.0-16.5 mg/dL. 4

• Cardiopulmonary bypass exposure increases acute kidney injury risk, which can precipitate hyperuricemia. 5

• Diuretic use for heart failure management contributes to hyperuricemia. 6

Prevention Strategy

The most effective prevention approach involves three components:

1. Optimize serum uric acid control before surgery to levels <7 mg/dL (ideally <6 mg/dL), particularly if levels are ≥9 mg/dL. 1, 3

2. Administer prophylactic colchicine starting before surgery and continuing through the high-risk postoperative period (at least 8 days). 1, 3

3. Minimize cyclosporine nephrotoxicity in transplant recipients, as this is the best management strategy for preventing accelerated gout. 4

Management Challenges in Cardiac Patients

NSAIDs should be avoided in patients with cardiovascular disease or heart failure due to increased risk of myocardial infarction, heart failure exacerbation, and reversible renal insufficiency (occurred in 4 of 6 heart transplant patients). 4, 7

Colchicine is considered safe and potentially cardioprotective, reducing myocardial infarction risk in patients with cardiovascular disease. 7

Short courses of low-dose glucocorticoids are efficacious alternatives when colchicine cannot be tolerated, though caution is warranted. 7

For long-term urate-lowering therapy, allopurinol is first-line in cardiovascular patients given its safety profile and potential for reducing cardiovascular outcomes. 7

Febuxostat should be avoided due to increased risk of cardiovascular death and heart failure hospitalization. 7

Critical Pitfalls

• Fever and leukocytosis from gout can mimic infection, leading to unnecessary diagnostic workups and delayed treatment—maintain high suspicion for gout in the first week postoperatively. 2

• Gout-related infections occurred in 50% of heart transplant patients with postsurgical gout, highlighting the importance of distinguishing between inflammatory arthritis and septic arthritis in immunosuppressed patients. 4

• Renal insufficiency complicates both prevention and treatment, requiring careful medication dosing and monitoring, particularly with NSAIDs and allopurinol. 4, 5, 8