OBJECTIVES: Gout patients in the Department of Veterans Affairs (VA) are often difficult to manage (DTM) with multiple co-morbidities (diabetes, hypertension, renal disease) that are  associated with cardiovascular thrombotic events (CVTE) and other cardiac events (OCE).  Our objectives were to describe rates of CVTE and OCE among patients with gout and to determine if increased CVTE or OCE occurred in patients with DTM gout. METHODS: We used VA national databases to select all patients with gout diagnoses (ICD-9=274.xx) in an index year of 2004 with follow-up through 2006. We identified patients with ICD-9 codes for OCEs and CVTE diagnoses, based upon definitions from the Antiplatelet Trialists' Collaboration. ICD-9 codes for gout nephropathy or tophi were used to identify DTM patients.  We calculated odds ratios with 95% confidence intervals (OR, CI) to compare risk of CVTE, OCE, and mortality among DTM versus other gout patients. RESULTS: Of 156,809 VA gout patients, 2534 (1.6%) had CVTE and 9759 (6.2%) had OCE in 2004.  Rates were similar for 2005 and 2006: 1.6% and 1.3% for CVTE, 6.2% and 5.7% for OCE. DTM patients, defined as having diagnostic codes of gout nephropathy (ICD-9 of 274.1x, n=1667) and/or tophi (ICD-9 of 274.8x, n=1780), had similar rates of CVTE as other gout patients in 2004 (1.9% vs. 1.6%, OR=1.16, CI=0.90-1.50), but increased risk in 2005 (2.2% vs. 1.5%, OR=1.41,  CI=1.13-1.77) and 2006 (2.0% vs. 1.3%, OR=1.54,  CI=1.23-1.93).  OCEs were significantly greater each year in DTM gout patients; 2004: 9.9% vs. 7.6%, OR=1.33, CI=1.19-1.50; 2005: 11.1% vs. 7.4%, OR=1.57, CI=1.41-1.74; 2006: 11.3% vs. 6.8%, OR=1.75, CI=1.58-1.94.  Mortality was significantly greater in DTM gout patients; 2004: 3.3% vs. 4.0%, OR=1.21, CI=1.01-1.44; 2005: 3.3% vs. 4.8%, OR=1.49, CI=1.28-1.73; 2006: 3.2% vs. 4.6%, OR=1.49, CI=1.27-1.73. CONCLUSIONS: Patients with DTM gout have greater risks for CVTEs, OCEs, and mortality.