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

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.