Herpes Zoster and Cardiovascular Disease

Herpes zoster (HZ), the reactivation of latent varicella zoster virus (VZV), is increasingly being recognized as more than a dermatologic and neurologic disease. In recent years, multiple meta-analyses have linked HZ infection to a clinically significant increase in the risk of stroke, myocardial infarction (MI), and other major adverse cardiovascular events, an effect that is most pronounced in the first days to weeks following the acute HZ infection, with a gradual decrease in risk over time. The proposed mechanism centers on a productive viral infection of arterial walls, a phenomenon described as VZV vasculopathy, with transmural inflammation, endothelial dysfunction, and thrombosis, all superimposed on the systemic inflammatory and prothrombotic state that accompanies the acute HZ infection. The evidence for an association between HZ infection and cardiovascular events has grown stronger with recent multiple large cohort studies demonstrating that patients who received HZ vaccination had a significantly lower rate of major adverse cardiovascular events, MI, stroke, heart failure, and arrhythmia. However, while these cohort studies have helped researchers identify the potential association of HZ vaccination and reduced cardiovascular risk, there remains a need for a randomized controlled trial to establish causality between these factors. Currently underway, a randomized controlled trial is directly evaluating whether HZ vaccination in a large population lowers the incidence of cardiovascular events, including stroke, MI, and cardiovascular death. Nevertheless, the 2026 American College of Cardiology guidelines now include a strong recommendation for HZ vaccination given the growing body of evidence regarding the association of HZ vaccination with cardiovascular events.