Would you use febuxostat for an African-American patient with gout and previous cardiovascular events (stroke, MI) who tested positive for HLA-B*5801?

Well, I would certainly avoid using allopurinol. The initial CARES trial raised concerns about the safety of febuxostat, using a median dose of 40 mg. The subsequent study FAST did not show any signals of CV disease using a median dose of 80 mg. The internal validity of the study was greater in the FAST trial. We also need to remember that chronic gout with hyperuricemia, if anything raises the risk of CV disease over time. So, in summary, I would not rule out using febuxostat in such a patient, and have in fact done so in the past several times, luckily without any untoward adverse side effects, with careful follow-up observation, as indicated,