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A 59-year-old woman with chronic hepatitis C presented with abdominal pain that had grown progressively worse during the past 3 months.

Intracranial Bleeding From Cerebral Amyloid Angiopathy

A 66-year-old woman had a mildly pruritic rash on the buttocks, lower back, abdomen, and upper posterior thighs. The eruption had been present for approximately 18 months.

A 66-year-old woman had a mildly pruritic rash on the buttocks, lower back, abdomen, and upper posterior thighs. The eruption had been present for approximately 18 months. Your diagnosis?

Clinical Topics

“Swimsuit Area” Rash: Your Dx?

A 5-year-old boy with a history of atopic dermatitis since 6 weeks of age, presents with a rash around his mouth that has been present for approximately 1 year. The patient’s mother reports that desonide topical cream was applied to the affected area for about 5 days, which initially resulted in improvement, however the rash returned after this medication was discontinued. The rash also recently improved after the patient took amoxicillin for an infection. She also notes that the patient has been licking his lips more frequently.

On examination there is an erythematous papulopustular eruption restricted to the perioral region, with sparing of the vermillion border. Mild hyperpigmentation is noted on the patient’s neck. There is no active involvement of other areas of the body.

The eruption has been present for 1 year and is restricted to the perioral region. What is included in your differential? 

Rash Around the Mouth of a 5-year-old Child

This mobile tender nodule was discovered on the left wrist of a 60-year-old woman with a history of many non-melanoma skin cancers.

This mobile tender nodule was discovered on the left wrist of a 60-year-old woman with a history of many non-melanoma skin cancers. What’s your best diagnostic guess? 

Another Non-Melanoma Skin Cancer?

A 68-year-old man presented with two growths on his chest, which he said had been slowly expanding over the past 2 years. They were occasionally tender and had bled with minimal trauma.

Can you identify the 2 slowly expanding growths on the chest of this 68-year-old man?

Pearly Pink Chest Lesions 

The American College of Cardiology (ACC) has issued new Concise Clinical Guidance (CCG) on vaccination in adults with 

 (CVD), underscoring the importance of respiratory vaccines—including 

 (RSV)—as part of standard prevention and treatment strategies. The guidance consolidates recommendations from prior ACC/AHA guidelines and the Centers for Disease Control and Prevention (CDC), while also reviewing emerging evidence that certain vaccines, eg, against  herpes zoster, may confer additional CV protection.

Patients with CVD face both a heightened risk of infection when exposed to respiratory viruses and a disproportionate risk of adverse outcomes, including hospitalization and death. Despite clear evidence that vaccination substantially mitigates these risks, uptake in practice remains suboptimal. A recent study cited by the ACC found that only 30% of primary care physicians routinely assess vaccination status during clinic visits,

 highlighting missed opportunities for prevention.

“Vaccination against communicable respiratory diseases and other serious diseases is critical for people with heart disease, but barriers exist to ensuring people are educated on which vaccines to get, how often to get them and why they are important,” Paul Heidenreich, MD, chair of the CCG writing committee, said in a statement.

 “With this document, we want to encourage clinicians to have these conversations and help their patients manage vaccination as part of a standard prevention and treatment plan.”

Annual immunization against influenza remains a cornerstone of preventive care in adults with heart disease. The 2023-2024 influenza season recorded approximately 18 million medical visits, 470,000 hospitalizations, and 28,000 deaths in the United States.

 Influenza infection increases the risk of acute myocardial infarction 6-fold and carries heightened complications for those living with CVD, including secondary infections and acute cardiovascular clinical events such as heart failure exacerbations.

ACC recommends annual injection-based influenza vaccines for all adults, with avoidance of nasal formulations in those over age 50. As immune response to flu vaccine wanes with aging, current CDC guidance recommends administering an enhanced vaccine formulation (ie, 

high dose, recombinant or adjuvanted formulations)

Pneumococcal Vaccination: Evidence Beyond Infection Control

, responsible for pneumonia, bacteremia, and meningitis, consists of over 100 capsular serotypes and poses a significant threat to individuals with chronic coronary conditions and older adults. Pneumococcal pneumonia contributes to an estimated 225,000 adult hospitalizations annually in the US,

 with a mortality rate ranging from 10% to 20%, escalating with age and comorbidities. This latter point is critical as approximately 90% of adults hospitalized with pneumococcal pneumonia or invasive disease present with at least 1 chronic condition.

 Further, acute CV  events frequently complicate pneumonia episodes, underscoring the necessity for vaccination.1 

Current national recommendations for pneumococcal vaccination for adults are: All adults aged 50 years and older who have not previously received a PCV and all adults aged 19 to 49 years with a chronic medical risk condition. Specifically, in accordance with CDC guidelines, the ACC guidance advises a single dose of PCV20 or PCV21, or PCV15 followed by PPSV23 depending on prior immunization status, in adults aged 19 or older with chronic medical conditions, in alignment with CDC guidelines.

COVID-19 Vaccination: Cardiac Protection Perspectives

The COVID-19 pandemic led to a nearly 3-year decline in US life expectancy, disproportionately impacting individuals with heart disease and amplifying their risk of severe disease by 3-fold.

 Benefits of immunization include reductions in overall infection risk, severe outcomes (myocardial infarction, pericarditis/myocarditis, stroke, atrial fibrillation), and long COVID symptoms. Cardiologists must remain vigilant about vaccination discussions, as CVD patients experience higher incidence and severity of COVID-19 complications.

For the 2024-25 season, adults with CVD should receive the seasonal COVID-19 vaccine, with future frequency subject to adjustment based on evolving epidemiological trends.

RSV Vaccine: Expanding Respiratory Protection

Respiratory syncytial virus (RSV) constitutes an under-recognized cause of morbidity in older adults, producing annual winter epidemics comparable in impact to influenza among vulnerable populations.

 While RSV has long been linked to pediatric illness, accumulating data confirm its significance in adults, resulting in approximately 60,000 to 160,000 hospitalizations and 6,000 to 10,000 deaths annually for adults aged 65 and older.

 As of June 2025, two subunit protein vaccines and one mRNA vaccine (pending further approval for expanded use) address RSV risk in adults 50 years and older.

ACC’s guidance recommends a single dose for adults 75 and older, and for those aged 50 to 74 with cardiovascular disease, specifically to prevent lower respiratory tract complications leading to hospitalization and death.

Shingles Immunization and Cardiovascular Implications

Herpes zoster infection provokes an inflammatory response that augments the risk of stroke and myocardial infarction, guidance authors wrote, and individuals with CVD are disproportionately susceptible to zoster infection and its sequelae. The zoster vaccine has demonstrated not only efficacy in reducing infectious burden but also significant benefits in lowering CV events, including reductions in myocardial infarction, stroke, heart failure, and arrhythmia lasting up to 8  years postvaccination.9 

The ACC guidance recommends a 2-dose vaccine regimen for adults 50 years or older, with particular attention to those with CVD. 

The ACC guidance also discusses strategies to improve vaccination rates, address vaccine hesitancy, and overcome barriers to access, noting that clinician-patient discussions about vaccination during cardiology visits can be an important opportunity to integrate vaccination into a CV care plan, complementing and augmenting established strategies such as lipid and blood pressure control, antithrombotic therapy, and smoking cessation. 

How to Address Barriers to Immunization for Adults with Cardiovascular Disease

8 FAQs About Vaccination From Patients With Cardiovascular Disease, from the ACC Concise Clinical Guideline 

Heidenreich PA, Bhatt A, Nazir NT, Schaffner W, Vardeny O. 2025 concise clinical guidance: an ACC expert consensus statement on adult immunizations as part of cardiovascular care. 

Lu PJ, Hung MC, Srivastav A, et al. Surveillance of vaccination coverage among adult populations - United States, 2018. 

Kwong JC, Schwartz KL, Campitelli MA, et al. Acute myocardial infarction after laboratory-confirmed influenza infection. 

Self WH, Johnson KD, Resser JJ, et al. Prevalence, clinical severity, and serotype distribution of pneumococcal pneumonia among adults hospitalized with community-acquired pneumonia in Tennessee and Georgia, 2018-2022. 

New ACC guidance emphasizes the critical role of vaccinations in reducing infection risks and improving outcomes for adults with cardiovascular disease.

Potjana Jitawatanarat, MD

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