New Vaccine Guidance from the American College of Cardiology Focuses on Adults with Heart Disease

The American College of Cardiology (ACC) has issued new Concise Clinical Guidance (CCG) on vaccination in adults with cardiovascular disease (CVD), underscoring the importance of respiratory vaccines—including influenza, COVID-19, and respiratory syncytial virus (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 cardiovascular disease 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.”

Influenza Immunization and CVD Risk

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 six-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. Furthermore, immunization not only prevents influenza illness but also mitigates the risk of adverse cardiovascular sequelae.

Pneumococcal Vaccination: Evidence Beyond Infection Control

Streptococcus pneumoniae, 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 U.S., with a mortality rate ranging from 10% to 20%, escalating with age and comorbidities. Remarkably, 90% of adults hospitalized with pneumococcal pneumonia or invasive disease present with one or more chronic conditions. Notably, acute cardiovascular events frequently complicate pneumonia episodes, underscoring the necessity for vaccination.

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 with heart disease, in alignment with CDC guidelines.

COVID-19 Vaccination: Cardiac Protection Perspectives

The pandemic engendered a substantial reduction in U.S. life expectancy, disproportionately impacting individuals with heart disease and amplifying their risk of severe disease three-fold. Benefits of immunization include reductions in overall infection risk, severe outcomes (myocardial infarction, pericarditis/myocarditis, stroke, atrial fibrillation), and long COVID symptoms. Cardiovascular clinicians 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 cardiovascular disease 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. Patients 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 cardiovascular events, as evidenced by observational studies and large cohort analyses—including durable reductions in myocardial infarction, stroke, heart failure, and arrhythmia lasting up to eight years post-vaccination.

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

The ACC notes that vaccination should be considered a core component of cardiovascular risk reduction, complementing established strategies such as lipid and blood pressure control, antithrombotic therapy, and smoking cessation. By integrating vaccine assessment and counseling into routine care, clinicians can address a frequently overlooked determinant of outcomes in patients with cardiovascular disease, reinforcing a more comprehensive approach to secondary prevention.