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Gout flares associated with subsequent cardiovascular events

Gout flares associated with subsequent cardiovascular events

Experts at the University of Nottingham, in collaboration with experts at Keele University, have found that the risk of heart attacks and strokes temporarily increases in the four months after a gout flare.

The research showed that gout patients who suffered from a heart attack or stroke were twice as likely to have had a gout flare in the 60 days prior to the event, and one and a half times more likely to have a gout flare in the 61-120 days prior.

The results of the study, led by Professor Abhishek in the School of Medicine at the University of Nottingham, are published in the journal JAMA.

Gout is a common form of arthritis that affects one in 40 adults in the UK. It is caused by high levels of uric acid, a chemical produced by breakdown of tissues in the body and present in certain foods and drinks.

At high levels, uric acid is deposited in and around joints as needle shaped urate crystals. Once released from their deposits, these crystals cause severe inflammation manifesting as joint pain, swelling, redness, and tenderness that often lasts for 1-2 weeks. These episodes, called gout flares, often recur. Inflammation is also a risk factor for heart attack and stroke.

People with gout tend to have more cardiovascular risk factors, although there have been no previous studies about whether gout flares are linked with an increased risk of heart attack and stroke. In this study, the experts examined whether there was a temporary increase in risk of heart attack or stroke after a gout flare.

The team used anonymized data from 62,574 patients with gout treated in the National Health Service in the UK. Of these, 10,475 experienced heart attack or stroke after the diagnosis of gout, while others of similar age, sex, and duration of gout, did not experience such events. They evaluated the association between heart attacks or strokes and recent gout flares and adjusted these results for comorbidities, socioeconomic deprivation, lifestyle factors and prescribed medications among other things. They found that gout patients who suffered a heart attack or stroke were twice as likely to have had a gout flare in the 60 days prior to the event, and one and a half times more likely to have a gout flare in the preceding 61-120 days.

They found a similar high rate of heart attack or stroke in the 0-60 and 61-120 days after gout flares compared with other time periods, when they used information from only patients who consulted for a gout flare and also experienced either heart attack or stroke. This further strengthened the finding that gout flares are associated with a transient increase in cardiovascular events following flares. The increased odds and rates persisted when people with pre-existing heart disease or stroke before their gout diagnosis were excluded, and when shorter exposure periods such as 0-15 and 16-30 days prior to heart attack or stroke, were considered.

Gout patients who died from a heart attack or stroke had over four times the odds of experiencing a gout flare in the preceding 0-60 days and over twice the odds of gout flare in the preceding 61-120 days.

This is the first study of its kind to examine whether there is an association between recent gout flares and heart attacks and strokes.

The results show that among patients with gout, patients who experienced a heart attack or stroke had significantly increased odds of a gout flare during the preceding 120-days compared with patients who did not experience such events. These findings suggest that gout flares are associated with a transient increase in cardiovascular events following flares.

People with recurrent gout flares should be considered for long-term treatment with urate lowering treatments such as allopurinol. This is a reliable way of removing urate crystal deposits and providing freedom from gout flares. Patients should also be considered for concurrent treatment with anti-inflammatory medicines such as colchicine for the first few months because urate lowering treatments may trigger gout flares in the short term.

People with gout should be encouraged to adopt a healthy lifestyle with appropriate treatment of conditions such as high blood pressure, high cholesterol, obesity and diabetes to minimise their background risk of heart attack and stroke”

Professor Abhishek, lead author on the study


Journal reference:

Cipolletta, E., et al. (2022) Association Between Gout Flare and Subsequent Cardiovascular Events Among Patients With Gout. JAMA.

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Should grand prix circuits change their rules to allow flares at Formula 1 events? · RaceFans

Should grand prix circuits change their rules to allow flares at Formula 1 events? · RaceFans

Formula 1 grands prix are routinely among the biggest live sporting events in the world by the sheer volume of fans who attend.

At the bigger venues like Silverstone or Circuit of the Americas, race day attendance easily reaches over 100,000 fans, with those numbers growing in recent years as F1’s popularity continues to pick up.

With so many people watching races, the passionate and vibrant fan culture witnessed at some of the more popular grands prix has always been one of the best qualities of the sport. And flares have become a major means for fans to express their love for their heroes.

Charles Leclerc will never forget the scene in front of him on the podium at the 2019 Italian Grand Prix after delivering victory for the Tifosi with red flares being set off by fans watching from the track below. The sight of Max Verstappen rounding the Hans Ernst Bocht for the final time in 2021 to take a home victory at the Dutch Grand Prix while bathed in a thick orange haze will always be one of the most iconic images of his championship winning season.

Circuit atmosphere, Red Bull Ring, 2022
The Red Bull Ring was bathed in orange smoke

However, this smokey symbol of celebration is not without its problems. For as common as flares have become in the grandstands of grand prix events, they technically are not even allowed to be brought into venues to start with.

Flares are explicitly banned by name from the Australian Grand Prix as well as from Imola, host of the Emilia-Romagna Grand Prix. But many other circuits – such as Silverstone and Circuit of the Americas – prohibit ticket holders from bringing “smoke canisters” and “incendiary devices” to their events. Even at many tracks where flares are most common, they often are not explicitly allowed by terms and conditions of entry. Imola, as mentioned, forbids flares, yet many Tifosi were pictured setting off scarlet red smoke in spectator areas, while Spa-Francorchamps only lists “firearms, bladed weapons and any other type of dangerous item” as a category of forbidden items that flares may arguably fall under.

The use of flares by fans reached a flashpoint in last weekend’s Austrian Grand Prix with plumes of orange smoke drifting over the track during the start of Sunday’s race, with some drivers later commenting that it had very slightly affected their visibility into turn seven on the opening lap. So thick was the smoke, one fan captured video of how the view of the track was completely obstructed at the start of the race from the centre grandstands between turns six and seven.


Didn’t even see the start 😭😭 #fyp #formula1 #austriangp #maxverstappen #redbull #checo #foryoupage #orangearmy #smoke #charlesleclerc #ferrari #f1 #austria #grandprix #fypシ

♬ original sound – Ranvision Official

But despite being technically prohibited from grand prix venues, should fans with flares be clamped down on, or should Formula 1 embrace this colourful form of expression and encourage circuits to allow them at their venues?


As already mentioned, flare smoke has become a key element of the fan culture at some European races – especially those that attract strong support for Ferrari or for world champion Max Verstappen. With Formula 1 having raced at so many circuits over the years with visibly empty grandstands, it should be a joy to see fans rich in both number and spirit expressing their love of the sport, their favourite driver or team during races.

The orange flares often seen at Zandvoort, the Red Bull Ring and even Spa-Francorchamps are becoming just as much an icon of modern F1 fan culture as the red flares used by the Tifosi at Imola and Monza are. Formula 1 certainly does not seem to mind sharing lingering wide shots of orange smoke covering grandstands on its world feed coverage.

There’s also the argument that even if bringing flares to circuits is discouraged or outright forbidden, the rules could be opened up to allow fans who want to show their support in this colourful way can do so, but with very strict rules about what is permitted – maybe even only allowing approved devices to be purchased at the circuit itself.


The main reason flares are prohibited from racing circuits is easy to figure out: safety. Not only is anything that combusts a potential fire risk, there’s also the health impact that smoke can have on other spectators around them who likely have not consented to their being filled by coloured smoke.

Inhaling potentially toxic fumes and chemicals from flare smoke is enough of a reason to argue flares have no place in grandstands and spectator areas. There’s also the environmental concern, as releasing those into the atmosphere is not ideal for the local ecosystem and potentially human residents who happen to live close to the confines of the circuit.

Finally, as demonstrated so visually in the Austrian Grand Prix, there’s the matter of flares impeding visibility during races. Not just for the drivers who have every expectation for their visibility not to be impeded by artificial factors, but for the other spectators who also should expect to be able to at least see the race that they have paid considerable money to watch.

I say

As Formula 1 enjoys a boom period, attracting legions of new fans across the world, the last thing the sport wants to do is to risk alienating some of those who pay good money to watch their heroes racing live and in person. The scenes of proud Dutch fans honouring their first grand prix winner and world champion by lighting the grandstands in orange is a spectacle in itself, while the Tifosi have long been rightly celebrated for being the most vivid, impassioned and devoted fanbase of any team or driver in motorsport.

Such visual support isn’t only impressive to witness, it also adds a true sense of home support to Formula 1 that is commonplace in most other sports like soccer, American football, hockey or basketball. The Dutch Grand Prix truly feels like Verstappen’s home race, while the Italian Grand Prix is unambiguously Ferrari territory due to the sea of red seen in the stands. The colour that flares can add to the atmosphere can very much help to make each round feel like its own event, rather than races held at soulless circuits with empty seats and little energy.

However, flares are prohibited from F1 races for good reasons. But while the frequency in which we see flares at races might cause some concerns about security at grand prix events, it would seem a shame if they were to disappear completely from the grandstands.

What fans should exercise – and what the sport should expect from its fans – is common sense. When the level of smoke at the start of the Austrian Grand Prix becomes a talking point for drivers after the race and some fans miss the on track action as a result, it’s clear that is going too far. But if fans can show some reasonable constraint, flares can hopefully continue to add to the fan atmosphere during Formula 1 races into the future.

You say

Do you agree that circuits should change their rules and allow flares at Formula 1 races?

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  • Slightly disagree (40%)
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