Serum Urate Improves Cardiovascular Risk Stratification Beyond SCORE2: Insights from a High-Risk Inflammatory Cohort

Background: Cardiovascular risk (CVR) prediction using SCORE2 may underestimate subclinical atherosclerosis in patients with chronic inflammatory conditions. Identify-ing simple, accessible markers to refine risk stratification remains an unmet need. Objective: To evaluate whether serum urate improves detection of subclinical athero-sclerosis beyond SCORE2 in a high-risk inflammatory cohort. Methods: We conducted a cross-sectional study including 250 patients with psoriatic arthritis fulfilling CASPAR criteria. Vascular assessment comprised carotid and femoral ultrasound and ab-dominal radiography. Atherosclerotic plaque was defined according to Mannheim criteria. The main outcomes were global plaque (≥1 vascular territory) and extended plaque (≥2 territories). Multivariable logistic regression adjusted for SCORE2 categories assessed independent associations. Incremental value was evaluated using decision curve analysis (DCA), category-free net reclassification improvement (cfNRI), and in-tegrated discrimination improvement (IDI). Results: Hyperuricemia prevalence was 21.6%. Patients with hyperuricemia showed a higher prevalence of global plaque (88.9% vs. 62.8%, p< 0.001). After adjustment for SCORE2, serum urate independently predicted global plaque (OR 4.23, 95% CI 1.26–14.2). Notably, 64.3% of patients classi-fied as low–moderate risk already exhibited plaque. In the 50–69-year subgroup, adding serum urate improved reclassification (cfNRI +0.60; IDI +0.031) and was asso-ciated with higher net clinical benefit across decision thresholds. The combined model (SCORE2+HU+cIMT) achieved the highest curves, although with limited incremental gain over HU alone. Conclusions: SCORE2 substantially underestimates subclinical atherosclerosis in this population. Serum urate, an inexpensive and widely available marker, may help refine cardiovascular risk stratification and identify patients who could benefit from further vascular assessment.