Influenza Vaccination as Secondary Prevention for Cardiovascular Disease

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

Influenza vaccination coverage and determinants of vaccination in peripheral arterial disease patients

Background: In the latest American Heart Association guidelines, influenza vaccination is recommended for patients with peripheral arterial disease (PAD). The vaccination coverage in this specific population is currently unknown. This study aims to determine the adherence to influenza vaccination in a PAD population and identify associated determinants. Patients and methods. Hospitalized patients and outpatients with PAD from two university departments of vascular medicine were prospectively included. A questionnaire was administered to collect sociodemographic data, cardiovascular risk factors, influenza vaccination status, history of cardiovascular disease, and perception and knowledge about vaccination. Logistic regression was conducted to assess vaccination determinants. Results: Over a six-month period, 494 patients were included (median age 69.5, IQR [63-77], 78% male). Overall, 60.1% were either vaccinated or intended to be (Group 1). Vaccination was associated with age (odds-ratio [OR]=1.055, 95% confidence intervals [95%CI]: 1.035-1.075, p<0.0001), abdominal aorta aneurysm (OR=0.390, 95%CI: 0.229-0.664, p=0.001), chronic obstructive pulmonary disease (OR=0.545, 95%CI: 0.367-0.810, p=0.003), chronic renal disease (OR=0.630, 95%CI: 0.400-0.993, p=0.046), and valvulopathy (OR=2.444, 95%CI: 1.122-5.326, p=0.025). Only 25.3% received vaccination information mainly from their general practitioners. Among patients against vaccination, 59.9% considered themselves not concerned about potential influenza consequences on their PAD, and 37.6% did not intend to change their decision. Conclusions: This study highlights the low adherence to influenza vaccination in the PAD population of 2 university hospital centers. Vaccination is often related to age, and there is a need for adapted information regarding influenza consequences on cardiovascular disease overall, particularly on PAD. Addressing common information and advice about vaccination will be a challenge.

Seasonal influenza vaccine uptake among patients with cardiovascular disease in Denmark, 2017-2019

BACKGROUND

Influenza vaccination protects against morbidity and mortality in patients with cardiovascular disease (CVD). We aimed to describe influenza vaccine uptake in patients with CVD in a universal-access healthcare system.

METHODS

Using nationwide Danish registries, we included all patients with prevalent CVD, defined as heart failure (HF), atrial fibrillation (AF), ischemic heart disease (IHD), or stroke during three consecutive influenza seasons (October-December 2017-2019). The outcome was relative frequency of influenza vaccination across strata of patient characteristics.

RESULTS

There was an average of 397 346 patients with CVD yearly during 2017-2019. Vaccine uptake was 45.6% for the whole population and ranged from 55.0% in AF to 61.8% in HF among patients aged ≥65 years. Among patients aged <65 years, uptake was 32.6% in HF, 19.0% in AF, 21.1% in IHD, and 18.3% in stroke. There was a lower uptake with decreasing age: 21.6% in HF, 5.5% in AF, 7.4% in IHD, and 6.3% in stroke among males aged <45 years, as opposed to 25.5% in HF, 11.5% in AF, 13.8% in IHD, and 12.1% in stroke for males aged 45-54 years. In the further stratified analyses, uptake ranged from a low of 2.5% for males <45 years with AF who were not vaccinated the previous season to a high of 87.0% for females ≥75 years with IHD who were vaccinated the previous season.

CONCLUSION

Seasonal influenza vaccine uptake is suboptimal among patients with CVD, even in a universal-access healthcare system with free-of-charge vaccinations. Vaccine uptake was particularly low among young patients.

Vaccines and cardiovascular outcomes: lessons learned from influenza epidemics

Cardiovascular disease (CVD) is the leading cause of death in the world and is largely preventable. An increasing amount of evidence suggests that annual influenza vaccination reduces CVD-related morbidity and mortality. Despite various clinical guidelines recommending annual influenza vaccination for the general population for influenza-like illness risk reduction, with a particular emphasis on people with CVD, vaccination rates fall consistently below the goal established by the World Health Organization. This review outlines the importance of influenza vaccination, mechanisms of cardiovascular events in influenza, summarizing the available literature on the effects of influenza vaccine in CVD and the benefits of influenza vaccine during the COVID-19 pandemic.

Disparities in Influenza Vaccination Coverage and Associated Factors Among Adults with Cardiovascular Disease, United States, 2011-2020

INTRODUCTION

Influenza vaccination can reduce the incidence of cardiovascular disease (CVD) in the US. However, differences in state-level trends in CVD and sociodemographic and health care characteristics of adults with CVD have not yet been studied.

METHODS

In this repeated cross-sectional study, we extracted 476,227 records of adults with a self-reported history of CVD from the Behavioral Risk Factor Surveillance System from January 2011 through December 2020. We calculated the prevalence and likelihood of annual influenza vaccination by sociodemographic characteristics, health care characteristics, and CVD risk factors. Additionally, we examined annual trends of influenza vaccination by geographic location.

RESULTS

The annual age-adjusted influenza vaccination rate among adults with CVD increased from 38.6% (2011) to 44.3% (2020), with an annual average percentage change of 1.1%. Adults who were aged 18 to 44 years, male, non-Hispanic Black/African American, or Hispanic, or had less than a high school diploma, annual household income less than $50,000, and no health insurance had a lower prevalence of vaccination. The odds of vaccination were lower among non-Hispanic Black/African American (adjusted odds ratio, 0.73; 95% CI, 0.70-0.77) and non-Hispanic American Indian/Alaska Native (adjusted odds ratio, 0.86; 95% CI, 0.75-0.98) compared with non-Hispanic White adults. Only 16 states achieved a vaccination rate of 50%; no state achieved the Healthy People 2020 goal of 70%. Nonmedical settings (supermarkets, drug stores) gained popularity (19.2% in 2011 to 28.5% in 2018) as a vaccination setting.

CONCLUSION

Influenza vaccination among adults with CVD improved marginally during the past decade but is far behind the targeted national goals. Addressing existing disparities requires attention to the role of social determinants of health in determining access to vaccination, particularly among young people, racial and ethnic minority populations, people who lack health insurance, and people with comorbidities.

Influenza Vaccination for Cardiovascular Prevention: Further Insights from the IAMI Trial and an Updated Meta-analysis

Purpose of Review

Influenza infection is a significant, well-established cause of cardiovascular disease (CVD) and CV mortality. Influenza vaccination has been shown to reduce major adverse cardiovascular events (MACE) and CV mortality. Therefore, major society guidelines have given a strong recommendation for its use in patients with established CVD or high risk for CVD. Nevertheless, influenza vaccination remains underutilized. Historically, influenza vaccination is administered to stable outpatients. Until recently, the safety and efficacy of influenza vaccination among patients with acute myocardial infarction (MI) had not been established.

Recent Findings

The recently published Influenza Vaccination after Myocardial Infarction (IAMI) trial showed that influenza vaccination within 72 h of hospitalization for MI led to a significant 28% reduction in MACE and a 41% reduction in CV mortality, without any excess in serious adverse events. Additionally, we newly performed an updated meta-analysis of randomized clinical trials (RCTs) including IAMI and the recent Influenza Vaccine to Prevent Adverse Vascular Events (IVVE) trial. In pooled analysis of 8 RCTs with a total of 14,420 patients, influenza vaccine, as compared with control/placebo, was associated with significantly lower risk of MACE at follow-up [RR 0.75 (95%CI 0.57–0.97), I² 56%].

Summary

The recent IAMI trial showed that influenza vaccination in patients with recent MI is safe and efficacious at reducing CV morbidity and mortality. Our updated meta-analysis confirms a 25% reduction in MACE. The influenza vaccine should be strongly encouraged in all patients with CVD and incorporated as an essential facet of post-MI care and secondary CVD prevention.

Determinants of Influenza Vaccine Uptake in Patients With Cardiovascular Disease and Strategies for Improvement

Cardiovascular disease (CVD) is the leading cause of death and disability worldwide. Influenza infection is associated with an increased risk of cardiovascular events (myocardial infarction, stroke, and heart failure exacerbation) and mortality, and all‐cause mortality in patients with CVD. Infection with influenza leads to a systemic inflammatory and thrombogenic response in the host body, which further causes destabilization of atherosclerotic plaques. Influenza vaccination has been shown to be protective against cardiovascular and cerebrovascular events in several observational and prospective studies of at‐risk populations. Hence, many international guidelines recommend influenza vaccination for adults of all ages, especially for individuals with high‐risk conditions such as CVD. Despite these long‐standing recommendations, influenza vaccine uptake among US adults with CVD remains suboptimal. Specifically, vaccination uptake is strikingly low among patients aged <65 years, non‐Hispanic Black individuals, those without health insurance, and those with diminished access to healthcare services. Behavioral factors such as perceived vaccine efficacy, vaccine safety, and attitudes towards vaccination play an important role in vaccine acceptance at the individual and community levels. With the ongoing COVID‐19 pandemic, there is a potential threat of a concurrent epidemic with influenza. This would be devastating for vulnerable populations such as adults with CVD, further stressing the need for ensuring adequate influenza vaccination coverage. In this review, we describe a variety of strategies to improve the uptake of influenza vaccination in patients with CVD through improved understanding of key sociodemographic determinants and behaviors that are associated with vaccination, or the lack thereof. We further discuss the potential use of relevant strategies for COVID‐19 vaccine uptake among those with CVD.

Influenza-associated cardiovascular mortality in older adults in Beijing, China: a population-based time-series study

OBJECTIVE

This study comprehensively estimated the excess cardiovascular disease (CVD) mortality attributable to influenza in an older (age ≥65 years) population.

DESIGN

Ecological study.

SETTING

Aggregated data from administrative systems on CVD mortality, influenza surveillance and meteorological data in Beijing, China.

MAIN OUTCOME MEASURE

Excess overall CVD, and separately for ischaemic heart disease (IHD), ischaemic stroke, haemorrhagic stroke mortality attributable to influenza, adjusting for influenza activity, time trend, seasonality and ambient temperature.

RESULTS

CVD (risk ratio (RR) 1.02, 95% CI 1.01, 1.02), IHD (RR 1.01, 95% CI 1.01, 1.02), ischaemic stroke (RR=1.03, 95% CI 1.02, 1.04), but not haemorrhagic stroke (RR=1.00, 95% CI 0.99, 1.01) mortality, were significantly associated with every 10% increase in influenza activity. An increase in circulating A(H1N1)09pdm, A(H3N2) and B type virus were all significantly associated with CVD and ischaemic stroke mortality, but only A(H3N2) and B type virus with IHD mortality. The strongest increase in disease mortality was in the same week as the increase in influenza activity. Annual excess CVD mortality rate attributable to influenza ranged from 54 to 96 per 100 000 population. The 3%-6% CVD mortality attributable to influenza activity was related to an annual excess of 916-1640 CVD deaths in Beijing, China.

CONCLUSIONS

Influenza activity has moderate to strong associations with CVD, IHD and ischaemic stroke mortality in older adults in China. Promoting influenza vaccination could have major health benefit in this population.

BACKGROUND

Influenza may trigger serious CVD events. An estimation of excess CVD mortality attributable to influenza has particular relevance in China where vaccination is low and CVD burden is high.

METHODS

This study analysed data at the population level (age ≥65 years) using linked aggregated data from administrative systems on CVD mortality, influenza surveillance and meteorological data during 2011 to 2018. Quasi-Poisson regression models were used to estimate the excess overall CVD, and separately for IHD, ischaemic stroke, haemorrhagic stroke mortality attributable to influenza, adjusting for influenza activity, time trend, seasonality and ambient temperature. Analyses were also undertaken for influenza subtypes (A(H1N1)09pdm, A(H3N2) and B viruses), and mortality risk with time lags of 1-5 weeks following influenza activity in the current week.

Influenza coverage rates in subjects with chronic heart diseases: results obtained in four consecutive immunisation seasons in the Local Health Unit of Ferrara (North Italy)"

Background

Seasonal influenza epidemics yearly affects 5–15% of the world’s population, resulting in 3–5 million serious cases and up to 650,000 deaths. According to the 2017–2019 Italian National Immunisation Plan, free immunisation is offered to the categories at increased risk of experience the complications of the infection (over 65 years old subjects, pregnant women and individuals with underlying conditions, including chronic heart diseases). Rising evidence suggests that influenza can trigger adverse cardiovascular events therefore the vaccination is recommended for secondary prevention of cardiovascular diseases. Despite this, the influenza coverage rate in subjects with chronic heart disease is underestimated.

Methods

The study investigated the coverage rate in four consecutive influenza seasons (from 2011/2012 to 2014/2015) in subjects that benefit from exemption from paying healthcare costs for chronic heart disease living in Local Health Unit (LHU) of Ferrara (Italy), comparing the databases of exemptions and immunisations.

Results

The levels of influenza vaccine uptake were unstable, reaching the 50.3% in 2011/2012 immunisation season and falling to 42.2% in the following year. Coverage rates increased with increasing age, without achieving the 75% target, neither in over 65 years old subjects. The logistic regression analysis showed that influenza coverage rates were statistically significant different (p < 0.0001, 0.003 only for category of disease in 2011/2012 immunisation season) according to age, district of residence, category of chronic heart disease and length of exemption, but not influenced by gender.

Conclusions

The recommendation of influenza immunisation was weakly followed in individuals with chronic heart diseases. A collaboration between cardiologists, GPs, scientific societies and patient associations could successfully support influenza vaccine uptake.

Sociodemographic Disparities in Influenza Vaccination Among Adults With Atherosclerotic Cardiovascular Disease in the United States

Importance

Atherosclerotic cardiovascular disease (ASCVD) remains a leading cause of death and disability in the US and worldwide. Influenza vaccination has shown to decrease overall morbidity, mortality, severity of infection, and hospital readmissions among these individuals. However, national estimates of influenza vaccination among individuals with ASCVD in the US are not well studied.

Objective

To evaluate the prevalence of and sociodemographic disparities in influenza vaccination among a nationally representative sample of individuals with ASCVD.

Design, Setting, and Participants

Pooled Medical Expenditure Panel Survey data from 2008 to 2016 were used and included adults 40 years or older with ASCVD. Participants' ASCVD status was ascertained via self-report and/or International Classification of Diseases, Ninth Revision diagnosis of coronary heart disease, peripheral artery disease, and/or cerebrovascular disease. Analysis began April 2020.

Main Outcomes and Measures

Prevalence and characteristics of adults with ASCVD who lacked influenza vaccination during the past year. Covariates including age, sex, race/ethnicity, family income, insurance status, education level, and usual source of care were assessed.

Results

Of 131 881 adults, 19 793 (15.7%) had ASCVD, corresponding to 22.8 million US adults annually. A total of 7028 adults with ASCVD (32.7%), representing 7.4 million adults, lacked influenza vaccination. The highest odds of lacking vaccination were observed among individuals aged 40 to 64 years (odds ratio [OR], 2.32; 95% CI, 2.06-2.62), without a usual source of care (OR, 2.00; 95% CI, 1.71-2.33), without insurance (OR, 2.05; 95% CI, 1.63-2.58), with a lower education level (OR, 1. 25; 95% CI, 1.12-1.40), with a lower income level (OR, 1.14; 95% CI, 1.01-1.27), and of non-Hispanic Black race/ethnicity (OR, 1.24, 95% CI, 1.10-1.41). A stepwise increase was found in the prevalence and odds of lacking influenza vaccination among individuals with increase in high-risk characteristics. Overall, 1171 individuals (59.7%; 95% CI, 55.8%-63.5%) with 4 or more high-risk characteristics and ASCVD (representing 732 524 US adults annually) reported lack of influenza vaccination (OR, 6.06; 95% CI, 4.88-7.53).

Conclusion and Relevance

Despite current recommendations, a large proportion of US adults with established ASCVD lack influenza vaccination, with several sociodemographic subgroups having greater risk. Focused public health initiatives are needed to increase access to influenza vaccinations for high-risk and underserved populations.

Higher admission rates and in-hospital mortality for acute type A aortic dissection during Influenza season: a single center experience

Triggering events for acute aortic dissections are incompletely understood. We sought to investigate whether there is an association between admission for acute type A aortic dissection (ATAAD) to the University of Michigan Medical Center and the reported annual influenza activity by the Michigan Department of Health and Human Services. From 1996–2019 we had 758 patients admitted for ATAAD with 3.1 admissions per month during November-March and 2.5 admissions per month during April-October (p = 0.01). Influenza reporting data by the Michigan Department of Health and Human Services became available in 2009. ATAAD admissions for the period 2009–2019 (n = 455) were 4.8 cases/month during peak influenza months compared to 3.5 cases/month during non-peak influenza months (p = 0.001). ATAAD patients admitted during influenza season had increased in-hospital mortality (11.0% vs. 5.8%, p = 0.024) and increased 30-day mortality (9.7 vs. 5.4%, p = 0.048). The results point to higher admission rates for ATAAD during months with above average influenza rates. Future studies need to investigate whether influenza virus infection affects susceptibility for aortic dissection, and whether this risk can be attenuated with the annual influenza vaccine in this patient population.

Influenza vaccine and cardiac protection: a study from a tertiary care center

Patients with heart disease (HD) are at increased risk of developing cardiac complications if they acquire the influenza virus. The objective of this study was to determine whether the influenza vaccine has a primary role in preventing newly diagnosed HD in patients who have no history of HD and who were being followed up at the American University of Beirut Medical Center (AUBMC). The study is a retrospective cohort, with 2-years follow up, which was conducted using electronic medical records between the years of 2011-2013 in a tertiary care center. All patients 60 years and older (n = 698) who have taken the flu vaccine were randomly selected from the University Health Service records (UHS) and compared to a group who has not taken the flu vaccine during the same period. The odds of developing HD among vaccinated people with cofactors are 0.97 times the odds of that among non-vaccinated. This odds ratio is not significantly different than that of people vaccinated without cofactors (OR = 1.74). The occurrence of HD in the presence of vaccination revealed a non-significant decrease trend with the increase in a number of risk factors (OR = 1.61 vs 0.97). Our results suggest that there was a non-significant difference between the effect of the vaccine for influenza on patients who had cofactors for HD and those who had not. Similarly, the effect of vaccine showed a non-significant increase in protective effect as the number of comorbidities increase. The potential effects of the vaccine may be related to the protection against flu.

Clinical efficacy of acute respiratory viral infections prevention in patients with chronic heart failure

AIM

The aim of the study was to evaluate the ARVI prevention effectiveness in patients with chronic heart failure (CHF) using interferon inducer amixin.

MATERIALS AND METHODS

Conducted a comprehensive survey, dynamic monitoring and treatment of 60 patients aged from 49 to 70 years (mean age 60.25±4.57 years, 17 men and 43 women) with CHF with preserved ejection fraction of left ventricle (LVEF) (≥50%), II-III functional class (FC) according to the classification of new York Heart Association (NYHA), which developed as a result of coronary heart disease (CHD), hypertensive disease (HD). Of these, 30 patients (group 1) on the background of standard therapy for CHF received for the prevention of ARVI tiloron (Amixin) at a dose of 125 mg once a week for 6 weeks, two courses for 1 year. Group 2 patients received only standard therapy for CHF.

RESULTS

A decrease in the frequency of ARVI in patients with CHF treated with Amixin was found, which was accompanied by a decrease in the severity of subclinical inflammation by reducing the production of proinflammatory (IL-1β) and increasing the production of anti-inflammatory (IL-10) cytokines, reducing neurohumoral activation (reducing levels of aldosterone and Nt-proBNP), increasing the level of α- and γ-interferon. The positive dynamics of biomarkers of systemic inflammation and neurohormonal activation explains the improvement of the clinical course in patients with CHF (increase of tolerance to physical loads, reducing the number of visits to General practitioner and hospital admissions in the hospital during 12 months of observation).

CONCLUSION

A promising approach to the prevention of SARS in patients with CHF is course therapy with Amixin (2 times a year before the seasonal rising in the incidence of respiratory viral infections and influenza), which allows to achieve both decreasing in the frequency of SARS per year, and improvement the clinical course of CHF.

Protective effect of influenza vaccination on outcomes in geriatric stroke patients: A nationwide matched cohort study

BACKGROUND AND AIMS

The effects of influenza vaccination (IV) on stroke outcomes are unclear. The purpose of this study is to evaluate the outcomes after stroke in elderly individuals who have received an IV.

METHODS

We used Taiwan's National Health Insurance Research Database 2000-2009 claims data to conduct a nested stroke cohort study including 148,909 hospitalized stroke patients aged 66 years and older. Using a matching procedure by propensity score, we selected 25,248 stroke patients with IV and 25,248 stroke patients without IV for comparison. Logistic regression was used to calculate the odds ratios (ORs) and 95% CIs of post-stroke complications and in-hospital mortality associated with IV.

RESULTS

Stroke patients with IV had significantly lower risks of post-stroke pneumonia (OR = 0.79; 95% CI, 0.74-0.83), septicemia (OR = 0.78; 95% CI, 0.70-0.86), urinary tract infection (OR = 0.87; 95% CI, 0.83-0.92), and 30-day in-hospital mortality (OR = 0.60; 95% CI, 0.54-0.67) compared with non-IV stroke patients. Vaccinated stroke patients also had shorter hospital stays (p < 0.0001) and less medical expenditures (p < 0.0001) during stroke admission than the control group. Lower rates of post-stroke adverse events in patients with IV were noted in both sexes of all age groups with various types of stroke.

CONCLUSIONS

Stroke patients with IV showed fewer complications and lower mortality compared with non-IV patients. These findings suggest the urgent need to promote IV for this susceptible population of stroke patients.

Beneficial Effects of Vaccination on Cardiovascular Events: Myocardial Infarction, Stroke, Heart Failure

Influenza and pneumococcal infections have been suggested to be potential risk factors for causing adverse cardiovascular events, especially in high-risk patients. Vaccination against respiratory infections in patients with established cardiovascular disease (CVD) could serve as a potential cost-effective intervention to improve their clinical outcomes and cardiac societies have encouraged it. Previous studies have shown that influenza vaccination reduce mortality, acute coronary syndromes and hospitalization in patients with coronary heart disease (CHD) and/or heart failure (HF). However, there is a paucity of randomized prospective clinical trials in the field of the pneumococcal vaccination, and additional higher-quality evidence is needed. Furthermore, questions around the role of vaccination in the primary prevention of CVD, the optimal dose and timing are largely unanswered. The pathophysiologic mechanism in which vaccination provides cardiovascular protection may be related to the modification of the immune-inflammatory model of atherogenesis. The present review summarizes the current evidence and understanding for vaccination against influenza and streptococcus pneumoniae in CHD, HF and stroke and highlights its beneficial effect in the reduction of adverse cardiovascular events.

High-dose influenza vaccine to reduce clinical outcomes in high-risk cardiovascular patients: Rationale and design of the INVESTED trial

BACKGROUND

Influenza leads to significant cardiopulmonary morbidity and mortality-particularly in patients with cardiovascular disease-that may be prevented with a standard influenza vaccine. However, patients with cardiovascular conditions have a reduced immune response to influenza vaccine, potentially resulting in reduced effectiveness for preventing clinical events. High-dose vaccine augments immune response in cardiac patients, suggesting that a high-dose influenza vaccination strategy may further reduce morbidity and mortality. Alternatively, broader coverage with an influenza vaccine containing an increased number of viral strains is an alternative strategy without direct evaluation.

RESEARCH DESIGN AND METHODS

INfluenza Vaccine to Effectively Stop Cardio Thoracic Events and Decompensated heart failure (INVESTED) is a pragmatic, randomized, double-blind, parallel-group, active-controlled trial comparing the effectiveness of an annual vaccination strategy of high-dose trivalent versus standard-dose quadrivalent influenza vaccine in patients with a history of recent heart failure or myocardial infarction hospitalization. The trial will enroll approximately 9,300 patients over 4 influenza seasons. The primary hypothesis is that high-dose influenza vaccine will reduce the composite outcome of all-cause mortality and hospitalization from a cardiovascular or pulmonary cause compared with standard-dose influenza vaccine within each enrolling season. Approximately 1,300 primary outcome events will provide >90% power to detect an 18% relative risk reduction at a 2-sided α level of .05.

CONCLUSION

INVESTED is the largest and longest study to assess whether high-dose influenza vaccine is superior to standard-dose influenza vaccine in reducing cardiopulmonary events in a high-risk cardiovascular population (ClinicalTrials.gov Identifier: NCT02787044).

Pneumonia as a cardiovascular disease

Community-acquired pneumonia (CAP) is an important cause of death around the globe. Up to 30% of patients admitted to hospital for CAP develop cardiovascular complications (i.e. new/worsening heart failure, new/worsening arrhythmias, myocardial infarctions and/or strokes), acutely and up to 10 years thereafter. Cardiac complications result from complex interactions between preexisting conditions, relative ischaemia, upregulation of the sympathetic system, systemic inflammation and direct pathogen-mediated damage to the cardiovascular system. The exact mechanisms underlying the direct host-pathogen interactions are of great interest to identify potential therapeutic and preventative targets for CAP. In this review, we summarize the epidemiological data, risk factors and the pathogen-driven cardiovascular damage affecting patients with CAP.

African American adults and seasonal influenza vaccination: Changing our approach can move the needle

Consistent disparities in influenza (flu) vaccine uptake among African Americans, coupled with a disproportionate burden of chronic diseases, places too many African Americans at high risk for complications, hospitalizations and premature mortality. This disparity is the result of individual attitudes and beliefs, social norms, and health care practices. Recent research identifies critical factors affecting vaccine uptake among African American adults including perceived risk of vaccine side effects, social norms that do not support for vaccination, and lower knowledge of the flu and the vaccine. Yet in our nationally representative survey of African Americans, we also found that there is substantial trust in one's own physician about the flu vaccine coupled with valuing the provider's vaccine recommendation. Other recent research has found that African Americans are not receiving strong recommendations and specific offers of the vaccine in their health care visit. This commentary suggests particular roles and strategies for health care providers, public health agencies, and African American communities and families, which can literally move the needle to increase seasonal flu vaccination.

shRNA‑mediated NP knockdown inhibits the apoptosis of cardiomyocytes induced by H1N1pdm2009 influenza virus

Acute influenza-associated myocarditis varies in clinical severity ranging between asymptomatic and fulminant varieties. The most severe cases can result in impaired cardiac function‑associated mortality; however, the mechanism underlying the development of viral myocarditis has yet to be fully elucidated. The present study investigated the apoptosis induced in H9C2 cardiomyocytes by infection with the H1N1pdm2009 virus. The H9C2 cells were transfected with nucleoprotein (NP)‑specific short hairpin (sh) RNA, and viral replication was re‑evaluated in H9C2 cells infected with the H1N1pdm2009 virus, as was the apoptosis induced by the virus. Reverse transcription‑quantitative polymerase chain reaction and western blot analysis were performed to measure the expression of NP and apoptosis‑associated molecules. A plaque forming assay was used to quantify viral replication in H9C2 cells. An MTT assay and flow cytometric analysis were performed to determine the virus‑associated alterations in cellular viability and apoptosis, respectively. Results demonstrated that the H1N1pdm2009 virus replicated effectively in H9C2 cells and promoted apoptosis in association with the viral infection. The expression levels of apoptosis‑associated markers, including released cytochrome c and activated caspase‑3 were markedly promoted in the H1N1pdm2009‑infected H9C2 cells. However, the NP‑specific shRNA‑mediated NP knockdown significantly inhibited viral infection in the cells. The virus‑induced apoptosis of the H9C2 cells was also significantly reduced by the shRNA, which occurred via a decrease in the number of apoptotic cells through downregulating the levels of apoptosis‑associated markers. Taken together, the present study demonstrated the key pathogenic role of NP in H1N1pdm2009‑induced apoptosis of cardiomyocytes, and this marker of the influenza virus may be important in influenza virus‑associated acute myocarditis. In addition, NP‑specific shRNA may be an effective agent for inhibiting influenza virus‑induced apoptosis in cardiomyocytes or in influenza virus‑associated acute myocarditis.

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, based on systematic methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care.

In response to reports from the Institute of Medicine1 ,2 and a mandate to evaluate new knowledge and maintain relevance at the point of care, the ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) modified its methodology.3 –5 The relationships among guidelines, data standards, appropriate use criteria, and performance measures are addressed elsewhere.5

Influenza Vaccination for Secondary Prevention of Cardiovascular Events: A Systematic Review

BACKGROUND

Influenza is a common respiratory infection that may cause complications, including cardiovascular events. Influenza illness has been shown to double the risk of myocardial infarction, with the highest risk among patients with established cardiovascular disease. Vaccination against influenza has been associated with reductions in myocardial infarction, cerebrovascular disease, and death.

OBJECTIVE

To evaluate the evidence for influenza vaccination as a strategy to reduce cardiovascular events specifically in patients with established cardiovascular disease.

DATA SOURCES AND STUDY SELECTION

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched with the terms "influenza vaccine" and "cardiovascular disease". Included in this review were randomized controlled trials (RCTs), nonrandomized studies, and meta-analyses that compared influenza vaccination against control in patients with established cardiovascular disease and that reported clinically meaningful cardiovascular outcomes (defined as cardiovascular death, myocardial infarction, and stroke).

DATA EXTRACTION AND SYNTHESIS

The search yielded 10 studies (3 nonrandomized studies, 5 RCTs, and 2 meta-analyses). The nonrandomized studies and the RCTs had inconsistent results with respect to cardiovascular death and adverse cardiovascular events. The 2 meta-analyses, which included the same 4 RCTs involving patients with established cardiovascular disease, showed that the influenza vaccine reduced cardiovascular death by about 50% relative to control. Vaccination also reduced major cardiovascular events by about 43%; the reduction was greater (54%) in the subgroup of patients with recent (≤ 1 year) acute coronary syndrome. However, these data are potentially confounded by small sample sizes, low event rates, and variable outcome reporting. There was also high clinical heterogeneity among the studies, which may not reflect contemporary practice.

CONCLUSIONS

Given the limitations of these data, it is unclear whether the cardiovascular benefit with influenza vaccination in patients with cardiovascular disease is a true effect. Nevertheless, because of the potential benefit and the low risk of adverse events, the annual influenza vaccine should be recommended for all patients with established cardiovascular disease.

Prevalence, pathogenesis, therapy, and prevention of cardiovascular events in patients with community-acquired pneumonia

It is now well recognised that cardiac events occur relatively commonly in patients with acute community-acquired pneumonia. While these events are more frequent in patients with underlying risk factors—such as those with underlying chronic cardiovascular and respiratory comorbidities, the elderly, and in nursing home residents—they also occur in patients with no underlying risks other than severe pneumonia. Recent research elucidating the underlying pathogenic mechanisms related to these cardiac events has indicated a probable role for platelet activation, which is possibly exacerbated by pneumolysin in the case of pneumococcal infections. This, in turn, has resulted in the identification of possible therapeutic strategies targeting platelet activation, as well as the cardio-toxic activity of pneumolysin. These issues represent the primary focus of the current review.

Cardiovascular Disease in Women: Primary and Secondary Cardiovascular Disease Prevention

Cardiovascular disease remains the leading cause of death in the United States. Primary prevention of cardiovascular disease requires involvement of an extended health care team. Obstetricians and gynecologists are uniquely positioned within the health care system because they are often the primary or only contact women have with the system. This review article discusses initial assessment, treatment recommendations, and practical tips regarding primary and secondary prevention of cardiovascular disease in women with a focus on coronary heart disease; discussion includes peripheral and cerebrovascular disease.

Higher risk for incident heart failure and cardiovascular mortality among community-dwelling octogenarians without pneumococcal vaccination

AIMS

Octogenarians have the highest incidence of heart failure (HF) that is not fully explained by traditional risk factors. We explored whether lack of pneumococcal vaccination is associated with higher risk of incident HF among octogenarians.

METHODS AND RESULTS

In the Cardiovascular Health Study (CHS), 5290 community-dwelling adults, ≥65 years of age, were free of baseline HF and had data on pneumococcal vaccination. Of these, 851 were octogenarians, of whom, 593 did not receive pneumococcal vaccination. Multivariable-adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for associations of lack of pneumococcal vaccination with incident HF and other outcomes during 13 years of follow-up were estimated using Cox regression models, adjusting for demographics and other HF risk factors including influenza vaccination. Octogenarians had a mean (±SD) age of 83 (±3) years; 52% were women and 17% African American. Overall, 258 participants developed HF and 662 died. Lack of pneumococcal vaccination was associated with higher relative risk of incident HF (aHR, 1.37; 95% CI, 1.01-1.85; P = 0.044). There was also higher risk for all-cause mortality (aHR, 1.23; 95% CI, 1.02-1.49; P = 0.028), which was mostly driven by cardiovascular mortality (aHR, 1.45; 95% CI, 1.06-1.98; P = 0.019). Octogenarians without pneumococcal vaccination had a trend toward higher risk of hospitalization due to pneumonia (aHR, 1.34; 95% CI, 0.99-1.81; P = 0.059). These associations were not observed among those 65-79 years of age.

CONCLUSIONS

Among community-dwelling octogenarians, lack of pneumococcal vaccination was associated with a significantly higher independent risk of incident HF and mortality, and trend for higher pneumonia hospitalization.

Increased defibrillator therapies during influenza season in patients without influenza vaccines

BACKGROUND

The association between influenza vaccination and implantable cardiac defibrillator (ICD) therapies during influenza season is not known and is described in this study. Understanding this association is important since reduction in ICD therapies during influenza season via use of influenza vaccination would benefit patients physically and psychologically.

METHODS

Patients presenting to the Sunnybrook Health Sciences Center ICD clinic between September 1st, 2011 and November 31st, 2011 were asked to complete a survey evaluating their use of the influenza vaccine. The number of patients with any ICD therapy and the total number of ICD therapies in the six months before and the three months during the 2010-2011 influenza season were determined. Poisson regression analysis was employed to assess differences in the average number of ICD therapies received during the influenza season based on vaccine status (vaccinated vs. unvaccinated). The analysis was repeated after limiting the cohort to patients with a left ventricular ejection fraction ≤35%.

RESULTS

A total of 229 patients completed the survey, 78% of whom received the influenza vaccine. Four patients had more than one ICD shock during the study period. Electrical storm was rare (n=2). A trend toward more ICD therapies (unadjusted incident rate ratio (IRR)=3.2; P=0.07) and appropriate ICD shocks (unadjusted IRR=9.0; P=0.17) was noted for unvaccinated compared to vaccinated patients. This association persisted when analysis was limited to patients with a left ventricular ejection fraction ≤35% (all ICD therapies: unadjusted IRR=5.8; P=0.045; adjusted IRR=2.6; P=0.33). No patient who received the influenza vaccine, and had a reduced ejection fraction, received an approprite ICD shock during influenza season (unadjusted P<0.002).

CONCLUSION

A trend toward more ICD therapies during influenza season was observed in patients who did not receive the influenza vaccine compared to those who did. The association was stronger in patients who received appropriate ICD shocks and in patients with left ventricular systolic dysfunction. Further work to confirm these findings is recommended.

Gene Expression Profiles Link Respiratory Viral Infection, Platelet Response to Aspirin, and Acute Myocardial Infarction

Background

Influenza infection is associated with myocardial infarction (MI), suggesting that respiratory viral infection may induce biologic pathways that contribute to MI. We tested the hypotheses that 1) a validated blood gene expression signature of respiratory viral infection (viral GES) was associated with MI and 2) respiratory viral exposure changes levels of a validated platelet gene expression signature (platelet GES) of platelet function in response to aspirin that is associated with MI.

Methods

A previously defined viral GES was projected into blood RNA data from 594 patients undergoing elective cardiac catheterization and used to classify patients as having evidence of viral infection or not and tested for association with acute MI using logistic regression. A previously defined platelet GES was projected into blood RNA data from 81 healthy subjects before and after exposure to four respiratory viruses: Respiratory Syncytial Virus (RSV) (n=20), Human Rhinovirus (HRV) (n=20), Influenza A virus subtype H1N1 (H1N1) (n=24), Influenza A Virus subtype H3N2 (H3N2) (n=17). We tested for the change in platelet GES with viral exposure using linear mixed-effects regression and by symptom status.

Results

In the catheterization cohort, 32 patients had evidence of viral infection based upon the viral GES, of which 25% (8/32) had MI versus 12.2% (69/567) among those without evidence of viral infection (OR 2.3; CI [1.03-5.5], p=0.04). In the infection cohorts, only H1N1 exposure increased platelet GES over time (time course p-value = 1e-04).

Conclusions

A viral GES of non-specific, respiratory viral infection was associated with acute MI; 18% of the top 49 genes in the viral GES are involved with hemostasis and/or platelet aggregation. Separately, H1N1 exposure, but not exposure to other respiratory viruses, increased a platelet GES previously shown to be associated with MI. Together, these results highlight specific genes and pathways that link viral infection, platelet activation, and MI especially in the case of H1N1 influenza infection.

Infection and Atherosclerosis Development

Atherosclerosis is a chronic disease hallmarked by chronic inflammation, endothelial dysfunction and lipid accumulation in the vasculature. Although lipid modification and deposition are thought to be a major source of the continuous inflammatory stimulus, a large body of evidence suggests that infectious agents may contribute to atherosclerotic processes. This could occur by either direct effects through infection of vascular cells and/or through indirect effects by induction of cytokine and acute phase reactant proteins by infection at other sites. Multiple bacterial and viral pathogens have been associated with atherosclerosis by seroepidemiological studies, identification of the infectious agent in human atherosclerotic tissue, and experimental studies demonstrating an acceleration of atherosclerosis following infection in animal models of atherosclerosis. This review will focus on those infectious agents for which biological plausibility has been demonstrated in animal models and on the challenges of proving a role of infection in human atherosclerotic disease.

Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association

The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.

Toll-like receptor 7 promotes the apoptosis of THP-1-derived macrophages through the CHOP-dependent pathway

Macrophage apoptosis is a prominent characteristic of advanced atherosclerotic plaques and leads to plaque destabilization. Certain studies have confirmed that influenza virus A (IVA) infection is related to acute myocardial infarction (AMI). However, it remains unknown as to whether this phenomenon is associated with Toll-like receptor (TLR)7, since single-stranded RNA (ssRNA) of IVA is a natural ligand of TLR7. Thus, in the present study, THP-1‑derived macrophages were infected with IVA or treated with imiquimod (IMQ) in the presence or absence of pre-treatment with oxidized low-density lipoprotein (oxLDL). The macrophages were pre-treated with oxLDL (5 µg/ml) for 24 h to mimic high lipid conditions. Cell viability and apoptosis were detected by 3-(4,5-dimethylthiazol-2-y-1)‑2,5-diphenyl-2H-tetrazolium bromide (MTT) assay and flow cytometry, respectively. Our results revealed that TLR7 played an important role in macrophage apoptosis and cytokine secretion. Both IVA infection and IMQ treatment increased TLR7 expression, as well as the secretion of pro-inflammatory cytokines [interleukin (IL)-6, monocyte chemotactic protein (MCP)-1] and apoptosis. However, this increase in cytokine secretion occurred independently of cell apoptosis. oxLDL had potential synergistic pro-apoptotic effects combined with TLR7 activation. To determine whether endoplasmic reticulum (ER) stress plays a role in cell apoptosis, the mRNA and protein expression of known markers of ER stress [glucose-regulated protein (GRP)78 and C/EBP homologous protein (CHOP)] was detected by reverse transcription PCR (RT-PCR), quantitative reverse transcription PCR (qRT-PCR) and western blot analysis. Our results revealed that apoptosis aggravated ER stress, as shown by the overexpression of the pro-apoptotic sensor, CHOP. In conclusion, our study demonstrates the converging role of oxLDL pre-treatment, IVA infection and IMQ in ER stress-induced cell apoptosis.

Acute infection contributes to racial disparities in stroke mortality

OBJECTIVE

It is unknown whether racial differences in exposure to acute precipitants of stroke, specifically infection, contribute to racial disparities in stroke mortality.

METHODS

Among participants in the nationally representative Health and Retirement Study with linked Medicare data (1991-2007), we conducted a case-crossover study employing within-person comparisons to study racial/ethnic differences in the risks of death and hospitalization from ischemic stroke following acute infection.

RESULTS

There were 964 adults hospitalized for ischemic stroke. Acute infection increased the 30-day risks of ischemic stroke death (5.82-fold) and ischemic stroke hospitalization (1.87-fold). Acute infection was a more potent trigger of acute ischemic stroke death in non-Hispanic blacks (odds ratio [OR] 39.21; 95% confidence interval [CI] 9.26-166.00) than in non-Hispanic whites (OR 4.50; 95% CI 3.14-6.44) or Hispanics (OR 5.18; 95% CI 1.34-19.95) (race-by-stroke interaction, p = 0.005). When adjusted for atrial fibrillation, infection remained more strongly associated with stroke mortality in blacks (OR 34.85) than in whites (OR 3.58) and Hispanics (OR 3.53). Acute infection increased the short-term risk of incident stroke similarly across racial/ethnic groups. Infection occurred often before stroke death in non-Hispanic blacks, with 70% experiencing an infection in the 30 days before stroke death compared to a background frequency of 15%.

CONCLUSIONS

Acute infection disproportionately increases the risk of stroke death for non-Hispanic blacks, independently of atrial fibrillation. Stroke incidence did not explain this finding. Acute infection appears to be one factor that contributes to the black-white disparity in stroke mortality.

Influenza vaccine for cardiovascular risk reduction

Cardiovascular disease is a leading cause of morbidity and mortality. Individuals with underlying cardiovascular disease are at high risk for adverse outcomes from influenza infections. Although additional studies are needed, current evidence suggests the influenza vaccine may reduce the risk of cardiovascular death and coronary events. In addition to their overall efforts to encourage influenza vaccination for all eligible persons, pharmacists should pay special attention to these high-risk individuals.

Influenza vaccine and survival in acute heart failure

AIMS

Influenza vaccine is a well-recommended secondary prevention measure for improving survival in patients with coronary artery disease, but it has generally been less studied in heart failure. We ask whether having influenza vaccination is associated with survival among patients with acute heart failure (HF).

METHODS AND RESULTS

This was a prospective population-based cohort study accompanied by an analysis of two cross-sectional population samples for external validation of baseline characteristics differences. We analysed all 1964 ambulatory patients with acute HF aged ≥50 years who were admitted to the Heart Failure Survey in Israel (HFSIS). We used the Israel Health Survey (IHS) 2009 and the Behavioural Risk Factor Surveillance System (BRFSS) 2003-2004 surveys (274 535 participants) for external validation. In the HFSIS, the multivariate-adjusted hazard ratios for in-hospital, 1 and 4 year mortality outcomes of influenza-vaccinated patients were 0.71 (P = 0.19), 0.81 (P = 0.04), and 0.83 (P = 0.006), respectively. In the IHS validation sample, a recent physician visit [odds ratio (OR) 1.61; 95% confidence interval (CI) 1.43-1.80] or having supplementary health insurance (OR 1.39; 95% CI 1.19-1.61) were associated with higher likelihood of being vaccinated against influenza. In the BRFSS validation sample, having > 1 healthcare providers (OR 2.31; 95% CI 2.22-2.40) or having any healthcare coverage were associated with higher likelihood of being vaccinated (OR 1.59; 95% CI 1.54-1.65).

CONCLUSIONS

Influenza vaccine might improve survival among patients with acute HF. This association, however, could be affected by unmeasured confounding and bias due to baseline medical surveillance and socioeconomic differences between vaccinated and non-vaccinated patients.

Atherosclerosis and infection: is the jury still not in?

Atherosclerosis is a chronic inflammatory process accounting for increased cardiovascular and cerebrovascular morbidity and mortality. A wealth of recent data has implicated several infectious agents, mainly Chlamydophila pneumoniae, Helicobacter pylori, CMV and periodontal pathogens, in atherosclerosis. Thus, we sought to comprehensively review the available data on the topic, exploring in particular the pathogenetic mechanisms, and discuss anticipated future directions.

Can noncommunicable diseases be prevented? Lessons from studies of populations and individuals

Noncommunicable diseases (NCDs)--mainly cancers, cardiovascular diseases, diabetes, and chronic respiratory diseases--are responsible for about two-thirds of deaths worldwide, mostly in low- and middle-income countries. There is an urgent need for policies and strategies that prevent NCDs by reducing their major risk factors. Effective approaches for large-scale NCD prevention include comprehensive tobacco and alcohol control through taxes and regulation of sales and advertising; reducing dietary salt, unhealthy fats, and sugars through regulation and well-designed public education; increasing the consumption of fresh fruits and vegetables, healthy fats, and whole grains by lowering prices and improving availability; and implementing a universal, effective, and equitable primary-care system that reduces NCD risk factors, including cardiometabolic risk factors and infections that are precursors to NCDs, through clinical interventions.