Vaccination Is the Fourth Pillar of CVD Prevention

This transcript has been edited for clarity. It's that time of year again, where we talk to patients about annual vaccinations. We're all familiar with the benefits of respiratory vaccines — influenza, COVID, RSV — on decreasing hospitalization from respiratory illness. However, most of us are not as familiar with the effects of these vaccines on cardiac outcomes, and what is astonishing is those effects are in the range of what we get when we treat hypertension, cholesterol, and diabetes. That is what is addressed in the European Society of Cardiology's consensus statement on vaccination. The statement suggests that we view vaccination as a new form of cardiovascular disease prevention.We treat hypertension. We treat high lipids. We treat diabetes. We recommend smoking cessation. These are all methods to decrease the likelihood of patients developing future cardiac disease. We should view vaccination in a similar light. This is important because I see a lot of patients who say things like, "I don't need the flu vaccine because I don't get the flu, and if I get it, it's never that bad." Well, the truth is they've never had a heart attack or a stroke, but we're treating high blood pressure and high cholesterol, nonetheless. And according to this consensus statement, vaccination falls into the same category.For high-risk patients, including those who have and who have not had previous vascular disease events, the increase in risk for major adverse cardiac events (MACE) with both viral and bacterial infections is clear. The infections can increase myocardial oxygen consumption, often can cause prothrombotic systemic effects, and stimulate systemic inflammatory pathways. All of this can lead to coronary plaque rupture, which in turn can lead to myocardial infarction (MI) and arrhythmias. This can cause stroke as well as depressed myocardial contractility, which can lead to heart failure exacerbations. The question, then, is whether vaccination decreases the likelihood of MACE. The consensus statement goes over this evidence. They cite, for instance, one meta-analysis that included over 9000 individuals and found that in patients with a history of acute coronary syndromes, subsequent influenza infection was associated with about a 5% risk for death, and vaccination lowered that risk by almost half. This level of benefit has been confirmed in multiple large meta-analyses, observational trials, and one randomized trial. A number of studies have looked at individuals who were hospitalized with acute MI and have shown that vaccinating them during that hospitalization for an MI led to an almost 50% decrease in cardiovascular mortality. That level of effect is greater over a pretty short period of time than we get with many traditional interventions.Another study showed that in older patients, high-dose influenza vaccine, when compared to standard dose, led to a greater reduction in cardiovascular and respiratory events.How about RSV? Cardiac events can occur in about 20% of individuals with prior cardiac conditions during infection with RSV. There's one large trial that is currently underway, but to date, there's no strong, clear evidence about the cardiovascular benefit of RSV vaccine.How about COVID? We know that COVID vaccination can reduce the severity of COVID infection, as well as hospitalization and death from COVID in people who are at high risk for severe disease.Although a number of studies have demonstrated a decrease in MACE in the first 2 years of the pandemic, the question has been raised about whether this is still true in an era where people have a high level of immunity, both from vaccination and natural infection. Well, that question has been answered by a large cohort study of over a million individuals which showed that receipt of the 2024-2025 COVID-19 vaccine was associated with a 38% lower risk for major cardiac events. This was statistically significant among individuals over 75 years of age, where the vaccine led to approximately a 50% decrease in COVID-associated MACE.What's also interesting is that the absolute benefit was larger when all-cause MACE was analyzed. The researchers found a 24% decrease in all-cause MACE after COVID vaccination. This suggests that there was an effect of vaccination on decreasing the thrombotic and inflammatory milieu and subsequent MACE, even in COVID that was less severe and did not lead to hospitalization.Finally, let's cover pneumococcal vaccine. A meta-analysis has shown that vaccination with pneumococcal polysaccharide vaccine led to a 10% reduction in any cardiovascular event, including MI, in people over 65 years of age. So, in summary, the ESC consensus statement concludes that for high-risk patients, given the level of effect of vaccination in cardiovascular outcomes, vaccination should be considered a fourth pillar of medical cardiovascular disease prevention, standing right beside antihypertensives, lipid-lowering agents, and medications that treat diabetes.This is a big deal, let me say. We and our patients spend a lot of time and effort doing things to decrease the risk for heart attack, stroke, heart failure, and death. We treat hypertension, we treat high cholesterol, we treat diabetes, and we engage in smoking cessation. This all takes a lot of effort, and when patients view vaccines as only helping them avoid symptomatic illness, they miss the important benefits of the vaccines in decreasing hospitalization and decreasing cardiac endpoints.My experience is that it doesn't take long to explain this concept to patients, and patients then truly understand. The right information at the right time matters. For high-risk patients who are deciding about vaccines, the fact that these vaccinations are protective against MI and stroke, and decrease the risk for cardiovascular death, makes a difference, and it doesn't take long to communicate that.I'm interested in your thoughts. Please leave them in the comments section. For Medscape, I'm Dr Neil Skolnik.