Multiorgan Outcomes Following BNT162b2 mRNA Vaccination vs SARS-CoV-2 Infection: A 30-Million-Person Real-World...

SARS-CoV-2 infection and BNT162b2 mRNA vaccination carry distinct cardiovascular risk profiles, yet direct comparative evidence across all immunological exposure groups and both sexes remains limited. Using the TriNetX Research Network (December 2020-December 2024), we stratified 30.3 million individuals into four mutually exclusive cohorts: uninfected/unvaccinated controls (G1), infected/unvaccinated (G2), vaccinated-only (G3), and hybrid immunity (G4). Fifty prespecified cardiovascular, cerebrovascular, and mortality outcomes were evaluated across four temporal windows (0-3, 3-6, 6-9, and >9 months) with analyses stratified by biological sex. SARS-CoV-2 infection was associated with 3- to 5-fold increases in cardiovascular events during the acute phase, including myocarditis (males: RR 4.44; females: RR 5.59) and all-cause mortality (males: RR 4.53), with risks persisting beyond nine months. BNT162b2 vaccination conferred 65-76% reductions in major adverse cardiovascular events (0-3 months). Post-infection vaccination (hybrid immunity) provided an additional 36-38% MACE reduction; males exhibited late pericarditis elevation beyond nine months. Completing the two-dose primary series maximally reduced mortality (by 77%) and myocarditis (by 62%) versus single dosing. In this US cohort, SARS-CoV-2 infection confers substantially greater and more sustained cardiovascular risk than BNT162b2 vaccination across all comparisons and both sexes, consistent with a favorable cardiovascular risk-benefit profile for vaccination.