Risk of stroke and transient ischaemic attack after herpes zoster

A systematic literature review of the epidemiology and burden of herpes zoster in selected locales in Asia Pacific

Herpes zoster (HZ) is a painful rash which typically affects older adults. This is of concern in Asia-Pacific given its aging population. As HZ epidemiology and burden are evolving, this systematic literature review aimed to update the current understanding of HZ burden and associated costs for selected Asia-Pacific locales. MEDLINE and Embase were searched for English articles of HZ studies conducted in Australia, China, Hong Kong, Japan, Korea, New Zealand, Singapore, and Taiwan. Eligible outcomes included HZ incidence and prevalence, occurrence of HZ-related complications, healthcare resource utilization, costs, and HZ-associated quality of life outcomes. This paper focused on HZ data in the general adult population (N = 90 articles). Substantial HZ-related disease and economic burden were observed in these locales, consistent with global trends. These findings reinforce the increasing burden of HZ and need for preventive strategies, which may include raising awareness and encouraging timely vaccination.

Burden of Herpes Zoster in Individuals With Chronic Conditions in the Republic of Korea: A Nationwide Population-Based Database Study

Background

Chronic conditions (CCs) may increase the risk of herpes zoster (HZ) infection, leading to a greater healthcare burden in these individuals compared to those without CCs. It is therefore clinically important to quantify HZ disease burden in individuals with and without CCs, given the rapidly aging population in the Republic of Korea (ROK).

Methods

This retrospective cohort study examines the trends in incidence rates (IRs) and incidence rate ratios (IRRs) in individuals aged ≥18 years with CCs, using the National Health Insurance Service National Sample Cohort (NHIS-NSC) database from 2010 to 2019. These patients were stratified by age group, sex, HZ complications, and CCs. The annual average number of HZ patients, IRs, and IRRs were calculated for individuals with and without CCs.

Results

In total, 729 347 patients with HZ were eligible for the study. HZ IRs were highest in patients with diabetes, followed by chronic obstructive pulmonary disease, chronic kidney disease, asthma, and chronic liver disease, with HZ IRRs following a similar trend. Overall, HZ IRs generally increased with age, typically peaking at 60-64 or 65-69 years, and were similar for females and males. HZ IRs were highest among patients without complications, followed by HZ with other, cutaneous, ocular, and neurologic complications across all CCs. For each of the CCs, HZ IRs were consistently higher than those of the non-CC population regardless of sex.

Conclusions

The findings of this study reiterate the importance of HZ prevention for healthy aging, especially for CC populations at increased risk of HZ in the ROK.

A comprehensive, updated systematic review and meta-analysis of epidemiologic evidence on the connection between herpes zoster infection and the risk of stroke

Stroke is a common worldwide cause of death and disability, resulting from an obstruction or reduction in blood flow to the brain. Research has demonstrated that systemic infection such as herpes zoster (HZ) / ophthalmicus herpes zoster (HZO) can potentially trigger stroke. This study includes an updated systematic review and meta-analysis of the epidemiologic data on the connection between HZ/HZO infection and the risk of stroke. A meticulous search of different database yielded 905 studies. Furthermore, an additional 14 studies from a previous meta-analysis were incorporated. Eligible studies underwent rigorous screening, resulting in 18 papers. Statistical analyses, including random/fixed effects models and subgroup analyses, were conducted to assess pooled relative risk (RR) and heterogeneity. The meta-analysis consisted of 5,505,885 participants and found a statistically significant association between HZ infection and the risk of stroke (pooled RR = 1.22, 95% confidence interval [CI] 1.12-1.34). The HZO infection showed a significantly higher overall pooled RR of 1.71 (95% CI 1.06-2.75), indicating a strong connection with the risk of stroke. Subgroup analysis revealed that the odds ratio might play a significant role in causing heterogeneity. Time since infection emerged as a crucial factor, with heightened stroke risk in the initial year post-HZ/HZO exposure, followed by a decline after the first year. Asian/Non-Asian studies demonstrated varied results in HZ/HZO patients. Meta-analysis reveals a significant HZ/HZO-stroke link. Subgroups highlight varied risks and warrant extended Asian/non-Asian patient investigation.

Stroke risk after varicella-zoster virus infection: a systematic review and meta-analysis

Varicella-zoster virus (VZV) infection may cause vascular inflammatory changes leading to an increased risk of stroke. Previous studies have focused on the risk of stroke and less on changes in stroke risk and prognosis. We aimed to explore the changing patterns of stroke risk and stroke prognosis after VZV infection. This study is a systematic review and meta-analysis. We searched PubMed, Embase, and the Cochrane Library for studies on stroke after VZV infection between January 1, 2000, and October 5, 2022. Relative risks were combined for the same study subgroups using a fixed-effects model and pooled across studies using a random-effects model. 27 studies met the requirements, including 17 herpes zoster (HZ) studies and ten chickenpox studies. There was an increased risk of stroke after HZ, and this risk decreased over time: relative risk 1.80 (95% CI 1.42-2.29) within 14 days, 1.61 (95% CI 1.43-1.81) within 30 days, 1.45 (95% CI 1.33-1.58) within 90 days, 1.32 (95% CI 1.25-1.39) within 180 days, 1.27 (95% CI 1.15-1.40) at one year and 1.19 (95% CI 0.90-1.59) after one year, with the same trend in the stroke subtype. The risk of stroke after herpes zoster ophthalmicus was higher, with a maximum relative risk of 2.26 (95% CI 1.35-3.78). The risk of stroke after HZ was higher in patients aged around 40 years: relative risk 2.53 (95% CI 1.59-4.02), and similar in men and women. Also, after pooling studies of post-chickenpox stroke, we found that the middle cerebral artery and its branches were most frequently involved (78.2%), with a better prognosis in most patients (83.1%) and less frequent vascular persistence progression (8.9%). In conclusion, the risk of stroke increases after VZV infection, decreasing over time. Post-infection vascular inflammatory changes often occur in the middle cerebral artery and its branches, with a better prognosis in most patients and less frequent persistent progression.

Risk of, and risk factors for, vasculopathy associated with acute herpes zoster

OBJECTIVES

We aimed to summarize the known risk of vasculopathy (stroke, myocardial infarction [MI], and transient ischemic attack [TIA]) after herpes zoster (HZ) and the impact of antiviral treatment and vaccination against HZ on the risk of vasculopathy.

MATERIALS AND METHODS

A narrative literature review was conducted in PubMed to identify evidence published in the past 15 years that was relevant to the scope of this article.

RESULTS

Ten studies reported that HZ was associated with an increased risk of stroke and one UK study reported no association. Four studies reported that HZ was associated with an increased risk of MI, and four reported that HZ was associated with an increased risk of TIA. Two studies reported that antiviral treatment was associated with a reduced risk of stroke and an additional two studies reported no association between antiviral treatment and the risk of stroke. In addition, two studies reported that vaccination against HZ using the live zoster vaccine (ZVL) was associated with a reduced risk of stroke, and an additional two studies reported that the risk of stroke or MI after HZ was similar between ZVL vaccinated and unvaccinated individuals.

CONCLUSIONS

HZ is associated with an increased risk of stroke, MI, or TIA (strongest association is between HZ and stroke). Further studies are needed to determine whether antiviral treatment or ZVL vaccination influence the risk of HZ-associated vasculopathy. In addition, the effect of the recombinant zoster vaccine on the risk of HZ-associated vasculopathy should be studied.

Prompt antiviral therapy is associated with lower risk of cerebrovascular accident following herpes zoster ophthalmicus

PURPOSE

To examine risk factors associated with cerebrovascular accident (CVA) following herpes zoster ophthalmicus (HZO).

DESIGN

Retrospective cohort study METHODS: : Review of medical records of all subjects with HZO seen at the department of Ophthalmology, Auckland District Health Board, New Zealand, between 1^st January 2006 and 31^st December 2016.

MAIN OUTCOME MEASURES

Cerebrovascular accident within 12 months of diagnosis.

RESULTS

869 patients diagnosed with HZO were included in the study. The median age at onset of HZO was 65.5 (Interquartile range, IQR 52.9 - 75.4) and 52.5% (n=456) were male. Antiviral therapy was started in 765 participants (88.0%), not utilised in 95 (10.9%) and not documented in 9 participants (1.0%). Four hundred sixty-eight participants (54.9%) received prompt oral antiviral therapy (≤72 hours of rash onset). A CVA occurred in the 12 months following HZO in 14 subjects (1.6%) and was most common in older subjects, occurring in 2.5% aged ≥65 years, 0.7% aged 40-65 years and 0.9% aged <40 years. Hazard of CVA was highest immediately following HZO, with median time to CVA of 2.3 months (IQR 0.8 - 5.9 months). Subjects that received prompt acyclovir had a 76.2% lower hazard of CVA (0.9% vs 2.6%, p=0.022) on multivariate analysis.

CONCLUSIONS

Cerebrovascular accident occurs in a low proportion of individuals within one year following HZO. Antiviral treatment for HZO may reduce the risk of subsequent CVA when given within 72 hours of rash onset.

Manifesto on the Value of Adult Immunization: "We Know, We Intend, We Advocate"

Immunization through vaccination is a milestone achievement that has made a tremendous contribution to public health. Historically, immunization programs aimed firstly to protect children, who were disproportionally affected by infectious diseases. However, vaccine-preventable diseases can have significant impacts on adult mortality, health, and quality of life. Despite this, adult vaccinations have historically been overlooked in favor of other health priorities, because their benefits to society were not well recognized. As the general population is aging, the issue of vaccination in older adults is gaining importance. In high-income countries, recommendations for the routine vaccination of older adults have been gradually introduced. The Italian National Immunization Plan is considered to be among the most advanced adult vaccination plans in Europe. However, available data indicate there is low adherence to vaccination recommendations in Italy. The COVID-19 pandemic has exposed the damage that can be caused by an infectious disease, especially among adults and individuals with comorbidities. The aim of this “Manifesto”, therefore, is to provide an overview of the existing evidence on the value of adult vaccination, in the Italian context, with a call to action to healthcare providers and health authorities.

Association Between the Risk for Cardiovascular Events and Antiviral Treatment for Herpes Zoster

BACKGROUND

Cardiovascular risk increases following herpes zoster. We investigated whether treatment with antiviral agents, steroids, and common cardiovascular medications was associated with the risk of postherpetic cardiovascular events.

METHODS

This was a nationwide population-based, retrospective, cohort study using the National Health Insurance Service health claims data in Korea. We included patients with a first-ever diagnosis of herpes zoster in 2003-2014 and no prior cardiovascular event. The primary outcome was the occurrence of composites of myocardial infarction (International Statistical Classification of Diseases, Tenth Revision, code I21) and stroke (codes I60-I63) since the herpes zoster. We analyzed the exposure (intravenous or oral administration) to antiviral agents, steroids, antithrombotics, and statins within ±7 days from the index date of herpes zoster diagnosis. Follow-up was performed until occurrence of the primary outcome, death, or 31 December 2015, whichever came first.

RESULTS

Of 84 993 patients with herpes zoster, the proportions of patients who received the treatment with antiviral agents, steroids, antithrombotics, and statins were 90.5%, 48.0%, 9.1%, and 7.9%, respectively. During the mean (standard deviation) follow-up period of 5.4 (3.1) years, 1523 patients experienced the primary outcome. Multivariate Cox regression analysis demonstrated that treatment with antiviral agents (adjusted hazard ratio, 0.82; 95% confidence interval, .71-.95) and statins (0.71; .59-.85) were significantly associated with the lower risk of primary outcome. Use of antithrombotics and steroids were not associated with the risk.

CONCLUSIONS

After herpes zoster, treatment with antiviral agents was significantly associated with lower risk of cardiovascular events. We need more information on the cardiovascular protective role of herpes zoster treatments.

Vaccination in Older Adults: An Underutilized Opportunity to Promote Healthy Aging in India

Over the last 50 years, the Indian population aged 50 years and above (older adults) has quadrupled and is expected to comprise 404 million people in 2036, representing 27% of the country's projected population. Consequently, the contribution of chronic disease to older adults' total burden of diseases in India is likely to escalate. Disease burden is notably amplified by immunosenescence, a deterioration of the immune system that develops with age, leading to increasing susceptibility to infectious diseases and other comorbidities. Older adults with infectious diseases have a higher incidence and likelihood of life-threatening comorbidities such as coronary artery disease, arrhythmia, stroke, myocardial infarction, hypertension, dyslipidemia, and diabetes mellitus. Therefore, immunization of older adults through vaccination might greatly reduce the burden imposed by vaccine preventable infectious diseases in this population. Here, we review evidence relevant to the disease burden among adults aged ≥ 50 years in India, and existing vaccination recommendations. Furthermore, we suggest a set of routine vaccinations for healthy older adults in India. There is a clear mandate to recognize the contributions of older adults to society and embrace strategies promoting healthy aging, which is described by the World Health Organization as the process of developing and maintaining functional ability and well-being in older age. Increasing vaccination awareness and coverage among older adults is an important step in that direction for India.

Reactivation of varicella-zoster virus in reversible cerebral vasoconstriction syndrome: a proof-of-concept study

Aim: Association between reversible cerebral vasoconstriction syndrome (RCVS) and the reactivation of varicella-zoster virus (VZV) was analyzed. Materials & methods: VZV-specific IgG and IgA responses on day 1 and 28 in plasma was compared and VZV DNA with real-time PCR in saliva was measured in case-patients (diagnosed with RCVS), control-patients (ischemic stroke with intracranial artery stenosis) and healthy volunteers. Results: The case-patients (n = 11) revealed significantly higher VZV-specific IgG levels on day 28 than on day 1 (p = 0.004), while the age-matched control-patients and healthy volunteers exhibited no significant changes. Positive VZV DNA PCR result in saliva was revealed in one case-patient. Conclusion: RCVS might be associated with VZV. This result warrants a full-scale study to evaluate the association between them.

Mediation effect of herpes zoster derived by statin use on cardiovascular disease risk

BACKGROUND/AIMS

Although statins are widely used to reduce the risk of cardiovascular disease (CVD) including stroke and myocardial infarction (MI), it is reported that statin use increases the incidence of herpes zoster (HZ) that is associated with increased risk of CVD. So, we evaluated the mediation effect of HZ caused by statin use on CVD.

METHODS

We analyzed a prospective cohort from the National Health Insurance Service-database of South Korea. All individuals received a medical check-up and were followed-up from 2002 to 2013.

RESULTS

A total of 275,382 individuals > 40 years old were followed up for 11 years from 2003. Of these, 11,415 people (4%) were classified as statin users and 263,967 (96%) as non-statin users. Those who used statins had significantly lower risks of cardiovascular events, stroke, and MI compared with non-statin users; the adjusted hazard ratios in the multivariate analysis were 0.90 (95% confidence interval [CI], 0.82 to 0.98), 0.88 (95% CI, 0.80 to 0.98), and 0.91 (95% CI, 0.79 to 1.07), respectively. When we calculated the mediating effect of cardiovascular events by statin use through HZ, 11.6% of the total beneficial effect of cardiovascular events by statin use was mitigated through the occurrence of HZ caused by statin use. This mediating effect was higher in the younger age group (< 60 years).

CONCLUSION

This study showed that statin use reduced CVD by 10%, but the protective effect of statin use against CVD was mitigated by approximately 10% through the development of HZ caused by statin use.

Association between Tuberculosis, Statin Use, and Diabetes: A Propensity Score-Matched Analysis

Statins have anti-inflammatory and immunomodulatory properties that may affect the development of tuberculosis (TB). We assessed the association between use of statins and the risk of active TB by propensity score matching. Furthermore, we analyzed the impact of statins on TB in patients according to the presence or absence of diabetes. The study was based on the National Health Insurance database and its subset database of the "medical checkup" population of South Korea. We identified 123,468 statin users and 439,546 non-statin users. After propensity score matching, 28,018 statin users and the same number of non-statin users were finally analyzed. The development of active TB was monitored in these matched pairs over 11 years. In the propensity score-matching analysis, the number of active TB cases was 30 in 30,303 person-years (0.99 per 1,000 person-years; 95% CI, 0.64-1.35) in the statin users and 235 in 167,857 person-years (1.40 per 1,000 person-years; 95% CI, 1.22-1.58) in the non-statin users. Statin users had a significantly lower risk of TB than non-statin users: hazard ratio (HR) 0.67 (95% CI, 0.46-0.98) (P = 0.04). A subgroup analysis showed that statin use reduced the risk of TB in subjects without diabetes, but not in patients with diabetes: HRs were, respectively, 0.28 (95% CI, 0.13-0.60) (P = 0.001) and 1.05 (95% CI, 0.66-1.67) (P = 0.84). There is epidemiologic evidence that statin decreases the risk of active TB. However, the protective effect of statins against TB is attenuated by diabetes.

Varicella Zoster Virus Vasculitis and Adult Cerebrovascular Disease

The role of Varicella zoster virus (VZV) in neurological illness, particularly cerebrovascular disease, has been increasingly recognized. Primary infection by VZV causes varicella (chickenpox), after which the virus remains latent in neuronal ganglia. Later, during aging or immunosuppression, the virus can reactivate causing zoster (shingles). Virus reactivation can also spread to cerebral arteries causing vasculitis and stroke. Zoster is a recognized risk factor for stroke, but stroke can occur without preceding zoster rash. The diagnosis of VZV cerebral vasculitis is established by abnormal brain imaging and confirmed by presence of viral DNA or anti-VZV antibodies in cerebrospinal fluid. Treatment with acyclovir with or without prednisone is usually recommended. VZV vasculitis is a unique and uncommon stroke mechanism that has been under recognized. Careful diagnostic investigation may be warranted in a subgroup of patients with ischemic stroke to detect VZV vasculitis and initiate appropriate therapy. In the following review, we detail the clinical presentation of VZV vasculitis, diagnostic challenges in VZV detection, and suggest the ways to enhance recognition and treatment of this uncommon disease.

Cerebrovascular events after herpes zoster infection: a risk that should be not underestimated

The occurrence of a cerebrovascular event after a herpes zoster (HZ) infection represents a nightmare in clinical practice, especially in those patients with concomitant cardiovascular comorbidities/risk factors and disease related per se to a higher risk of zoster infection. Moreover, the absence of a consensus opinion regarding a specific and adequate prevention of cerebrovascular events in these patients further complicates the treatment. Accumulating evidences demonstrated that HZ and HZ ophtalmicus (HZO) increase the risk of cerebrovascular events in the short-and long-term periods. Moreover, patient's ages < 40 years old, despite having fewer traditional cardiovascular comorbidities, demonstrated a higher risk of cerebrovascular events after both HZ and HZO infection. Further prospective studies are needed to analyse the role of antiviral treatments and vaccination in these subjects to clarify if they could be able to reduce the risk of stroke after a zoster infection. In the meanwhile, physicians must be aware of a higher risk of cerebrovascular events, especially in younger patients, with few cardiovascular risk factors, after an HZ infection.

Analysis of Vascular Event Risk After Herpes Zoster From 2007 to 2014 US Insurance Claims Data

OBJECTIVE

To estimate the risk of transient ischemic attack (TIA), stroke, and myocardial infarction in periods covering 4 weeks before to 52 weeks after herpes zoster (HZ) diagnosis in US adults.

PATIENTS AND METHODS

This retrospective study (GSK study identifier: HO-15-15771) with matched cohorts used the Truven Health MarketScan Commercial and Medicare claims data set linked with obesity and smoking status information. Patients 18 years and older at the date of HZ diagnosis and 1-year pre- and post-HZ diagnosis continuous insurance enrollment (from January 1, 2007, through December 31, 2014) were propensity score matched to controls in terms of demographic characteristics, risk factors for vascular events, other comorbid disorders, general health, obesity, and smoking status. A post hoc sensitivity analysis was performed not matching for obesity and smoking status information. Adjusted incidence rate ratios (IRRs) were estimated using multivariate Poisson models during an aggregate period (1-month before and after the index date).

RESULTS

A total of 23,339 patients with HZ were matched to 46,378 controls (mean age, 56 years; 45,173 [65%] women). During the aggregate period, patients with HZ were statistically significantly more likely to suffer a TIA: IRRs for all patients and patients aged 18 to 49 years were 1.56 (95% confidence interval [CI], 1.13-2.15) and 5.12 (95% CI, 1.37-19.10), respectively (P<.05); the respective IRRs for stroke were 1.40 (95% CI, 0.93-2.11) and 8.12 (95% CI, 0.93-71.27). In the sensitivity analysis, IRRs for TIA and stroke were statistically significantly increased regardless of age.

CONCLUSION

Herpes zoster was associated with an increased risk of composite events, TIA, and stroke in adults in the period around diagnosis. More research on the HZ and vascular risk association is needed.

GSK STUDY IDENTIFIER

HO-15-15771.

Does Herpes Zoster Increase the Risk of Stroke and Myocardial Infarction? A Comprehensive Review

Herpes zoster (HZ) caused by varicella zoster virus (VZV) reactivation is characterized as a vesicular rash of unilateral distribution that can also cause multiple complications; such as post-herpetic neuralgia; ophthalmic zoster; and other neurological issues. VZV can also increase incident hemorrhagic or ischemic complications by causing inflammatory vasculopathy. Thus; emerging epidemiological and clinical data recognizes an association between HZ and subsequent acute strokes or myocardial infarction (MI). This study reviewed published articles to elucidate the association between HZ and cerebrovascular and cardiac events. Individuals exposed to HZ or herpes zoster ophthalmicus had 1.3 to 4-fold increased risks of cerebrovascular events. Higher risks were noted among younger patients (age < 40 years) within one year after an HZ episode. The elevated risk of CV events diminished gradually according to age and length of time after an HZ episode. The putative mechanisms of VZV vasculopathy were also discussed. Several studies showed that the development of herpes zoster and herpes zoster ophthalmicus increased the risks of stroke; transient ischemic attack; and acute cardiac events. The association between VZV infection and cardiovascular events requires further studies to establish the optimal antiviral treatment and zoster vaccination to reduce zoster-associated vascular risk

Optimal gender-specific age for cost-effective vaccination with adjuvanted herpes zoster subunit vaccine in Chinese adults

Background

Adjuvanted herpes zoster (HZ) subunit (HZ/su) vaccine is recommended for healthy adults aged ≥50 years, yet vaccine efficacy is expected to wane over time. Age-sex specific cost-effectiveness analyses of HZ/su vaccine are warranted to inform decision-making on vaccine policy. We aimed to determine the optimal gender-specific age for cost-effective HZ/su vaccination in Hong Kong.

Methods

A Markov model was used to compare outcomes with and without HZ/su in healthy males and females at age 50–80 years. Model outcome measures were total cost, HZ cases, and HZ-associated quality-adjusted life-years (QALYs) loss. Incremental cost per QALY saved (ICER) by HZ/su was estimated for each age-sex group. Sensitivity analyses were performed to examine robustness of model results.

Results

HZ/su reduced incidence of HZ in both males and females aged 50–80 years and the numbers needed to vaccinate to avoid one HZ case were lowest at age 60 years for males (6.05) and females (5.50). The highest QALY-saved occurred in females (0.00396 QALYs) and males (0.00379 QALYs) who were vaccinated at 60 years old. The ICERs were lowest at age 60–70 years for both genders. Using 1× gross domestic product per capita of Hong Kong (USD46,153) as willingness-to-pay threshold, HZ/su vaccine was accepted to be cost-effective for all female and male age groups at vaccine cost = USD160, for female aged 50–79 years and male aged 54–74 years at vaccine cost = USD200, and for female aged 59–71 years at vaccine cost = USD240.

Conclusions

HZ/su vaccine is more likely to be cost-effective for males and females aged between 60–70 years than the extreme age groups (less than 60 years and older than 70 years) in Hong Kong. The age range for cost-effective acceptance of HZ/su vaccine appears to be broader in females than males given the same vaccine cost and willingness-to-pay threshold.

Association of herpesviruses and stroke: Systematic review and meta-analysis

BACKGROUND

Herpesviruses induce a range of inflammatory effects potentially contributing to an increased risk of stroke.

OBJECTIVES

To investigate whether patients with infection, or reactivation of, human herpesviruses are at increased stroke risk, compared to those without human herpesviruses.

DATA SOURCES

Six medical databases and grey literature sources from inception to January 2017.

STUDY ELIGIBILITY CRITERIA

Studies where the exposure was any human herpesvirus and the outcome was stroke. We included randomised controlled trials, cohort, case-control, case-crossover and self-controlled case series designs.

METHODS

Meta-analyses when sufficiently homogeneous studies were available. Quality of evidence across studies was assessed.

RESULTS

We identified 5012 publications; 41 met the eligibility criteria. Across cohort and self-controlled case series studies, there was moderate quality evidence that varicella infection in children was associated with a short-term increased stroke risk. Zoster was associated with a 1.5-fold increased stroke risk four weeks following onset (summary estimate: 1.55, 95%CI 1.46-1.65), which resolved after one year. Subgroup analyses suggested post-zoster stroke risk was greater among ophthalmic zoster patients, younger individuals and those not prescribed antivirals. Recent infection/reactivation of cytomegalovirus and herpes simplex viruses, but not past infection, was associated with increased stroke risk; however the evidence across studies was mainly derived from small, very low quality case-control studies.

CONCLUSIONS

Our review shows an increased stroke risk following zoster and suggests that recent infection or reactivation of other herpesviruses increases stroke risk, although better evidence is needed. Herpesviruses are common and potentially preventable; these findings may have implications for reducing stroke burden.

Herpes Zoster: Epidemiological Links With Stroke and Myocardial Infarction

Routine data from electronic health records (EHRs) provide insights into links between herpes zoster (HZ) and cardiovascular complications such as stroke or myocardial infarction (MI) in different populations worldwide. Evidence from large EHR studies using both self-controlled case series and traditional cohort designs suggests that there is a transient increase in the risk of stroke after HZ, which gradually resolves over 6-12 months. In these studies, herpes zoster ophthalmicus was associated with a higher risk of stroke than HZ at other sites. A larger effect size was seen in people aged under 40 years. Existing studies also suggest that HZ may have a triggering effect on MI, although fewer studies examined this outcome. Further evidence is needed on the effectiveness and cost-effectiveness of vaccine and antiviral drugs to reduce cardiovascular complications after HZ from studies that are designed to minimize selection biases and confounding by indication.

Statins increase the risk of herpes zoster: A propensity score-matched analysis

OBJECTIVES

Statins, which are lipid-lowering agents, have anti-inflammatory and immunomodulatory properties that may affect the occurrence of various infectious diseases. We assessed whether statins increase the risk of herpes zoster (HZ) with propensity score-matching.

METHODS

The study was based on the National Health Insurance database and its subset database of the "medical check-up" population of South Korea. These cohorts consist of about one million and 570,000 people, respectively, representative of the entire population of South Korea. We identified 103,930 statin users and 430,685 non-statin users. After propensity score-matching, 25,726 statin users and the same number of non-statin users were finally analyzed. The development of HZ was monitored in these matched pairs over the 11 years from 2003 to 2013.

RESULTS

Statin users had a significantly higher risk of HZ than non-statin users: hazard ratio (HR) 1.25 (95% CI, 1.15 to 1.37) (p < .0001). The risk of HZ associated with statins was especially high in the elderly: HR 1.39 (95% CI, 1.12 to 1.73) in the over 70-year-olds (p = 0.003) and HR 1.18 (95% CI, 1.00 to 1.39) in the 60-to-69-year-olds (p = 0.056). Furthermore, there was a significant p for trend in terms of cumulative dose effect between the risk of HZ and the duration of statin use (p < .0001).

CONCLUSIONS

These epidemiologic findings provide strong evidence for an association between HZ and statin use, and suggest that unnecessary statins should be avoided.

Risk of Stroke/Transient Ischemic Attack or Myocardial Infarction with Herpes Zoster: A Systematic Review and Meta-Analysis

BACKGROUND

Accumulating evidence indicates that herpes zoster (HZ) may increase the risk of stroke/transient ischemic attack (TIA) or myocardial infarction (MI), but the results are inconsistent. We aim to explore the relationship between HZ and risk of stroke/TIA or MI and between herpes zoster ophthalmicus (HZO) and stroke.

METHODS

We estimated the relative risk (RR) and 95% confidence intervals (CIs) with the meta-analysis. Cochran's Q test and Higgins I² statistic were used to check for heterogeneity.

RESULTS

HZ infection was significantly associated with increased risk of stroke/TIA (RR = 1.30, 95% CI: 1.17-1.46) or MI (RR = 1.18, 95% CI: 1.07-1.30). The risk of stroke after HZO was 1.91 (95% CI 1.32-2.76), higher than that after HZ. Subgroup analyses revealed increased risk of ischemic stroke after HZ infection but not hemorrhagic stroke. The risk of stroke was increased more at 1 month after HZ infection than at 1-3 months, with a gradual reduced risk with time. The risk of stroke after HZ infection was greater with age less than 40 years than 40-59 years and more than 60 years. Risk of stroke with HZ infection was greater without treatment than with treatment and was greater in Asia than Europe and America but did not differ by sex.

CONCLUSIONS

Our study indicated that HZ infection was associated with increased risk of stroke/TIA or MI, and HZO infection was the most marked risk factor for stroke. Further studies are needed to explore whether zoster vaccination could reduce the risk of stoke/TIA or MI.

A systematic review and meta-analysis on herpes zoster and the risk of cardiac and cerebrovascular events

Background

Patients who develop herpes zoster or herpes zoster ophthalmicus may be at risk for cerebrovascular and cardiac complications. We systematically reviewed the published literature to determine the association between herpes zoster and its subtypes with the occurrence of cerebrovascular and cardiac events.

Methods/Results

Systematic searches of PubMed (MEDLINE), SCOPUS (Embase) and Google Scholar were performed in December 2016. Eligible studies were cohort, case-control, and self-controlled case-series examining the association between herpes zoster or subtypes of herpes zoster with the occurrence of cerebrovascular and cardiac events including stroke, transient ischemic attack, coronary heart disease, and myocardial infarction. Data on the occurrence of the examined events were abstracted. Odds ratios and their accompanying confidence intervals were estimated using random and fixed effects models with statistical heterogeneity estimated with the I² statistic. Twelve studies examining 7.9 million patients up to 28 years after the onset of herpes zoster met our pre-defined eligibility criteria. Random and fixed effects meta-analyses showed that herpes zoster, type unspecified, and herpes zoster ophthalmicus were associated with a significantly increased risk of cerebrovascular events, without any evidence of statistical heterogeneity. Our meta-analysis also found a significantly increased risk of cardiac events associated with herpes zoster, type unspecified.

Conclusions

Our results are consistent with the accumulating body of evidence that herpes zoster and herpes zoster ophthalmicus are significantly associated with cerebrovascular and cardiovascular events.

Herpes Zoster and the Risk of Stroke in Patients With Autoimmune Diseases

OBJECTIVE

Herpes zoster (HZ) is an opportunistic infection caused by varicella-zoster virus and observed with increasing frequency in patients receiving immunosuppressive therapies. The literature has suggested that the risk of stroke may increase shortly after HZ, but little is known about this association in patients with autoimmune diseases, who are at increased risk of both zoster and stroke.

METHODS

Medicare data from January 1, 2006 through December 31, 2013 were used to identify patients with autoimmune diseases. The outcome of interest was hospitalized stroke. The hypothesis tested was that the incidence of stroke immediately following HZ is increased compared to the incidence of stroke at later time points. Secondary analyses included assessment of the impact of antiviral therapy on subsequent stroke, as well as the influence of varicella-zoster virus-related complications on stroke incidence.

RESULTS

The crude incidence of stroke ranged from a high of 2.30 per 100 patient-years (95% confidence interval [95% CI] 0.96-5.52) within 90 days of HZ in patients who had HZ-related cranial nerve complications and did not receive treatment to a low of 0.87 per 100 patient-years (95% CI 0.75-1.02) at 366-730 days in those without complication who received antiviral treatment. After multivariable adjustment for multiple stroke-related factors, the overall incidence rate ratio (IRR) for stroke in the first 90 days after HZ was 1.36 (95% CI 1.10-1.68) compared to stroke occurring at 366-730 days after HZ. The risk was greater for patients with zoster and cranial nerve complications (IRR 2.08 [95% CI 0.99-4.36]). Prompt antiviral therapy was associated with lower incidence of subsequent stroke (IRR 0.83 [95% CI 0.70-0.98]).

CONCLUSION

In patients with autoimmune diseases, incident HZ was associated with as much as a 2-fold increased risk of stroke in the subsequent few months. These data underscore the urgency of developing strategies for reducing the risk of varicella-zoster virus.

A meta-analysis of stroke risk following herpes zoster infection

Background

The incidence of herpes zoster (HZ) is increasing and poses a significant health concern to aging populations. Several studies suggest an increased risk of stroke following zoster infection, but the results are conflicting. We conducted a systematic review and meta-analysis to determine if stroke risk is increased following HZ infection.

Methods

A search of MEDLINE, EMBASE, Google scholar, Web of Science, CAB Direct, Cumulative Index to Nursing and Allied Health Literature, and Evidence Based Medicine Reviews was conducted for observational studies of adults with HZ infection that examined stroke and TIA risk from January 1, 1966 to May 31, 2016. Adjusted relative risks reported for similar follow-up durations were pooled across studies separately using random-effects inverse variance models.

Results

Data were pooled from nine studies. Relative risk for stroke after zoster was 1.78 (95% CI 1.70–1.88) for the first month following herpes zoster, dropping progressively to 1.43 (95% CI 1.38–1.47) after 3 months, to 1.20 (95% CI 1.14–1.26) after 1 year. We found that stroke risk increases by a larger margin during the first month after a herpes zoster ophthalmicus episode: relative risk 2.05 (95% CI 1.82–2.31). The risk remains elevated one year after the acute episode.

Conclusions

Herpes zoster is an established risk factor for increasing the risk of stroke, especially shortly after infection. Vaccination should be encouraged in patients at high risk of cardiovascular disease.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2278-z) contains supplementary material, which is available to authorized users.

Stroke Associated With Varicella Zoster Vasculopathy: A Clinicoradiological Profile of 3 Patients

INTRODUCTION

Varicella zoster (VZ) vasculopathy is a rare but well recognized cause of stroke. In the absence of zoster rash and infection in remote past, the disease can pose diagnostic challenge. We report 3 cases of anterior circulation stroke occurring in close temporal relation to VZ. Their clinical, radiologic, and angiographic features are discussed.

CASE REPORT

Of the 3 patients, 2 had stroke within a span of 4 to 6 weeks of herpes zoster ophthalmicus while the third patient had zoster of cervical dermatome. Magnetic resonance imaging revealed acute subcortical infarcts in 2, while 1 patient showed acute on chronic infarct in left middle cerebral artery territory. The magnetic resonance angiography was abnormal in 2 patients while it was normal in third. All the patients were treated with acyclovir and antiplatelets with good recovery in 2.

CONCLUSIONS

VZ associated vasculopathy may have diverse clinical profile and neuroimaging features. It should be considered as an important and treatable cause of stroke in appropriate clinical settings.

Risk of Stroke in Patients with Herpes Zoster: A Systematic Review and Meta-Analysis

BACKGROUND

Several observational studies suggest that herpes zoster (HZ) may increase the risk of stroke, but the results are inconsistent. Our study was designed to assess the association between HZ and the risk of stroke through a meta-analysis of cohort studies.

METHODS

The electronic databases PubMed and EMBASE were searched from inception to May 31, 2016 to identify relevant cohort studies that assess the risk of stroke in patients with HZ. Reference lists were also reviewed to identify potential studies. The random-effects model and fixed-effects model were used to calculate the summary relative risks (RRs) with 95% confidence intervals (CIs).

RESULTS

Six cohort studies (251,076 HZ patients and 8462 cases of stroke) were identified in the study. The result showed that HZ was significantly correlated with increased risk of stroke, and the pooled RR was 1.36 (95% confidence interval [CI]: 1.10, 1.67) (P = .004). In the subgroup analysis, the significant association was observed except for stroke type (hemorrhage group). In the sensitivity analysis, excluding 1 study, the pooled RR was 1.45 (95% CI: 1.17, 1.80) (P = .001) for HZ, and 4.42 (95% CI: 2.75, 7.11) (P = .000) for herpes zoster ophthalmicus. Considerable heterogeneity was observed in our study.

CONCLUSION

Our study furnishes evidence of a positive association between HZ and the risk of stroke.

The Short- and Long-Term Risk of Stroke after Herpes Zoster: A Meta-Analysis

Background

Accumulating evidence indicates that stroke risk may be increased following herpes zoster. The aim of this study is to perform a meta-analysis of current literature to systematically analyze and quantitatively estimate the short and long-term effects of herpes zoster on the risk of stroke.

Methods

Embase, PubMed and Cochrane library databases were searched for relevant studies up to March 2016. Studies were selected for analysis based on certain inclusion and exclusion criteria. Relative risks with 95% confidence interval (CI) were extracted to assess the association between herpes zoster and stroke.

Results

A total of 8 articles were included in our analysis. The present meta-analysis showed that the risks of stroke after herpes zoster were 2.36 (95% CI: 2.17–2.56) for first 2 weeks, 1.56 (95% CI: 1.46–1.66) for first month, 1.17 (95% CI: 1.13–1.22) for first year, and 1.09 (95% CI: 1.02–1.16) for more than 1 year, respectively.

Conclusion

The results of our study demonstrated that herpes zoster was associated with a higher risk of stroke, but the risks decreased along with the time after herpes zoster.