Inflammation’s role in heart disease

Jared Spitz, MD, is a board-certified cardiovascular disease physician. He practices at the Inova Cardiology offices in Fairfax, Fair Oaks and Ballston.

An elevated cholesterol level is a major risk factor for heart attack and stroke. Increasingly, treatment of inflammation has gained attention as an important part of heart disease prevention. The U.S. Food and Drug Administration’s recent approval of a new low-dose version of colchicine, which has long been used for inflammatory conditions, has opened another avenue to consider in preventing heart attacks. 

Among those who have experienced a heart attack, low-grade, systemic inflammation is a powerful predictor of future cardiac events and cardiac death. In addition, several large, successful trials have shown that for individuals with stable coronary artery disease, targeting inflammation can potentially reduce the likelihood of future coronary artery events.

An overview of colchicine’s advantages and disadvantages     

There has been tremendous buzz around colchicine, a well-established, anti-inflammatory medication most well known as a treatment for acute gout attacks. It is also used to treat pericarditis (inflammation of the sac surrounding the heart) and other inflammatory conditions.

Healthcare providers should consider many factors when adding colchicine to a treatment plan, starting with whether the patient falls in line with any of the recommendations for use. That would include patients with established coronary artery disease who have uncontrolled risk factors such as high blood pressure, high cholesterol or diabetes including people who have recurrent heart attacks or issues with chest pain.

Any time a healthcare provider prescribes a drug for a patient, the provider must also consider cost, side effects, benefits of another drug and how colchicine may interact with a patient’s other medications. Perhaps colchicine’s two biggest limitations are that it can build up to toxic levels in patients with kidney disease and that it can have potentially significant interactions with other medications. So, while colchicine is generally safe and effective, patients and their doctors need to discuss the risk and benefits of its use ahead of time.

There is some debate about whether patients need to be tested for inflammation at all, as none of the major colchicine trials used a lab test to determine eligibility. Some doctors, however, will test for high-sensitivity C-reactive protein (hs-CRP) and consider prescribing colchicine if the level is elevated. Within the U.S., there are no current recommendations at this time for the use of colchicine as a preventive treatment for heart disease. The biggest organization to present a formal recommendation in favor of the drug was the European Society of Cardiology. In 2021, the society recommended that colchicine “may be considered” in cases where patients have known coronary artery disease but keep having heart attacks or uncontrolled risk factors as above.

Determining which patients are eligible for colchicine

Patients who have coronary artery disease may want to talk with their doctors about whether colchicine is a medication that could benefit them. If patients still have uncontrolled high blood pressure, high cholesterol or diabetes, the drug may help. If patients have recurring issues with their coronary artery disease, they may benefit. Additionally, some doctors may elect to test their patients for hs-CRP and if elevated, may also talk to their patients about colchicine. The addition of colchicine at this point would not reduce the need to treat for high cholesterol, blood pressure or diabetes but may represent an additional tool to help reduce the risk of future heart disease.

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