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Table 1.  Baseline Characteristics and Vaccination: Description of Cardiovascular Events That Occurred in Hospitals in France Between December 15, 2020, and April 30, 2021
Baseline Characteristics and Vaccination: Description of Cardiovascular Events That Occurred in Hospitals in France Between December 15, 2020, and April 30, 2021
Table 2.  Relative Incidence of Severe Cardiovascular Events During the 14-Day Risk Periods After Exposure to the First and Second Dose of BNT162b2 Vaccine vs the Nonrisk Periods
Relative Incidence of Severe Cardiovascular Events During the 14-Day Risk Periods After Exposure to the First and Second Dose of BNT162b2 Vaccine vs the Nonrisk Periods
1.
Polack  FP, Thomas  SJ, Kitchin  N,  et al; C4591001 Clinical Trial Group.  Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine.   N Engl J Med. 2020;383(27):2603-2615. doi:10.1056/NEJMoa2034577PubMedGoogle ScholarCrossref
2.
Farrington  CP, Whitaker  HJ, Hocine  MN.  Case series analysis for censored, perturbed, or curtailed post-event exposures.   Biostatistics. 2009;10(1):3-16. doi:10.1093/biostatistics/kxn013PubMedGoogle ScholarCrossref
3.
Barda  N, Dagan  N, Ben-Shlomo  Y,  et al.  Safety of the BNT162b2 mRNA Covid-19 vaccine in a nationwide setting.   N Engl J Med. 2021;385(12):1078-1090. doi:10.1056/NEJMoa2110475PubMedGoogle ScholarCrossref
4.
Klein  NP, Lewis  N, Goddard  K,  et al.  Surveillance for adverse events after COVID-19 mRNA vaccination.   JAMA. 2021;326(14):1390-1399. doi:10.1001/jama.2021.15072PubMedGoogle ScholarCrossref
2 Comments for this article
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Vaccination and Infarction, Ischemic Stroke, and Pulmonary Embolism
Artemesia Dona, Associate Professor | Department of Forensic Medicine and Toxicology, Medical School, University of Athens, Greece
I have read this interesting paper but have three questions:

1) Table 1 does not specify how many vaccinated people vs unvaccinated have died. Does the last row correspond to vaccinated or unvaccinated (or both)?

2) How many days after vaccination did the event (myocardial infarction, stroke, embolism) take place?

3) Since the number of unvaccinated patients with acute myocardial infarction is 4603 (41.4), the number of vaccinated is 6510 (58.6), and there are more people with acute myocardial infarction who were vaccinated. The same can be said for vaccinated with ischemic stroke (9162 (54.0)); and vaccinated
with pulmonary embolism (3993 (55.3)). How do you interpret these findings?

Thanking you in advance,
Artemis Dona
Associate Professor
Dept. Forensic Medicine and Toxicology

CONFLICT OF INTEREST: None Reported
READ MORE
Important Limitation Missing
Nir Tsabar, M.D. D.Sc. | Clalit, Northern District

While more than half the world's population has received at least one dose of a COVID-19 vaccine, it should be remembered that all-cause mortality has not been an outcome in COVID-19 vaccine trials.

Hence a reminder here that

1. Not reporting all-cause mortality is a limitation, especially when sudden death may be a complication of undiagnosed myocardial infarction, stroke, or pulmonary embolism

and

2. Any non-randomized controlled research has a major limitation of bias due to unmeasured and unknown confounders.

CONFLICT OF INTEREST: None Reported
Research Letter
November 22, 2021

Myocardial Infarction, Stroke, and Pulmonary Embolism After BNT162b2 mRNA COVID-19 Vaccine in People Aged 75 Years or Older

Author Affiliations
  • 1EPI-PHARE, French National Agency for Medicines and Health Products Safety, French National Health Insurance, Saint-Denis, France
  • 2School of Mathematics and Statistics, the Open University, Milton Keynes, United Kingdom
JAMA. 2022;327(1):80-82. doi:10.1001/jama.2021.21699

The BNT162b2 mRNA vaccine (Pfizer-BioNTech) was the first SARS-CoV-2 vaccine authorized and the most widely used in older persons in France. Although no increases in cardiovascular events were reported in phase 3 trials,1 questions emerged once the vaccine was used on a large scale because older people were underrepresented in the trials. We evaluated the short-term risk of severe cardiovascular events among French people aged 75 years or older after the administration of the BNT162b2 mRNA vaccine.

Methods

This population-based study used the French National Health Data System linked to the national COVID-19 vaccination database. Eligible participants were all persons unvaccinated or vaccinated with the BNT162b2 vaccine, aged 75 years or older, admitted to the hospital between December 15, 2020, and April 30, 2021, for acute myocardial infarction, hemorrhagic stroke, ischemic stroke, or pulmonary embolism (diagnoses identified using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes) (Table 1 and eTable in the Supplement).

We undertook within-person comparisons using a self-controlled case-series method adapted to cardiovascular event–dependent exposures and high event-related mortality that can cancel or defer subsequent vaccination or increase short-term mortality2 (eMethods in the Supplement). Only exposures preceding the event were considered. Exposure risk intervals were days 1 through 14 following each of the 2 vaccine doses. The exposure risk interval was further subdivided into days 1 through 7 and days 8 through 14. Except for the vaccination day, the remaining periods were regarded as nonrisk periods. Unvaccinated persons were included to account for temporal effects. Unbiased estimating equations were used to calculate the relative incidence (RI) adjusted for temporality (in 7-day increments) to consider any changes in background rates of both events and vaccination. All analyses were performed using the SCCS package in R, version 3.6.1. A 95% CI around the RI that did not include 1 defined statistical significance.

The research group has permanent regulatory access to the data from the French National Health Data System (French decree No. 2016-1871 of December 26, 2016, on the processing of personal data called National Health Data System and French law). No informed consent was required because data are anonymized.

Results

As of April 30, 2021, nearly 3.9 million persons aged 75 years or older had received at least 1 dose of the BNT162b2 vaccine and 3.2 million had received 2 doses. Over the observation period, 11 113 persons aged 75 years or older were hospitalized for an acute myocardial infarction, 17 014 for an ischemic stroke, 4804 for a hemorrhagic stroke, and 7221 for pulmonary embolism, of whom 58.6%, 54.0%, 42.7%, and 55.3%, respectively, received at least 1 dose of the vaccine (Table 1). In the 14 days following either dose, no significant increased risk was found for any outcome: the RI for myocardial infarction for the first dose was 0.97 (95% CI, 0.88-1.06) and for the second dose, 1.04 (95% CI, 0.93-1.16); for ischemic stroke for the first dose, 0.90 (95% CI, 0.84-0.98) and for the second dose, 0.92 (95% CI, 0.84-1.02); for hemorrhagic stroke for the first dose, 0.90 (95% CI, 0.78-1.04) and for the second dose, 0.97 (95% CI, 0.81-1.15); and for pulmonary embolism for the first dose, 0.85 (95% CI, 0.75-0.96) and for the second dose, 1.10 (95% CI, 0.95-1.26) (Table 2). No significant increase for any of the cardiovascular events was observed in the 2 subdivided exposure intervals (days 1-7 and days 8-14) (Table 2).

Discussion

In this nationwide study involving persons aged 75 years or older in France, no increase in the incidence of acute myocardial infarction, stroke, and pulmonary embolism was detected 14 days following each BNT162b2 mRNA vaccine dose.

Israeli and US studies reported that persons receiving the BNT162b2 vaccine were not at increased risk of myocardial infarction, pulmonary embolism, or cerebrovascular events in the 42 days3 and 21 days4 following vaccination. Based on a self-controlled case-series design that compensates for the lack of randomization by eliminating the effect of time-invariant confounding factors, this study provides further evidence regarding the risk of serious cardiovascular adverse events in older people. Limitations of the study include the possibility of residual time-dependent confounding.

Further investigations are needed to measure these risks in younger populations and for other types of vaccines against SARS-CoV-2.

Section Editors: Jody W. Zylke, MD, Deputy Editor; Kristin Walter, MD, Associate Editor.
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Article Information

Corresponding Author: Marie Joelle Jabagi, PharmD, PhD, EPI-PHARE, 143-147 Boulevard Anatole France, F-93285 Saint-Denis CEDEX, France (marie-joelle.jabagi@ansm.sante.fr).

Accepted for Publication: November 15, 2021.

Published Online: November 22, 2021. doi:10.1001/jama.2021.21699

Author Contributions: Dr Jabagi and Ms Bertrand had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Jabagi, Botton, Bertrand, Weill, Zureik, Dray-Spira.

Drafting of the manuscript: Jabagi, Bertrand, Zureik.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Jabagi, Botton, Bertrand, Farrington.

Supervision: Botton, Weill, Zureik, Dray-Spira.

Conflict of Interest Disclosures: None reported.

Additional Contributions: Stephane Le Vu, PharmD, PhD, and Kim Bouillon, MD, PhD, EPI-PHARE, reviewed the manuscript without compensation. Bérangère Baricault, MSc, and Jerome Drouin, MSc, EPI-PHARE, provided unpaid technical support related to data management.

References
1.
Polack  FP, Thomas  SJ, Kitchin  N,  et al; C4591001 Clinical Trial Group.  Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine.   N Engl J Med. 2020;383(27):2603-2615. doi:10.1056/NEJMoa2034577PubMedGoogle ScholarCrossref
2.
Farrington  CP, Whitaker  HJ, Hocine  MN.  Case series analysis for censored, perturbed, or curtailed post-event exposures.   Biostatistics. 2009;10(1):3-16. doi:10.1093/biostatistics/kxn013PubMedGoogle ScholarCrossref
3.
Barda  N, Dagan  N, Ben-Shlomo  Y,  et al.  Safety of the BNT162b2 mRNA Covid-19 vaccine in a nationwide setting.   N Engl J Med. 2021;385(12):1078-1090. doi:10.1056/NEJMoa2110475PubMedGoogle ScholarCrossref
4.
Klein  NP, Lewis  N, Goddard  K,  et al.  Surveillance for adverse events after COVID-19 mRNA vaccination.   JAMA. 2021;326(14):1390-1399. doi:10.1001/jama.2021.15072PubMedGoogle ScholarCrossref
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