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Meta-Analysis
. 2025 Aug 14;121(9):1330-1344.
doi: 10.1093/cvr/cvaf092.

Systematic review and meta-analysis of respiratory viral triggers for acute myocardial infarction and stroke

Tu Q Nguyen  1   2 , Diana Vlasenko  2 , Aishwarya N Shetty  2 , Eric Zhao  2 , Christopher M Reid  3   4 , Hazel J Clothier  1   2   5 , Jim P Buttery  1   2   6
Affiliations
Meta-Analysis

Systematic review and meta-analysis of respiratory viral triggers for acute myocardial infarction and stroke

Tu Q Nguyen et al. Cardiovasc Res. .

Abstract

Respiratory viral infections may trigger acute cardiovascular events. However, relative pathogen-specific associations are poorly understood, limiting optimal preventive recommendations. The aim of this study was to systematically review the association between respiratory viruses with two primary outcomes, acute myocardial infarction (AMI) and stroke. We searched MEDLINE, PubMed, Embase, Cochrane, and Web of Science, from database inception to 26 August 2024. Analytical epidemiological studies of respiratory viruses identified by laboratory-confirmatory testing, involving human participants of any age in any country, were eligible for inclusion. Risk of bias was assessed using the Cochrane Collaboration approach. Data from studies of sufficient quality and homogeneity were pooled using a random-effects model. Certainty of the evidence was assessed for each identified viral trigger. Of 11 017 articles identified, we included a total of 48 studies published between 1978 and 2024. All were observational studies, of which 28 were suitable for quantitative synthesis. There was moderate-certainty evidence that influenza triggers AMI (incidence rate ratio, 5.37; 95% CI, 3.48-8.28; I2 = 69.4%). We found high-certainty evidence that influenza triggers stroke-influenza was associated with a 4.7-fold increased risk of stroke within the first 28 days following infection (incidence rate ratio, 4.72; 95% CI, 3.78-5.90; I2 = 0%). SARS-CoV-2 and cytomegalovirus may trigger stroke, while SARS-CoV-2, respiratory syncytial virus, and Coxsackie B were also identified as potential triggers for AMI. In this systematic review and meta-analysis, the findings suggest that common, often vaccine-preventable, respiratory viral infections are associated with an increased risk of acute cardiovascular events.

Keywords: Acute myocardial infarction; Respiratory virus; Stroke; Systematic review; Vaccine preventable.

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Conflict of interest statement

Conflict of interest: All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. J.P.B. reports participation on a data and safety monitoring board for the Centre for Epidemic Preparedness and Innovation, academic institutions, and GSK, for which his employing institution (Murdoch Children’s Research Institute) is compensated for his time, as well as financial support for serving on the Australian Therapeutic Goods Administration Advisory Committee on Vaccines, outside the submitted work. All other authors report no potential conflicts.

Figures

Graphical Abstract
Graphical Abstract
Figure 1
Figure 1
PRISMA flow diagram. Of 344 full-text articles assessed for eligibility, 54 reports of studies that met the inclusion criteria; multiple reports from the same study were merged, leaving 48 unique records. Of these, 18 studies at very high overall risk of bias and two studies using self-reported acute myocardial infarction (AMI) diagnosis were excluded from quantitative synthesis; thus 28 studies were selected for quantitative synthesis.
Figure 2
Figure 2
Risk of bias of included studies based on ROBINS-E domains.
Figure 3
Figure 3
Forest plot for the effect of respiratory viral infection triggers on acute myocardial infarction (n = 19 studies). The dotted vertical line represents the line of no effect (effect size = 1). Boxes indicate reported estimates with whiskers representing 95% confidence intervals. Diamonds indicate pooled estimates from meta-analysis. HR, hazard ratio; IRR, incidence rate ratio; OR, odds ratio.
Figure 4
Figure 4
Forest plot for the effect of respiratory viral infection triggers on stroke (n = 18 studies). The dotted vertical line represents the line of no effect (effect size = 1). Boxes indicate reported estimates with whiskers representing 95% confidence intervals. Diamonds indicate pooled estimates from meta-analysis. HR, hazard ratio; IRR, incidence rate ratio; OR, odds ratio; RR, relative risk.
See this image and copyright information in PMC

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