Associations between Pneumococcal Vaccinationand Adverse Outcomes in Patients with Suspected Acute Coronary Syndrome


Background: Although pneumococcal vaccination prevents the most common pneumonia of bacterial etiology, its associations without comes of Acute Coronary Syndrome (ACS) are unknown. Methods: This is a prospective cohort study of 1436 patients hospitalized with suspected ACS/non-ST elevation MI that were eligible for pneumococcal vaccination. Primary outcomes were death and subsequent Myocardial Infarction (MI) within 6-months of the index hospitalization. We used Cox regression to assess associations between pneumococcal vaccination and outcomes, adjusting for influenza vaccination and relevant clinical covariates. We also utilized propensity scores to adjust for potential confounding. Results: Overall, 937 (65.3%) patients received pneumococcal vaccination either prior to or during the index hospitalization. Unvaccinated patients had higher mortality (26.9% vs. 7.9%; p < 0.001) and non-significantly higher frequency of subsequent MI (7.4% vs. 3.5%; p = 0.06).Compared to patients who did not receive either pneumococcal or influenza vaccination, the unadjusted Hazard Ratio (HR) of death was significantly lower for those who received only pneumococcal vaccination (HR = 0.13; 95% CI 0.07 - 0.23) or both vaccinations (HR = 0.66, 95% CI 0.47 - 0.92), and significantly higher for patients who received only influenza vaccination (HR = 1.88, 95% CI 1.33 - 2.64). The corresponding HRs and 95% CIs for subsequent MI were 0.58 (95% CI 0.32 - 1.03) for pneumococcal vaccination only, 0.41 (95% CI 0.21 - 0.80) for both vaccinations and 0.97 (95% CI 0.48 - 1.95) for influenza vaccination alone. These remained unchanged after covariate or propensity score adjustment. Conclusions: Among patients hospitalized with suspected ACS, pneumococcal vaccination, with or without influenza vaccination, was associated with significantly lower risk of mortality within 6 months.

Share and Cite:

M. Zahid, I. Singla, C. B. Good, R. A. Stone, S. Kim, M. J. Fine and A. F. Sonel, "Associations between Pneumococcal Vaccinationand Adverse Outcomes in Patients with Suspected Acute Coronary Syndrome," Advances in Infectious Diseases, Vol. 2 No. 4, 2012, pp. 122-134. doi: 10.4236/aid.2012.24021.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] F. A. Spencer, R. J. Goldberg, R. C. Becker and J. M. Gore, “Seasonal Distribution of Acute Myocardial Infarction in the Second National Registry of Myocardial Infarction,” Journal of the American College of Cardiology, Vol. 31, No. 6, 1998, pp. 1226-1233. doi:10.1016/S0735-1097(98)00098-9
[2] N. Rumana, Y. Kita, T. C. Turin, Y. Murakami, H. Sugihara, et al., “Seasonal Pattern of Incidence and Case Fatality of Acute Myocardial Infarction in a Japanese Population (from the Takashima AMI Registry, 1988 to 2003),” American Journal of Cardiology, Vol. 102, No. 10, 2008, pp. 1307-1311. doi:10.1016/j.amjcard.2008.07.005
[3] L. Smeeth, S. L. Thomas, A. J. Hall, R. Hubbard, P. Farrington, et al., “Risk of Myocardial Infarction and Stroke after Acute Infection or Vaccination,” The New England Journal of Medicine, Vol. 351, No. 25, 2004, pp. 2611-2618. doi:10.1056/NEJMoa041747
[4] G. N. Fredrikson, B. Hedblad, G. Berglund, R. Alm, M. Ares, et al., “Identification of Immune Responses against Aldehyde-Modified Peptide Sequences in Apob Associated with Cardiovascular Disease,” Arteriosclerosis, Thrombosis, and Vascular Biology, Vol. 23, No. 5, 2003, pp. 872-878. doi:10.1161/01.ATV.0000067935.02679.B0
[5] K. J. Mattila, V. V. Valtonen, M. S. Nieminen and S. Asikainen, “Role of Infection as a Risk Factor for Atherosclerosis, Myocardial Infarction, and Stroke,” Clinical Infectious Diseases, Vol. 26, No. 3 1998, pp. 719-734. doi:10.1086/514570
[6] H. Uzui, A. Harpf, M. Liu, T. M. Doherty, A. Shukla, et al., “Increased Expression of Membrane Type 3-Matrix Metalloproteinase in Human Atherosclerotic Plaque: Role of Activated Macrophages and Inflammatory Cytokines,” Circulation, Vol. 106, No. 24, 2002, pp. 3024-3030. doi:10.1161/01.CIR.0000041433.94868.12
[7] C. Buono, C. J. Binder, G. Stavrakis, J. L. Witztum, L. H. Glimcher, et al., “T-Bet Deficiency Reduces Atherosclerosis and Alters Plaque Antigen-Specific Immune Responses,” Proceedings of the National Academy of Sciences of the United States of America, Vol. 102, No. 5, 2005, pp. 1596-1601. doi:10.1073/pnas.0409015102
[8] P. K. Shah, K. Y. Chyu, G. N. Fredrikson and J. Nilsson, “Immunomodulation of Atherosclerosis with a Vaccine,” Nature Clinical Practice Cardiovascular Medicine, Vol. 2, No. 12 2005, pp. 639-646. doi:10.1038/ncpcardio0372
[9] C. P. Cannon, E. Braunwald, C. H. McCabe, J. T. Grayston, B. Muhlestein, et al., “Antibiotic Treatment of Chlamydia Pneumoniae after Acute Coronary Syndrome,” The New England Journal of Medicine, Vol. 352, No. 16, 2005, pp. 1646-1654. doi:10.1056/NEJMoa043528
[10] J. B. Muhlestein, J. L. Anderson, J. F. Carlquist, K. Salunkhe, B. D. Horne, et al., “Randomized Secondary Prevention Trial of Azithromycin in Patients with Coronary Artery Disease: Primary Clinical Results of the Academic Study,” Circulation, Vol. 102, No. 15, 2000, pp. 1755-1760. doi:10.1161/01.CIR.102.15.1755
[11] M. Naghavi, Z. Barlas, S. Siadaty, S. Naguib, M. Madjid, et al., “Association of Influenza Vaccination and Reduced Risk of Recurrent Myocardial Infarction,” Circulation, Vol. 102, No. 25 2000, pp. 3039-3045. doi:10.1161/01.CIR.102.25.3039
[12] E. P. Gurfinkel, R. L. de la Fuente, O. Mendiz and B. Mautner, “Influenza Vaccine Pilot Study in Acute Coronary Syndromes and Planned Percutaneous Coronary Interventions: The FLU Vaccination Acute Coronary Syndromes (FLUVACS) Study,” Circulation, Vol. 105, No. 18, 2002, pp. 2143-2147. doi:10.1161/01.CIR.0000016182.85461.F4
[13] C. J. Binder, S. Horkko, A. Dewan, M. K. Chang, E. P. Kieu, et al., “Pneumococcal Vaccination Decreases Atherosclerotic Lesion Formation: Molecular Mimicry between Streptococcus Pneumoniae and Oxidized LDL,” Nature Medicine, Vol. 9, No. 6, 2003, pp. 736-743. doi:10.1038/nm876
[14] S. A. Moberley, J. Holden, D. P. Tatham and R. M. Andrews, “Vaccines for Preventing Pneumococcal Infection in Adults,” Cochrane Database of Systematic Reviews, 2008.
[15] A. Huss, P. Scott, A. E. Stuck, C. Trotter and M. Egger, “Efficacy of Pneumococcal Vaccination in Adults: A Meta-Analysis,” Canadian Medical Association Journal, Vol. 180, No. 1, 2009, pp. 48-58. doi:10.1503/cmaj.080734
[16] M. J. Fine, M. A. Smith, C. A. Carson, F. Meffe, S. S. Sankey, et al., “Efficacy of Pneumococcal Vaccination in Adults. A Meta-Analysis of Randomized Controlled Trials,” Archives of Internal Medicine, Vol. 154, No. 23, 1994, pp. 2666-2677.
[17] D. M. Musher, A. M. Rueda, A. S. Kaka and S. M. Mapara, “The Association between Pneumococcal Pneumonia and Acute Cardiac Events,” Clinical Infectious Diseases, Vol. 45, No. 2, 2007, pp. 158-165. doi:10.1086/518849
[18] V. F. Corrales-Medina, K. N. Suh, G. Rose, J. A. Chirinos, S. Doucette, et al., “Cardiac Complications in Patients with Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis of Observational Studies,” PLoS Medicine, Vol. 8, 2011, p. e1001048.
[19] F. Lamontagne, M. P. Garant, J. C. Carvalho, L. Lanthier, M. Smieja, et al., “Pneumococcal Vaccination and Risk of Myocardial Infarction,” Canadian Medical Association Journal, Vol. 179, No. 8, 2008, pp. 773-777. doi:10.1503/cmaj.070221
[20] H. F. Tseng, J. M. Slezak, V. P. Quinn, L. S. Sy, S. K. Van den Eeden, et al., “Pneumococcal Vaccination and Risk of Acute Myocardial Infarction and Stroke in Men,” The Journal of the American Medical Association, Vol. 303, No. 17, 2010, pp. 1699-1706. doi:10.1001/jama.2010.529
[21] J. P. Nuorti and C. G. Whitney, “Updated Recommendations for Prevention of Invasive Pneumococcal Disease among Adults Using the 23-Valent Pneumococcal Polysaccharide Vaccine (PPS V23),” Morbidity and Mortality Weekly Report, Vol. 59, No. 34, 2010, pp. 1102-1106.
[22] C. P. Cannon, A. Battler, R. G. Brindis, J. L. Cox, S. G. Ellis, et al., “American College of Cardiology Key Data Elements and Definitions for Measuring the Clinical Management and Outcomes of Patients with Acute Coronary Syndromes. A Report of the American College of Cardiology Task Force on Clinical Data Standards (Acute Coronary Syndromes Writing Committee),” Journal of the American College of Cardiology, Vol. 38, No. 7, 2001, pp. 2114-2130.
[23] A. Phrommintikul, S. Kuanprasert, W. Wongcharoen, R. Kanjanavanit, R. Chaiwarith, et al., “Influenza Vaccination Reduces Cardiovascular Events in Patients with Acute Coronary Syndrome,” European Heart Journal, Vol. 32, No. 14, 2011, pp. 1730-1735. doi:10.1093/eurheartj/ehr004
[24] I. F. Hung, A. Y. Leung, D. W. Chu, D. Leung, T. Cheung, et al., “Prevention of Acute Myocardial Infarction and Stroke among Elderly Persons by Dual Pneumococcal and Influenza Vaccination: A Prospective Cohort Study,” Clinical Infectious Diseases, Vol. 51, No. 9, 2010, pp. 1007-1016. doi:10.1086/656587
[25] A. N. Siriwardena, S. M. Gwini and C. A. Coupland, “Influenza Vaccination, Pneumococcal Vaccination and Risk of Acute Myocardial Infarction: Matched Case-Control Study,” Canadian Medical Association Journal, Vol. 182, No. 15, 2010, pp. 1617-1623. doi:10.1503/cmaj.091891

Copyright © 2024 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.