Risk of myocardial infarction in adults with gout treated with allopurinol: A systematic review and meta-analysis

Aims Although allopurinol is used for urate-lowering therapy, its effect on myocardial infarction risk remains unclear. This study assessed the association between allopurinol use and myocardial infarction in adults with gout. Methods A systematic review and meta-analysis was conducted following PROSPERO registration (CRD420261305257). PubMed, Scopus, and Web of Science were searched from inception to January 2026. Observational studies of adults with confirmed gout that reported adjusted hazard ratios (HRs) for myocardial infarction and separately identifiable allopurinol exposure were included. Pooled estimates were calculated using an inverse-variance random-effects model with the Paule–Mandel estimator. Robustness was assessed through leave-one-out, active-comparator, and Hartung–Knapp sensitivity analyses. Results Four retrospective cohort studies met the revised eligibility criteria. In the primary random-effects analysis, allopurinol use was associated with a lower risk of myocardial infarction (HR 0.84; 95% CI 0.76–0.94; I 2 = 0%). However, the association was not statistically significant after excluding the study contributing the greatest weight (HR 1.04; 95% CI 0.79–1.36), when restricted to active comparators (HR 1.04; 95% CI 0.79–1.36), or using the Hartung–Knapp adjustment (HR 0.84; 95% CI 0.71–1.00). Conclusion Allopurinol therapy was associated with a modest but significant reduction in myocardial infarction risk in adults with gout.