Expert consensus for the diagnosis and treatment of patients with hyperuricemia and high cardiovascular risk: 2025 update

BACKGROUND: Hyperuricemia has traditionally been viewed primarily as a cause of gout; however, accumulating evidence indicates that elevated serum uric acid (sUA) is also associated with increased cardiovascular and renal risk. Recent epidemiological studies suggest that adverse outcomes may occur at sUA levels well below the classic crystal-based thresholds, particularly in patients with high cardiovascular risk. METHODS: This expert consensus document was developed by a multidisciplinary European panel of cardiology, internal medicine, nephrology, and hypertension specialists. The recommendations are based on a critical narrative review of the literature published, including large cohort studies, meta-analyses, randomized controlled trials, and contemporary European guidelines (ESC, ESH, KDIGO, EULAR). Particular emphasis was placed on outcome-driven serum urate thresholds and clinically applicable risk stratification. RESULTS: Hyperuricemia is common and increasingly prevalent, especially among individuals with hypertension, chronic kidney disease, obesity, diabetes, and established cardiovascular disease. Elevated sUA is independently associated with cardiovascular mortality, heart failure, stroke, and faster progression of chronic kidney disease. However, randomized trials have not shown clear cardiovascular or renal benefit from routine urate-lowering therapy in patients with asymptomatic hyperuricemia. Based on current evidence, this consensus proposes a risk-based, individualized approach to hyperuricemia management and presents a pragmatic six-rung therapeutic ladder integrating lifestyle measures, optimization of comorbidities, and pharmacological urate-lowering therapy when clinically indicated. CONCLUSIONS: Hyperuricemia should be recognized as a relevant cardiovascular and renal risk factor rather than a benign biochemical finding. Serum urate measurement can improve risk stratification in selected high-risk populations. While routine treatment of asymptomatic hyperuricemia cannot be universally recommended, targeted urate-lowering strategies may be appropriate in patients with high cardiovascular risk, symptomatic disease, or very high sUA levels. Future randomized trials are needed to define whether urate-lowering therapy can improve hard cardiovascular and renal outcomes in these populations.