Uric acid—our body’s Dr. Jekyll and Mr. Hyde

Time and again, we’ve discussed in this column not too well recognized risk factors that can contribute to the development of cardiovascular disease (CVD) and might even lead to heart attacks and strokes.

This week, during the convention of the Philippine Heart Association (PHA)—the mother organization of all heart specialists in the country—we had the privilege to lecture on the role of elevated uric acid levels in developing CVD, and in increasing the risk of heart attacks, strokes, kidney failure and heart failure, and dying prematurely from these and other causes.

Elevated uric acid has always been believed to be only significant in causing gouty arthritis and kidney stones, but insofar as the cardiovascular system (heart) is concerned, it was thought to be a benign factor that should not be cause for alarm. Physicians are now aggressive in bringing down the blood pressure if elevated, reducing high blood sugar and cholesterol levels, but a seemingly benign neglect has been generally noted among clinicians when it comes to dealing with elevated uric acid levels.

One of the reasons

This could be one of the reasons despite all the advances in the treatment of hypertension, diabetes and hypercholesterolemia, there is still an alarmingly high incremental or remaining risk of our high-risk patients to succumb to heart attacks, strokes and other cardiovascular complications. We’ve likely not covered all bases, and elevated uric acid level could be one of them.

The scientific evidence has been accumulating over the last 15 years and although admittedly the data may not be that air tight yet or conclusive, the signal is too strong to ignore that elevated uric acid contributes to the development of CVD and increases one’s risk to  heart attack, stroke, kidney failure, heart failure and other potentially life-threatening complications. It also increases one’s risk of dying from cardiovascular causes, specifically, and dying from all causes, in general.

Uric acid is a natural substance produced in our body which has both good and bad effects. Some authors have alluded that we have a Dr. Jekyll and Mr. Hyde in our body in the form of the uric acid found in our circulation. Under normal concentrations, it’s a very potent antioxidant which accounts for more than 50 percent of the antioxidant activity in our blood. In that regard, when its levels are normal, it is beneficial. But when it’s high, it precipitates into crystals and can be too hot to handle. It is suddenly transformed to the evil and maleficent Mr. Hyde. In its crystal form, uric acid causes a lot of swelling or inflammation in the various tissues of the body.

Increased risk

This explains the increased cardiovascular risk with elevated uric acid levels in the blood. If you know someone with gout, which is caused by increased uric acid levels, ask him how it feels and he’d likely tell you how the swelling of even just one joint can literally cripple him and make him beg for anything that can help relieve the excruciating pain.

Uric acid crystals can really be that potent in causing severe inflammation in the joints. If it could do that to the joints which are supposed to be sturdier tissues, just imagine what damage it could do to the fine, delicate lining of the arteries called the endothelium. It slowly but surely damages the delicate endothelial lining and accelerates the development of atherosclerosis, which is the progressive narrowing of all arteries. When the arteries to the heart and brain are significantly occluded already, heart attacks and strokes can’t be far behind.

Many heart and brain experts are now looking at high uric acid levels with serious concern, but there are still some skeptics who are looking for more robust and conclusive studies done in bigger populations. The problem though with big population studies is that it’s very difficult to isolate the impact of one risk factor. Usually, high uric acid levels come with elevated blood pressure, blood sugar and cholesterol levels. Obese individuals and those with so-called metabolic syndrome also have increased blood uric acid.

So all these coexistent risk factors can be confounding, which can always make these skeptics argue about the independent contribution of elevated uric acid level in increasing the cardiovascular risk. This is where the science of medicine may lag behind its actual applicability in clinical practice.

I think it would always be prudent not to ignore high uric acid levels in our patients and to bring it down either by diet or medicines. As  we always advise to  our young physicians, it’s always better to err on the safe side. And our patients will always be on the safer side if we control their uric acid level.

Congratulations to outgoing PHA president Dr. Eugene Reyes and his board of directors for a very successful term, and our congratulations and best wishes likewise to incoming president Dr. Joel Abanilla and his board.