. . . . . . . . . . . . . . . . Pneumococcal vaccination in adults at very high risk or with established cardiovascular disease: systematic review and meta-analysis Miguel Marques Antunes 1 , Gonc¸alo S. Duarte 2,3 , Dulce Brito 4 , Margarida Borges 2,5 , Jo~ ao Costa 2,3,5 , Joaquim J. Ferreira 2,3,6 , Fausto J. Pinto 4 , and Daniel Caldeira 2,3,4 * 1 Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal; 2 Laborato´rio de Farmacologia Clı ´nica e Terapeˆutica, Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal; 3 Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal; 4 Servic¸o de Cardiologia, Hospital Universita´rio de Santa Maria (CHULN), CAML, Centro Cardiovascular da Universidade de Lisboa — CCUL, Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal; 5 Centro de Estudos de Medicina Baseada na Evideˆncia, Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal; and 6 CNS—Campus Neurolo´gico Se´nior, Bairro de Santo Anto´nio, N. 47 2560-280 Torres Vedras, Portugal Received 16 March 2020; revised 28 March 2020; editorial decision 1 April 2020; accepted 1 April 2020; online publish-ahead-of-print 7 April 2020 Aims There are several guidelines that recommend pneumococcal vaccination (PPSV23 and/or PCV13) in adults with a history of cardiovascular disease (established heart failure, coronary disease, and cerebrovascular disease) or at a very high risk of cardiovascular disease. However, there is no randomized controlled trial (RCT) systematic review that evaluates the impact of vaccination on all-cause mortality compared to no vaccination in this particular popula- tion. Our objective is to conduct a systematic review and meta-analysis of the impact of pneumococcal vaccination in the referred population. ................................................................................................................................................................................................... Methods and results We searched CENTRAL and MEDLINE for relevant RCTs and observational studies. Data were screened, extracted, and appraised by two independent reviewers. We pooled results using a random effects model, and used hazard ratios (HRs) with 95% confidence intervals (CIs) to assess measure of effect. The primary outcome was all-cause mortality and we assessed the confidence in the evidence using the GRADE framework. No RCTs were found. Seven observational studies were included for analyses. Pooled results from five studies enrolling a total of 163 756 participants showed a significant decrease in all-cause mortality (HR 0.78, 95% CI 0.73–0.83, very low confidence), without statistically significant heterogeneity (v 2 test P = 0.21; I 2 = 32%). ................................................................................................................................................................................................... Conclusions Pneumococcal vaccination was associated with a 22% decrease of all-cause mortality in patients with cardiovascular disease or at a very high cardiovascular risk. However, limitations due to study design and the serious risk of bias in three of the included studies leads to a decreased level of result confidence.                                                                                                                                                                                                                     Keywords Pneumococcal vaccine • Myocardial infarction • Stroke • Diabetes • Dialysis • Prevention Introduction Cardiovascular diseases are the leading causes of death worldwide and the burden disease reduction relies on risk factor management and treatment. 1 Some data suggest that inflammation may play a role in the development of acute cardiovascular diseases. 2,3 Infectious dis- eases are one of the main causes of inflammation, and acute respira- tory infections are known to be a trigger of cardiovascular events, 4,5 leading to de novo events such as myocardial infarction (MI), 6 or to ex- acerbation of comorbid cardiovascular conditions such as heart * Corresponding author. Tel: þ351 21 797 34 53, Email: dgcaldeira@hotmail.com Published on behalf of the European Society of Cardiology. All rights reserved. VC The Author(s) 2020. For permissions, please email: journals.permissions@oup.com. European Heart Journal - Quality of Care and Clinical Outcomes (2021) 7, 97–106 ORIGINAL ARTICLE doi:10.1093/ehjqcco/qcaa030 Downloaded from https://academic.oup.com/ehjqcco/article/7/1/97/5817309 by guest on 13 November 2023