In addition to numerous other contributing factors and comorbidities, influenza and pneumococcal infections are also responsible for worsening outcomes in patients with CVD. Here, Prof. Dr. Sundeep Mishra elaborates on important immunisation options to be recommended to patients with established cardiovascular disease.

Globally, the number one causes of morbidity and mortality are cardiovascular disease. (CVD), Acute coronary syndrome (ACS) including myocardial infarction (MI) is the worst manifestations of CVD and can contribute to death. Infections are one of the commonest precipitating factors for development of MI in a patient with atherosclerotic CVD.

On the other hand, chronic CVD by itself (perhaps because of lack of immunity) predisposes to develop and once they develop make it more difficult for patients to fight off infections. In this context immunisation can play an important role in patients with pre-existing CVD in preventing infection and thus subsequently protecting from serious illness, hospitalisation, and even death.

These 4 are especially important in patients with heart disease: influenza; pneumococcal; tetanus, diphtheria, and acellular pertussis (DPT); and herpes zoster.

Influenza Vaccine

The PARADIGM-HF study of more than 4000 patients was the largest RCT examined whether in-hospital influenza vaccination can serve as secondary prevention after MI (;which (as a secondary outcome). It revealed that influenza vaccination was associated with reduced mortality. Another meta-analysis of 5 observational studies revealed that influenza vaccination was associated with reduced risk of death in patients with heart failure.

There are four types of influenza viruses: A, B, C and D but only Influenza A and B are relevant.

• Human influenza A (new and different strain emerges every year) and B viruses cause seasonal epidemics
• Influenza type C generally causes a mild respiratory illness & no epidemics
• Influenza D primarily affects cattle but no human disease

Various types of flu vaccines are available in India but a quadrivalent vaccine accounting for 2 seasonal strains of Influenza A strains of H1N1 and H3N2 and Influenza B both Yamagata and Vitoria strains is important. The vaccine should be administered once a year before the onset of season; monsoon in whole of India.

Pneumococcal Vaccine

Pneumococcal infections result in increased stress and reduced blood pressure, which in turn puts a patient at risk for heart attack, rhythm disorder and heart failure. In these patients CVDs that are precipitated have a worse outcome as well. In a meta-analysis of 8 studies in patients ≥65 years, pneumococcal vaccine was associated with a lower risk of ACS.

The CDC recommends that CVD individuals,

• between 19 to 64 years should receive 1 dose of the 23-valent pneumococcal polysaccharide vaccine (PPSV23),
• after 65 years, should receive 1 dose of the 13-valent pneumococcal conjugate vaccine (PCV13) if they did not previously receive it, and
• another dose of PPSV23 be administered ≥1 year after PCV13 and at ≥5 years after the first dose of PPSV23

Other Vaccines

The DPT vaccine should be administered to adults who previously did not receive a dose as an adult or child. Herpes zoster may adversely affect patients with CVD; stroke and MI. Patients ≥50 years should receive the 2-dose series of zoster vaccine recombinant, adjuvanted (Shingrix). The second dose should be administered 2 to 6 months after the first dose.

Influenza vaccines available in India

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The writer, Dr. Sundeep Mishra is a Professor of Cardiology.