The Panicos are on a mission to change how we think about gout. Why? As a husband-and-wife DO duo, the Panicos each have a unique perspective on gout and how physicians in their respective fields can better collaborate to help patients who live with this systemic disease.
Cross-specialty collaboration in treating gout is crucial—people who live with gout face a higher risk of other serious conditions and are twice as likely as the general public to have a heart attack or stroke.1
It’s been a career-long learning for both of us. Through our experiences treating patients, we’ve both seen firsthand how gout’s impact can forge a connection between our 2 fields.
Together, we’re committed to improving understanding among patients with gout on the risk of cardiovascular comorbidities. And we’re seeking to increase awareness of this connection across the industry.
The reality: Gout is more than flares or swollen joints
For us, learning about this condition and its impact began early in our careers through separate work in a VeteransAffairs (VA) health system and the emergency department. In the VA health system, a lot of the patients Brittany saw had gout and was able to witness firsthand what a devastating and debilitating disease it can be. But it also showed how the right care can create a drastic improvement for patients, and so the education aspect and raising awareness around this condition have become very important to us.
Ambrose’s early work in the emergency department exposed him to many gout cases and made him aware of the implications for heart health that people living with gout face. But in conversations with peers in the cardiovascular field, this connection is almost never discussed. Gout is often talked about as a reaction—either to an unhealthy lifestyle, overindulgence in food and alcohol, or medications. But the reality is that such patients face the risk of urate crystals, which characterize this disease, being deposited all around their body due to many factors outside of diet, including genetics and kidney function.
In medical school, the amount of exposure we had to gout was maybe several paragraphs in a textbook. But this disease causes a significant burden in patients’ lives, especially when it’s left untreated. In fact, uncontrolled gout can lead to uric acid depositing in vital organs—including the heart.
The impact: Gout and cardiovascular complications, contextualized
Emerging evidence continues to suggest a connection between gout and cardiovascular health. Elevated uric acid is associated with cardiovascular disease (CVD), and gout has been shown to be an independent risk factor for heart failure,1 hypertension,1 atrial fibrillation,2 peripheral artery disease (PAD),3 peripheral vascular disease (PVD),4 heart attack,5 and stroke.5 High uric acid levels are also associated with an increased severity of coronary artery disease (CAD).6 And finally, patients with high serum urate levels have an increased risk of all-cause cardiovascular mortality.7
The connection: How this association became clear for both Panicos
Statistics like the ones above, as well as conversations with each other, have helped us to acknowledge and further understand this connection.
The connection became much clearer to Brittanywhenpresented with an example of dual-energy CT imaging depicting urate deposits in a patient’s heart. She realized that these crystals embed themselves all over the body, so why wouldn’t they be present in the vessels of the heart? Rheumatologists know that gout patients have an elevated risk of certain cardiovascular conditions, but they never really had anything to ground that knowledge in—this imaging demonstrated it clearly.
So, you start to understand how these things that seemed more generally associated with one another are likely more tangibly related.Treating a gout patient isn’t just about dealing with the pain. Gout is a lifelong journey, and it requires regular attention and management. Rheumatologists and cardiologists don’t oversee just one organ; we know that the diseases we treat affect the whole body. Gout is no different.
The challenge: Collaborating across specialties
Cross-specialty collaboration can help ensure that gout patients receive the care they need. But extra effort is required to establish that collaboration in what has become an increasingly siloed healthcare industry. Industry events are excellent opportunities to share best practices and collaboration methods, but today, these gatherings are often related to one specific specialty. We must start by coming together on social media, where we’re all under one roof. Then, when we have the network to learn from each other and strategize treatment plans together, we can organize in-person events.
The goal is to change the way we think about gout and how we tactically address it. We believe that effort starts with education—we need to get this kind of information to our boards, the people who write test questions for recertification, to get our practitioners to learn about it. We have to reach physicians directly, too, and social media is a great way to do that. Basically, we need to keep inserting messaging about the connection between gout and cardiovascular conditions where it doesn’t currently exist.
A great example of that: a sign in a cardiologist’s waiting room encouraging patients who live with gout to talk to their cardiologist about it. This kind of awareness lets patients know that their cardiologist is an essential part of managing their gout, and it prompts their cardiologist to learn—and then explain—the connection. We want to be advocates for our patients and their health education, so they feel comfortable asking who the best person on their team is to help with each diagnosis.
To cardiologists, we would also say—start by really looking at your patients. You might begin to notice things like lumps on the skin or a patient sitting uncomfortably. And when you ask them who they’re seeing about things like that, you can uncover a little more of their holistic health picture and better serve them as a healthcare provider. And they’ll appreciate it. Even if we could just get cardiologists to say, “I see you have gout, and it’s not under control. That may be an important factor in your cardiovascular health; let’s get you in touch with a gout specialist so you can manage it,” that’s going to make a huge difference.
Even if spending a few extra minutes on these details means you’re a little late to your next appointment, your patients won’t mind when they realize you’re taking an interest in their holistic health.
The call to action: Work together, and our patients will benefit
As the medical field has become increasingly siloed, the need for provider engagement is more important than ever to address diseases with implications across specialties. Gout is an excellent example of such an area. As marriage between a cardiologist and a rheumatologist is perhaps not the most sustainable way to achieve that collaboration, we believe the insights we’ve offered here are viable methods to connect across our industry.
There’s no “staying in your lane” with a disease like gout, because the “lane” is the human body. We’re a product of our training, and we need to understand when that training has limitations. We have to come together as a medical community to learn about the connection between gout and heart health. Because when we do that, our patients will ultimately benefit. And that is our shared goal.
Ambrose Panico, DO, is an electrophysiologist in Mesa, Arizona. He specializes in diagnosing and treating complex arrhythmias or electrical conduction abnormalities in the heart. Brittany Panico, DO, is a rheumatologist in Gilbert, Arizona, specializing in adult rheumatology.
1. Brody B. Gout and heart disease: Why you're at increased risk. CreakyJoints. https://creakyjoints.org/about-arthritis/gout/gout-heart-disease-risk/#:~:text=Studies%20have%20shown%20that%20people,pump%20blood%20throughout%20the%20body. Published February 17, 2022.
2. Ding M, Viet NN, Gigante B, Lind V, Hammar N, Modig K. Elevated uric acid is associated with new-onset atrial fibrillation: results from the Swedish AMORIS cohort. J Am Heart Assoc. 2023;12(3):e027089. doi:10.1161/JAHA.122.027089
3. Singh TP, Wong S, Quigley F, Jenkins J, Golledge J. Association of gout with major adverse cardiovascular events and all-cause mortality in patients with peripheral artery disease. Atherosclerosis. 2020;312:23-27. doi:10.1016/j.atherosclerosis.2020.08.029
4. Coblyn J. Is Gout Associated with Vascular Disease? NEJM Journal Watch. https://www.jwatch.org/na37335/2015/03/24/gout-associated-with-vascular-disease. Published April 2015. Accessed August 9, 2023.
5. Solan M. Gout linked with risk for heart attack and stroke. Harvard Health. https://www.health.harvard.edu/diseases-and-conditions/gout-linked-with-risk-for-heart-attack-and-stroke#:~:text=Researchers%20looked%20at%20more%20than,days%20and%20then%20gradually%20declined. Published December 1, 2022. Accessed August 9, 2023.
6. Padda J, Khalid K, Almanie AH, et al. Hyperuricemia in patients with coronary artery disease and its association with disease severity. Cureus. 2021;13(8):e17161. doi:10.7759/cureus.17161
7. Rahimi-Sakak F, Maroofi M, Rahmani J, Bellissimo N, Hekmatdoost A. Serum uric acid and risk of cardiovascular mortality: A systematic review and dose-response meta-analysis of cohort studies of over a million participants. BMC Cardiovasc Disord. 2019;19(1):218. doi:10.1186/s12872-019-1215-z