Association of herpes zoster vaccination and cardiovascular risk in patients with diabetes: long-term insights from a retrospective cohort study

Abstract

Objectives: Herpes zoster (HZ) infection is associated with a higher risk of major adverse cardiovascular events (MACE), including stroke and coronary artery disease (CAD). Patients with diabetes are at an increased risk of MACE, highlighting the importance of studying this population to assess the potential protective effects of HZ vaccination. This study aims to investigate the risk of MACE after HZ vaccination in patients with diabetes.

Design: Retrospective cohort study.

Setting: Community-based population in the USA.

Participants: Using the TriNetX database, the study included 4.9 million patients with diabetes from 2006 to 2022. It established two cohorts: 68 178 patients in the HZ vaccination (comprising any HZ vaccine, Shingrix or Zostavax) and 4 835 246 patients in the no HZ vaccination group. After excluding patients with a history of MACE, immune disease and complications of HZ prior to the index date, the study cohort was reduced to 45 960 patients. Propensity score matching, accounting for age, sex, race, socio-economic status and disease comorbidities, was conducted to minimise study bias.

Interventions: HZ vaccination.

Outcome measures: MACE outcomes are defined as the first occurrence of CAD or stroke. Comparative risk analysis was conducted using HRs.

Results: Post matching, the mean patient age was 63.5 years, with 49.2% females. The incidence rate of MACE was lower among vaccinated patients compared with unvaccinated individuals, with an HR of 0.76 (0.72-0.79). For secondary endpoints, the HRs were 0.73 (0.69-0.78) for CAD, 0.79 (0.74-0.84) for stroke and 0.54 (0.52-0.57) for all-cause mortality. These protective effects remained consistent across different age groups, sexes and diabetes types, supporting the potential benefit of HZ vaccination in reducing cardiovascular risk.

Conclusions: HZ vaccination is associated with a lower risk of MACE in patients with diabetes. Further prospective studies are critically needed to confirm this finding.

Keywords: DIABETES & ENDOCRINOLOGY; INTERNAL MEDICINE; Vaccination.

Figure 1. Detailed flowchart illustrating the division of participants into four groups based on herpes zoster (HZ) vaccination status. Matching of any HZ-vaccinated cases to no-vaccinated controls yielded 45 958 pairs (model 1). Matching Shingrix-vaccinated to no-vaccinated controls resulted in 14 142 pairs (model 2), Zostavax-vaccinated to no-vaccinated controls yielded 11 285 pairs (model 3) and Shingrix vs Zostavax vaccination resulted in 10 505 pairs (model 4). MAZE, major adverse cardiovascular events; PSM, propensity score matching.