Safety and efficacy of allopurinol in hyperuricemic patients presenting with acute coronary syndrome

Background: Hyperuricemia is a significant risk factor for cardiovascular diseases, particularly acute coronary syndrome (ACS). Elevated serum uric acid levels contribute to endothelial dysfunction, oxidative stress, and inflammation, which ex-acerbate the progression of coronary artery disease. Allopurinol, a xanthine oxidase inhibitor, has demonstrated potential cardio-protective effects beyond its urate-lowering properties. Aim: This study aimed to evaluate the safety and efficacy of allopurinol in patients with hyperuricemia presenting with ACS. Methods: We conducted a prospective study at the Aswan University Hospital from June 2024 to June 2025. A total of 120 patients with ACS were enrolled and divided into two groups: Group A (n = 60) comprised patients with hyperuricemia (serum uric acid > 6.8 mg/dL) who received allopurinol plus standard anti-ischemic therapy, and Group B (n = 60) comprised patients with normal uric acid levels who received standard therapy alone. Allopurinol was administered at 600 mg/day during the acute phase (first 14 days), followed by 200 mg/day for a total of 4 weeks. All patients underwent comprehensive evaluation, including coronary angiography, echocardiography, and laboratory assessments at baseline and after 3-months. Results: Baseline characteristics showed that Group A had a significantly higher BMI (24.7 ± 3.9 vs. 23 ± 3.4 kg/m², p = 0.015), lower HDL cholesterol (39.8 ± 15.2 vs. 74.6 ± 37.8 mg/dL, p < 0.001), and higher troponin positivity (81.7% vs. 20%, p < 0.001) compared to Group B. Angiographic analysis revealed that Group A had more proximal coronary lesions (45% vs. 20%, p < 0.001), higher rates of severe stenosis (93.3% vs. 30%, p < 0.001), and higher SYNTAX scores (23.1 ± 3.6 vs. 17.7 ± 3.9, p < 0.001). Group A also demonstrated a higher prevalence of arrhythmias (48.3% vs. 13.3%, p < 0.001), particularly atrial fibrillation. Following allopurinol therapy, Group A showed significant improvements in left ventricular ejection fraction (from 50.4% to 52.2%, p < 0.001), reduction in left atrial volume index (from 38 to 32.8 m², p < 0.001), and decreased incidence of arrhythmias (from 48.3% to 25%, p = 0.008). Only three patients experienced mild adverse effects (mood and sleep disturbances), with no treatment discontinuation reported. Conclusion: Allopurinol is safe and efficacious in hyperuricemic patients with ACS, demonstrating significant improvements in cardiac function, a reduction in arrhythmic events, and favorable modification of echocardiographic parameters. These findings support the incorporation of uric acid screening and targeted allopurinol therapy in the comprehensive management of ACS patients with hyperuricemia.