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## Complete Summary

#### GUIDELINE TITLE

Influenza vaccination as secondary prevention for cardiovascular
disease. A science advisory from the American Heart Association/American
College of Cardiology: endorsed by the American Association of
Cardiovascular and Pulmonary Rehabilitation, the American Association of
Critical Care Nurses, the American Association of Heart Failure Nurses,
the American Diabetes Association, the Association of Black
Cardiologists, Inc., the Heart Failure Society of America, and the
Preventive Cardiovascular Nurses Association. The American Academy of
Nurse Practitioners supports the recommendations of this scientific
advisory. This science advisory is consistent with the recommendations
of the Centers for Disease Control and Prevention and the Advisory
Committee on Immunization Practices.

#### BIBLIOGRAPHIC SOURCE(S)

Davis MM, Taubert K, Benin AL, Brown DW, Mensah GA, Baddour LM, Dunbar
S, Krumholz HM, American Heart Association, American College of
Cardiology. Influenza vaccination as secondary prevention for
cardiovascular disease: a science advisory from the American Heart
Association/American College of Cardiology. Circulation 2006 Oct
3;114(14):1549-53. \[33 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16982936)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Influenza

-   Cardiovascular disease (CVD)

#### GUIDELINE CATEGORY

Prevention

#### CLINICAL SPECIALTY

Cardiology\
Family Practice\
Infectious Diseases\
Nursing\
Pediatrics\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Physician Assistants\
Physicians\
Public Health Departments

#### GUIDELINE OBJECTIVE(S)

To equip practitioners with the information they need to adopt these
recommendations into practice and ensure that cardiovascular patients
have routine, annual influenza vaccination

#### TARGET POPULATION

Children and adults with chronic conditions, including cardiovascular
disease (CVD) and diabetes

#### INTERVENTIONS AND PRACTICES CONSIDERED

Vaccination against seasonal influenza (inactivated influenza vaccine)

#### MAJOR OUTCOMES CONSIDERED

-   Target vaccination rates

-   Effectiveness of influenza vaccine for secondary prevention of
    cardiovascular events

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Level of Evidence**

**Level of Evidence A** Data derived from multiple randomized clinical
trials or meta-analyses.

**Level of Evidence B** Data derived from a single randomized trial or
nonrandomized studies.

**Level of Evidence C** Only consensus opinion of experts, case studies,
or standard-of-care.

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Class of Recommendation**

**Class I** Conditions for which there is evidence and/or general
agreement that a given procedure/therapy is beneficial, useful, and
effective.

**Class II** Conditions for which there is conflicting evidence and/or a
divergence of opinion about the usefulness/efficacy of performing the
procedure/therapy.

**Class IIa** Weight of evidence/opinion is in favor of
usefulness/efficacy.

**Class IIb** Usefulness/efficacy is less well established by
evidence/opinion.

**Class III** Conditions for which there is evidence and/or general
agreement that a procedure/therapy is not useful or effective and in
some cases may be harmful.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

This statement was approved by the American Heart Association Science
Advisory and Coordinating Committee on August 11, 2006, and by the
American College of Cardiology Foundation Board of Trustees on August 7,
2006.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions for the weight of the evidence (Class I-III and Level A-C)
can be found at the end of the \"Major Recommendations\" field.

Seasonal influenza represents a major preventable threat to the health
of persons with cardiovascular disease (CVD). Clinical trials and
observational studies have demonstrated that vaccination against
influenza is associated with significantly reduced risk of
cardiovascular death and nonfatal events. Vaccination is currently
recommended for persons with diabetes, a condition common to patients
with CVD. On the basis of this evidence, the American Heart Association
(AHA) and American College of Cardiology (ACC) recommend inactivated
influenza vaccination as a component of secondary prevention for persons
with coronary disease and other atherosclerotic vascular conditions
(**Class I, Level B**). This level of recommendation is based on the
judgment that influenza vaccination should be administered to all
persons with CVD (unless they have a contraindication to receiving the
vaccine) and on evidence from a single randomized clinical trial and
several nonrandomized population cohort studies.

Currently, below-target vaccination rates and disparities in vaccination
coverage across different ethnic groups represent missed opportunities
to maximize the preventive benefits of influenza vaccination. Providers
who care for patients with CVD can increase influenza vaccination
coverage among their patients by stocking the vaccine and promoting
annual vaccination immunization with strong recommendations and standing
orders.

**[Definitions]{.underline}**:

**Classification of Recommendations**

**Class I** Conditions for which there is evidence and/or general
agreement that a given procedure/therapy is beneficial, useful, and
effective.

**Class II** Conditions for which there is conflicting evidence and/or a
divergence of opinion about the usefulness/efficacy of performing the
procedure/therapy.

**Class IIa** Weight of evidence/opinion is in favor of
usefulness/efficacy.

**Class IIb** Usefulness/efficacy is less well established by
evidence/opinion.

**Class III** Conditions for which there is evidence and/or general
agreement that a procedure/therapy is not useful or effective and in
some cases may be harmful.

**Level of Evidence**

**Level of Evidence A** Data derived from multiple randomized clinical
trials or meta-analyses.

**Level of Evidence B** Data derived from a single randomized trial or
nonrandomized studies.

**Level of Evidence C** Only consensus opinion of experts, case studies,
or standard-of-care.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Influenza vaccination is associated with a significantly reduced risk of
cardiovascular events for individuals with known coronary and other
atherosclerotic conditions, including prior cerebrovascular accident.

#### POTENTIAL HARMS

Anaphylactic hypersensitivity to the inactivated influenza vaccine

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   It is currently recommended that individuals with cardiovascular
    disease (CVD) not receive the live, attenuated influenza vaccine
    because it has not been approved for use in persons with CVD or
    other conditions that increase the risk of influenza-related
    complications.

-   Persons with known anaphylactic hypersensitivity to eggs or a
    history of Guillain-Barre syndrome should not receive the
    inactivated influenza vaccine without first consulting a physician.
    If a person eligible for vaccination has moderate-to-severe acute
    febrile illness, vaccination should be delayed until symptoms have
    resolved.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

**Low Vaccination Coverage Rates Among Persons With Cardiovascular
Disease (CVD)**

The American Heart Association (AHA) American College of Cardiology
(ACC) recommend that the \>12 million persons in the United States with
cardiovascular conditions get annual influenza vaccination. Current
influenza vaccination coverage among persons with heart disease is far
below national coverage goals set in Healthy People 2010 (\>60% for
persons [\<]{.underline}65 years of age; \>90% for persons
[\>]{.underline}65 years of age): Only 1 in every 3 adults with heart
disease (34%) received influenza vaccination in 2005, a level of
coverage that is essentially unchanged from other below-target rates
achieved in 2002. In 2005, vaccination coverage among older adults
([\>]{.underline}65 years old) with heart disease was much higher (71%)
than among middle-aged (50 to 64 years old) and younger (18 to 49 years
old) adults with heart disease (41% and 23%, respectively). Non-Hispanic
white adults had similar influenza vaccination rates (38%) to black
adults (36%), but rates in both groups were higher than among Hispanic
adults (30%).

Failure to vaccinate persons with cardiovascular conditions and
disparities in vaccination coverage across age categories and ethnic
groups represent major opportunities for healthcare providers to improve
the care of this patient population. A central barrier to vaccination
against influenza is that only about one half of cardiology practices
nationwide stock influenza vaccine, as opposed to \>70% of endocrinology
practices and of generalist primary care practices and \>90% of
pulmonology practices.

Outpatient visits to cardiology practices present a superb but
frequently missed opportunity to administer influenza vaccine to
millions of adults with CVD, as do outpatient visits in primary care
settings and hospitalizations for cardiovascular causes. A recent study
suggests that the most effective ways to improve influenza vaccination
rates among nonelderly adults with heart disease are for cardiology
practices to have influenza vaccine available in their offices for
patient visits, for cardiovascular care providers to strongly recommend
vaccination to their patients during vaccination season, and for
practices to implement standing-orders protocols that permit staff to
administer influenza vaccine to patients with cardiovascular indications
without waiting in each case for a physician\'s order.

It is important to emphasize that strong recommendations from health
professionals about vaccination against influenza can be very
influential, especially for urban, predominantly black patients.
Patient-level barriers to influenza vaccination, specifically for
persons with CVD, have not been well characterized and should be
examined in future research.

Providers and practices that provide care for patients with CVD should
stock influenza vaccine annually. There is a choice of manufacturers,
and the vaccines are considered equally effective. Ordering information
for all manufacturers licensed to provide influenza vaccine in the
United States for the 2006/2007 season is provided on the American Heart
Association Web site (www.americanheart.org) and in the Table.

**Table. How Providers Can Place an Order for Influenza Vaccine in the
United States**

  ---------------------- ----------------------------------------------------------------
  **Influenza Vaccine    **How to Order for the 2006/2007 Influenza Season^+,++^**
  Manufacturers\*\       
  (Alphabetical Order)** 

  GlaxoSmithKline        Call Fluarix Service Center at 1-866-475-8222 (choose option 1).

  Novartis (formerly     Call 1-800-244-7668 (choose option 2) to receive a list of
  Chiron)                vaccine distributors in your area.

  Sanofi Pasteur         Set up a provider account and then place order at
                         [http://www.vaccineshoppe.com](http://www.vaccineshoppe.com/).
  ---------------------- ----------------------------------------------------------------

\*These are manufacturers of inactivated trivalent influenza vaccine.
Live, attenuated intranasal influenza vaccine (FluMist;MedImmune) is not
recommended for individuals with cardiovascular conditions.

^+^Providers are encouraged to order vaccine in the spring and summer
for delivery in the fall before each influenza season.

^++^Providers who wish to have more information about influenza vaccine
should contact their local or state public health departments.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Davis MM, Taubert K, Benin AL, Brown DW, Mensah GA, Baddour LM, Dunbar
S, Krumholz HM, American Heart Association, American College of
Cardiology. Influenza vaccination as secondary prevention for
cardiovascular disease: a science advisory from the American Heart
Association/American College of Cardiology. Circulation 2006 Oct
3;114(14):1549-53. \[33 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16982936)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006 Oct 3

#### GUIDELINE DEVELOPER(S)

American College of Cardiology Foundation - Medical Specialty Society\
American Heart Association - Professional Association

#### SOURCE(S) OF FUNDING

American Heart Association

#### GUIDELINE COMMITTEE

Writing Group

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Authors*: Matthew M. Davis, MD, MAPP; Kathryn Taubert, PhD,
FAHA; Andrea L. Benin, MD; David W. Brown, MSPH, MSc; George A. Mensah,
MD, FAHA, FACC; Larry M. Baddour, MD; Sandra Dunbar, RN, DSN, FAHA;
Harlan M. Krumholz, MD, FAHA, FACC

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The findings and conclusions in this report are those of the authors and
do not necessarily represent the views of the Centers for Disease
Control and Prevention. The American Heart Association and the American
College of Cardiology make every effort to avoid any actual or potential
conflicts of interest that may arise as a result of an outside
relationship or a personal, professional, or business interest of a
member of the writing panel. Specifically, all members of the writing
group are required to complete and submit a Disclosure Questionnaire
showing all such relationships that might be perceived as real or
potential conflicts of interest.

**Writing Group Disclosures**

  --------------------------------------------------------------------------------------------------------------------------------------
  **Writing   **Employment**   **Research   **Other     **Speakers\'   **Honoraria**   **Ownership   **Consultant/Advisory   **Other**
  Group                        Grant**      Research    Bureau**                       Interest**    Board**                 
  Member**                                  Support**                                                                        
  ----------- ---------------- ------------ ----------- -------------- --------------- ------------- ----------------------- -----------
  Larry M.    Mayo Clinic      None         None        None           None            None          None                    None
  Baddour                                                                                                                    

  Andrea L.   Yale New Haven   None         None        None           None            None          None                    None
  Benin       Health System                                                                                                  

  David W.    Centers for      None         None        None           None            None          None                    None
  Brown       Disease Control                                                                                                
              and Prevention                                                                                                 

  Matthew M.  University of    None         None        None           None            None          None                    None
  Davis       Michigan                                                                                                       

  Sandra      Emory University None         None        None           None            None          None                    None
  Dunbar                                                                                                                     

  Harlan M.   Yale University  None         None        None           None            None          None                    None
  Krumholz                                                                                                                   

  George A.   Centers for      None         None        None           None            None          None                    None
  Mensah      Disease Control                                                                                                
              and Prevention                                                                                                 

  Kathryn     American Heart   None         None        None           None            None          None                    None
  Taubert     Association                                                                                                    
  --------------------------------------------------------------------------------------------------------------------------------------

This table represents the relationships of writing group members that
may be perceived as actual or reasonably perceived conflicts of interest
as reported on the Disclosure Questionnaire, which all members of the
writing group are required to complete and submit.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Heart Association Web
site](http://circ.ahajournals.org/cgi/content/full/114/14/1549).

Print copies: Available from the American Heart Association, Public
Information, 7272 Greenville Ave, Dallas, TX 75231-4596; Phone:
800-242-8721

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Methodology manual for ACC/AHA guideline writing committees.
    Available from the [American Heart Association Web
    site](http://www.americanheart.org/presenter.jhtml?identifier=3039684).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on March 13, 2007. The information
was verified by the guideline developer on April 20, 2007.

#### COPYRIGHT STATEMENT

Copyright to the original guideline is owned by the American Heart
Association, Inc. (AHA). Reproduction of the AHA Guideline without
permission is prohibited. Single reprint is available by calling
800-242-8721 (US only) or writing the American Heart Association, Public
Information, 7272 Greenville Ave., Dallas, TX 75231-4596. Ask for
reprint No. 71-0276. To purchase additional reprints: up to 999 copies,
call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies,
call 410-528-4121, fax 410-528-4264, or email <kgray@lww.com>. To make
photocopies for personal or educational use, call the Copyright
Clearance Center, 978-750-8400.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008