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Herpes zoster as a risk factor for stroke and TIA

Herpes zoster (HZ) is an independent risk factor for vascular disease in the UK population, according to a study published recently in Neurology.1 This is particularly the case for stroke, transient ischaemic attack (TIA), and myocardial infarction (MI) in subjects affected before the age of 40 years.

A retrospective cohort of 106,601 HZ cases and 213,202 controls matched for age, sex, and general practice was identified from the THIN (The Health Improvement Network) general practice database. Cox proportional hazard models were used to examine the risks of stroke, TIA, and MI in cases and controls, adjusted for vascular risk factors, including body mass index >30 kg/m2, smoking, cholesterol >6.2 mmol/L, hypertension, diabetes, ischemic heart disease, atrial fibrillation, intermittent arterial claudication, carotid stenosis, and valvular heart disease, up to 24 years (median 6.3 years) after HZ occurrence.

Risk factors for vascular disease were significantly increased in cases of HZ compared with controls. Adjusted hazard ratios (AHRs) for TIA and MI but not stroke were increased in all patients with HZ (AHR [95% confidence interval]: 1.15 [1.09–1.21] and 1.10 [1.05–1.16], respectively). However, stroke, TIA, and MI were increased in cases whose HZ occurred when they were younger than 40 years (AHR [95% confidence interval]: 1.74 [1.13–2.66], 2.42 [1.34–4.36], 1.49 [1.04–2.15], respectively). Subjects younger than 40 years were significantly less likely to be asked about vascular risk factors than were older patients (p < 0.001).

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Professor Judith Breuer (University College London)

A reduction in risk of stroke after the occurrence of HZ was found in older patients, which might be explained by better ascertainment of vascular risk factors and earlier intervention, the authors suggest.

Speaking to BJC Arrhythmia Watch, lead author Professor Judith Breuer (University College London) said: “The mechanism of stroke up to 24 years after shingles is not entirely clear. We do know that stroke can be a complication of acute ophthalmic zoster. In these cases the virus can be found in vascultic lesions in cerebral arteries. Similar varicella zoster virus (VZV) positive cerebral lesions can be found in subjects with risk factors for shingles but with no history. This together with evidence that asymptomatic salivary shedding of VZV is more common in patients with shingles, suggests that both asymptomatic reactivation and symptomatic shingles can lead in some cases to vasculitis of cerebral arteries and stroke.”

“It is possible that this occurs because the virus, at the same time as being shed in saliva, tracks asymptomatically via afferent cranial nerves to cerebral arteries,” Professor Breuer added.

“A take home message for primary care physicians is that patients who present with shingles should be screened and treated for vascular risk factors, which may in itself prevent stroke,” Professor Breuer continued. “At the same time, it may be worth considering vaccinating to prevent shingles in people who present with risk factors for stroke and vascular disease. It should be remembered that currently   the zoster vaccine is only recommended for those aged 70–80 years,” she concluded.


1. Breuer J, Pacou M, Gauthier A, Brown MM, et al. Herpes zoster as a risk factor for stroke and TIA. Neurology 2014;82:206–12.

Published on: April 30, 2014

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