Cardiac Events Common in Older, Hospitalized RSV Patients

More than one in five older adults hospitalized for respiratory syncytial virus (RSV) infection experienced an acute cardiac event, an observational study found.

Among 6,248 hospitalized patients 50 or older with laboratory-confirmed RSV infection, 22% experienced an acute cardiac event, most often acute heart failure (16%), reported researchers led by Rebecca Woodruff, PhD, MPH, of the CDC’s Division for Heart Disease and Stroke Prevention in Chamblee, Georgia.

Patients who experienced an acute cardiac event had significantly greater risk for ICU admission (25.8% vs 16.5%; ARR 1.54, 95% CI 1.23-1.93) and in-hospital death (8.1% vs 4.0%; ARR 1.77, 95% CI 1.36-2.31), the study in JAMA Internal Medicine showed.

“Findings of this study suggest acute cardiac events are common among hospitalized older adults with RSV infection and are associated with severe clinical outcomes,” Woodruff and colleagues said. The study also supports previous findings that acute heart failure, coronary events, and atrial fibrillation occur frequently among adults hospitalized with acute respiratory infections, including influenza and SARS-CoV-2, they added.

The prevalence of acute cardiac events was highest in patients with underlying cardiovascular disease (33%). However, acute cardiac events also occurred in 8.5% of patients without underlying heart disease, suggesting that severe RSV infection may precipitate or reveal undiagnosed cardiovascular disease, Woodruff’s team said.

“Another novel finding of this study was the identification of less common but life-threatening events that may occur in the context of RSV infection including ventricular tachycardia, hypertensive crisis, cardiogenic shock, and acute myocarditis,” the researchers wrote.

The findings are particularly relevant in light of the FDA approval of the first two RSV vaccines in 2023 for adults 60 or older, recommended for use via shared decision-making, the study authors noted. Additional candidate vaccines are in clinical trials, and indications may be expanded to adults age 50 to 59. The current study suggests there is a substantial burden of potentially vaccine-preventable disease, they said.

Uptake of the new RSV vaccines has been low, especially compared with the influenza vaccine, said Tracy Wang, MD, of the Patient-Centered Outcomes Research Institute in Washington, D.C., and an associate editor at JAMA Internal Medicine, in an accompanying editorial.

“Prior RSV-related efforts have focused on infants and young children, with many clinicians and patients still unaware of RSV burden of disease and prognosis in older adults,” Wang wrote, adding that older adults are particularly vulnerable due to more preexisting cardiopulmonary comorbidities and lower functional reserve.

In the RSV infection surge last year, the CDC reported up to 10,000 deaths in adults older than 60, with highest risk of severe RSV infections among those living in long-term care facilities or with preexisting lung, heart, or kidney disease or immunosuppression, Wang said.

“This report confirms for RSV a similar severity of cardiovascular adverse outcomes observed with other acute respiratory pathogens, such as influenza and SARS-CoV-2, that stem from infection-related metabolic and myocardial stress at the very least, but may also implicate other, more direct pathogen-mediated effects,” Wang explained.

Pathogen-mediated effects linked with RSV may include increased cytokine-related inflammatory responses that contribute to coronary plaque destabilization, hypercoagulability resulting in an increased risk of thromboses, demand ischemia due to physiologic and metabolic stress from acute respiratory illness, and direct myocardial injury, Woodruff’s group noted.

Woodruff and colleagues’ cross-sectional study analyzed surveillance data from the RSV Hospitalization Surveillance Network, a CDC program that collects information on hospitalized patients with RSV infection detected through clinician-directed laboratory testing. The study included data on adults 50 or older within 12 states over five RSV seasons. The researchers estimated weighted period prevalence and 95% confidence intervals for acute cardiac events.

A notable limitation of the study was the inclusion only of patients with laboratory-confirmed RSV infection, Woodruff’s group said. These patients may have tended to have more severe infection, and therefore more cardiac events, because not all adults with acute respiratory illness are tested for RSV, particularly if their symptoms are mild.

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