Heart Failure Outcomes Improved With Respiratory Vaccination

A new review published in JACC Heart Failure explored research pertaining to the link between heart failure (HF) outcomes and respiratory vaccination.¹

According to previous findings, respiratory infection precipitates approximately 50% of HF exacerbations and represents the top cause of HF hospitalization.^2,3 Vaccination against such infections may help reduce these outcomes and associated cost, morbidity, and mortality, although few studies have directly investigated this relationship. The Centers for Disease Control and Prevention (CDC) has recommended annual influenza vaccination for adults with chronic cardiovascular disease (CVD).⁴

It has been proposed that the influenza vaccine may buffer the effects of infection-induced inflammation on myocardial contractility, fibrosis, and atherogenesis, and that the pneumococcal pneumonia vaccine may prevent atherogenesis by impairing low-density lipoprotein oxidation.^5,6 “A direct link between vaccination-induced reduction in atherogenesis and the HF phenotype is not yet clearly established, though it would be theorized to reduce the incidence and progression of ischemic cardiomyopathy,” the researchers of the current paper wrote.

The researchers from Duke University Medical Center in Durham, North Carolina, examined evidence regarding these vaccines in patients with CVD in general and HF in particular. Notable relevant findings were:

• In the Flu Vaccination Acute Coronary Syndromes (FLUVACS) study, CVD mortality was lower in vaccinated vs unvaccinated patients who were admitted to the hospital for myocardial infarction or planned percutaneous coronary intervention.⁷
• A randomized placebo-controlled trial of patients post-acute coronary syndrome found lower rates of all-cause mortality and hospitalization in patients who were vaccinated.⁸
• An epidemiologic study of 140,000 patients reported a 19% reduction in CVD hospitalization in vaccinated vs unvaccinated patients, including 72 fewer HF hospitalizations during a particular flu season.⁹
• In a case series of patients with HF, patients who had been vaccinated against influenza had lower rates of all-cause hospitalization and CVD hospitalization.¹⁰

Additional research indicates that patients with HF have a weaker immune response to vaccination and thus may benefit from a high-dose vaccination (30 ug hemagglutinin) vs a standard-dose vaccination (15 ug hemagglutinin).¹¹

Although there is a significant need for further research on the effect of vaccination on HF outcomes, the evidence to date suggests that it “represents a low-cost intervention that may be able to [prevent] the significant morbidity, mortality, and system-wide cost[s] associated with HF,” the researchers concluded.

Disclosures: Drs Devore, Hernandez, and Mentz report research support from numerous sources, including Amgen, Bristol-Myers Squibb, GlaxoSmithKline, Gilead, Medtronic, Novartis, and Thoratec/St. Jude Medical. 

References

1. Bhatt AS, DeVore AD, Hernandez AF, Mentz RJ. Can vaccinations improve heart failure outcomes? Contemporary data and future directions [published online February 1, 2017]. JACC Heart Fail. doi:10.1016/j.jchf.2016.12.007
2. Alon D, Stein GY, Korenfeld R, Fuchs S. Predictors and outcomes of infection-related hospital admissions of heart failure patients. PLoS One. 2013; 8(8):e72476. doi:10.1371/journal.pone.0072476
3. Fonarow GC, Abraham WT, Albert NM, et al. Factors identified as precipitating hospital admissions for heart failure and clinical outcomes: findings from OPTIMIZE-HF. Arch Intern Med. 2008;168(8):847-854. doi:10.1001/archinte.168.8.847
4. Harper SA, Fukuda K, Uyeki TM, Cox NJ, Bridges CB. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomms Rep. 2004;53(RR-6):1-40.
5. Posthouwer D, Voorbij HA, Grobbee DE, Numans ME, van der Bom JG. Influenza and pneumococcal vaccination as a model to assess C-reactive protein response to mild inflammation. Vaccine. 2004;23(3):362-365.
6. Binder CJ, Hörkkö S, Dewan A, et al. Pneumococcal vaccination decreases atherosclerotic lesion formation: molecular mimicry between Streptococcus pneumoniae and oxidized LDL. Nat Med. 2003;9(6):736-743.
7. Gurfinkel EP, Leon de la Fuente R, Mendiz O, Mautner B. Flu vaccination in acute coronary syndromes and planned percutaneous coronary interventions (FLUVACS) study. Eur Heart J. 2004;25(1):25-31.
8. Phrommintikul A, Kuanprasert S, Wongcharoen W, Kanjanavanit R, Chaiwarith R, Sukonthasarn A. Influenza vaccination reduces cardiovascular events in patients with acute coronary syndrome. Eur Heart J. 2011; 32(14):1730-1735. doi:10.1093/eurheartj/ehr004
9. Nichol KL, Nordin J, Mullooly J, Lask R, Fillbrandt K, Iwane M. Influenza vaccination and reduction in hospitalizations for cardiac disease and stroke among the elderly. N Engl J Med. 2003;348(14):1322-1332.
10. Mohseni H, Kiran A, Khorshidi R, Rahimi K. Influenza vaccination and risk of hospitalization in patients with heart failure: a self-controlled case series study [published online September 21, 2016]. Eur Heart J. doi:10.1093/eurheartj/ehw411
11. Van Ermen A, Hermanson MP, Moran JM, Sweitzer NK, Johnson MR, Vardeny O. Double dose vs standard dose influenza vaccination in patients with heart failure: a pilot study. Eur J Heart Fail. 2013;15(5):560-564. doi:10.1093/eurjhf/hfs207