Risk of herpes zoster in patients with cardiovascular diseases: a systematic literature review and meta-analysis

Background Herpes zoster (HZ, shingles) is a common and painful disease associated with long-term and difficult-to-manage complications, such as postherpetic neuralgia (PHN). HZ is caused by the reactivation of the varicella-zoster virus. The risk of the disease increases with age, in individuals who are immunocompromised/ immunosuppressed, and in patients with certain comorbidities. Purpose This is the first systematic literature review (SLR) to focus on assessing the risk of HZ and PHN in patients with cardiovascular disease (CVD). Methods A global SLR (2004–2024, Medline, Embase, LILACS) and meta-analysis was conducted of clinical trials and observational studies on CVD as a risk factor for HZ and PHN. The primary objective was to identify the relative risk (RR) of HZ in patients (≥18 years-of-age, YOA) with CVD (overall, by type of CVD) versus no CVD. The secondary objective was to identify the RR of HZ (≥50 YOA) and PHN in patients (≥18 YOA and ≥50 YOA) with CVD versus no CVD. Results The SLR included 27 observational studies on CVD as a risk factor for HZ and PHN, of which 11 were eligible for inclusion in the meta-analysis on HZ RR (≥18 YOA), five on HZ RR (≥50 YOA) and three on PHN RR (≥18 YOA). A meta-analysis on PHN RR (≥50 YOA) was not feasible. Patients with CVD (≥18 YOA and ≥50 YOA) had a significantly higher risk of HZ (pooled RR 1.27, 95% confidence interval [CI, 1.14–1.40] and 1.14 [1.03–1.27], respectively) than those without CVD (Figure 1). In subgroups by type of CVD, HZ risk was significantly higher in patients (≥18 YOA) with coronary heart disease (RR 1.17 [1.10–1.24]) and heart failure (RR 1.25 [1.05–1.49]) versus patients without these conditions. In patients with stroke, a non-significant increase was seen (RR 1.33 [95% CI 0.96–1.84]). Additionally, patients (≥18 YOA) with any CVD were 75% more likely to develop PHN compared with those without CVD (RR 1.75 [1.29–2.38]) (Figure 2). Conclusions These findings provide evidence that patients with CVD can have an increased risk of developing HZ and PHN. Effective vaccines to prevent HZ are available for adults, including those with comorbidities, and should be considered as part of integrated cardiovascular care.