Acute respiratory tract infections: A potential trigger for the acute coronary syndrome

Figures & data

Table I. Outcome studies: respiratory infections and risk of acute cardiovascular events.

Author, year (ref)	Population	Number	Period (yrs)	Parameters	Conclusions	Findings
Pesonen, 1981 18	Patients with MI and controls	99	1	ARTI versus MI	↑ ARTI within 7 days prior to MI	1 day: P<0.05 3 days: P<0.01 7 days: P<0.05
Tillett, 1983 25	Cohort (UK)	120,100	10	Influenza epidemic versus death CVD	↑ Mortality CVD	31% of excess deaths (P<0.05)
Spodick, 1984 7	Patients with MI/controls	300	1	Symptoms ARTI versus MI	↑ Symptoms of ARTI prior to MI (<14 days)	OR = 6.35
Marshall, 1988 27	New Zealand (cohort)	±5000 (deaths)	12	ARTI versus death of CVD	↑ Mortality CVD from ARTI (patients ⩾55 years old)	Male: OR: 4.5 (±1.8) female: OR: 2.7 (±1.7)
Mattila, 1989 29	Patients with MI and controls with stable angina	70	1	ARTI (symptoms and workup) versus MI	↑ Symptoms of ARTI prior to MI; workup for ARTI: no difference	P<0.05
Meier, 1998 10	Patients with MI and controls	9,571	2	ARTI (symptoms <10 days prior to event) versus MI	↑ Risk for MI	OR: 3.6 (2.2–5.7)
Smeeth, 2004 11	Patients with first MI, first CVA, and controls	39,909	14	ARTI versus MI and CVA	↑ MI and CVA (<14 days after ARTI	MI: OR = 4.95 (4.43–5.53) CVA: OR = 3.19 (2.81–3.62)
Dvorakova, 2004 35	Patients with first MI	65,000	24	Influenza versus MI	↑ MI during influenza epidemic	P<0.05
Madjid, 2007 36	Autopsies (death with or without infection)	27	11	MI, CAD, and acute systemic infections <2 weeks	↑ Macrophages and T cells in coronary artery wall; infection associated with ACS	P<0.05; P<0.05

ARTI = acute respiratory tract infections; ACS = acute coronary syndrome; CVA = cerebrovascular accident; CVD = cardiovascular disease; CAD = coronary artery disease; HTN = hypertension; IHD = ischemic heart disease; MI = myocardial infarction; OR = odds ratio.

Table II. Outcome studies: influenza vaccination and risk of acute cardiovascular events.

Author, year (ref)	Population	n	Period (yrs)	Parameters	Conclusions	Odds ratio (95% CI)
Naghavi, 2000 37	CAD patients	218	1	Vaccination versus MI	↓ Recurrent nonfatal MI	0.33 (0.13–0.82)
Siscovick, 2000 38	CAD patients	891	8	Vaccination versus MI	↓ Cardiac arrest	0.51 (0.33–0.79)
Nichol, 2003 39	Cohort	286,383	2	Vaccination versus CVD	↓ IHD	0.80 (0.70–0.91)
Gurfinkel, 2004 40	Randomized control study (patients with MI, unstable angina)	301	1	Vaccination versus subsequent MI, CVD death	↓ CVD death; ↓ CVD death/nonfatal MI/severe IHD	0.25 (0.07–0.86); 0.50 (0.29–0.85)
Smeeth, 2004 11	Patients with first MI, first CVA, and controls	41,407	14	Vaccination versus MI	↓ MI	0.68 (0.56–0.84)
Heffelfinger, 2006 41	Case‐control study	2,485	6	Vaccination versus MI	No difference between groups	0.98 (0.75–1.30)

CVD = cardiovascular disease; CAD = coronary artery disease; HTN = hypertension; IHD = ischemic heart disease; MI = myocardial infarction.

Table III. Various mechanisms by which acute infections affect arterial inflammation and atherosclerosis.

Effect	Mechanism
Plaque rupture	Acute infections and inflammation cause plaque rupture and thereby precipitating acute coronary events 70, 71.
Endothelial dysfunction	Acute infections cause endothelial dysfunction 72, 73, partly due to increased serum glucose and triglycerides levels 74, 75. Dysfunctional endothelium leads to coronary vasoconstriction, attachment of leukocytes and reduces its fibrinolytic and anticoagulant capacity 76.
↑ Coagulability	Acute infections increase the coagulability of circulating blood via leukocytosis, platelet aggregation, fibrinogen, and C‐reactive protein, decrease in antithrombin‐III, and activation of circulating leukocytes 77, 78.
↑ Plasma viscosity	Plasma viscosity can be increased during fever, especially in combination dehydration 79.
Tachycardia	An increase in heart rate in response to fever increases the statistical chance that a given cardiac contraction will lead to mechanical rupture of the plaque 80.
Psychological stress	Infection, like other illnesses, may trigger depression or anxiety, which are independent predictors of MI 81.

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