2025 ACC Concise Clinical Guidance: Adult Immunizations as Part of Cardiovascular Care

Authors, Journal, Affiliations, Type, DOI

• Heidenreich PA, Bhatt A, Nazir NT, Schaffner W, Vardeny O, Dudzinski DM, Gulati M, Hendel R, Krittanawong C, Wiggins B
• Journal of the American College of Cardiology (JACC), Vol. 86, No. 21, November 25, 2025: 2085–2098
• American College of Cardiology (ACC) — Concise Clinical Guidance (Expert Consensus Statement)
• DOI: https://doi.org/10.1016/j.jacc.2025.07.003

Overview

The first ACC Concise Clinical Guidance (CCG) positioning vaccination as a formal component of cardiovascular secondary prevention. Targets clinicians managing patients with cardiovascular disease (CVD) and synthesises ACC/AHA guideline recommendations alongside CDC Advisory Committee on Immunization Practices (ACIP) guidance as of May 2025. Five respiratory/systemic vaccines are addressed: influenza, pneumococcal, COVID-19, RSV, and zoster. The document also covers implementation strategies, vaccine hesitancy, and access barriers relevant to cardiology practice.

Keywords

Cardiovascular disease, immunization, vaccination, influenza, pneumococcal, COVID-19, RSV, zoster, vaccine hesitancy, secondary prevention

Key Takeaways

Evidence for Vaccine Benefit — General Framework

• Patients with CVD carry elevated risk of adverse outcomes (hospitalisation, death) from respiratory infections compared with the general population
• Four evidence lines support vaccination in CVD: (1) higher infection risk/severity; (2) RCT evidence for benefit; (3) consistent observational data; (4) extremely rare adverse effects far outweighed by benefit
• The ACC endorses CDC ACIP recommendations as of May 2025

Influenza Vaccine

• Influenza infection increases acute MI risk 6-fold
• Annual vaccination recommended for all persons ≥6 months; nasal vaccine NOT recommended for adults >50 years
• AHA/ACC 2023 Chronic Coronary Disease guideline: Class I, Level A recommendation for annual influenza vaccination
• AHA/ACC/HFSA 2022 Heart Failure guideline: Class 2a, Level B-NR for respiratory vaccination to reduce mortality
• Meta-analysis of 6 RCTs (n=6,734): vaccination vs placebo — MACE (CV death/MI/unstable angina/stroke/HF/urgent revasc) RR 0.64 (95% CI 0.48–0.96); follow-up 7.9 months; more pronounced benefit in recent ACS vs stable disease
• IAMI trial (n=2,571 post-acute MI): terminated early due to COVID-19 pandemic; influenza vaccine reduced primary composite (all-cause death/MI/stent thrombosis at 12 months) by 28% (HR 0.72; 95% CI 0.52–0.99)
• HF-specific RCT (n=5,129; Asia/Africa/Middle East): primary endpoint of CV death/nonfatal MI/nonfatal stroke neutral (HR 0.93; P=0.30); however, significant benefits on all-cause hospitalisation and pneumonia, especially during influenza season
• Adverse effects: mild injection site reactions common; systemic effects (low-grade fever, headache, myalgias) less frequent; Guillain-Barré syndrome extremely rare (~1–2 cases/million doses)
• Enhanced formulations (high-dose, recombinant, or adjuvanted) preferred for older adults due to waning immune response with aging

Pneumococcal Vaccine

• Streptococcus pneumoniae causes ~225,000 adult hospitalisations annually in the US; fatality rate 10–20%; ~90% of hospitalised patients have ≥1 chronic condition
• Pneumococcal pneumonia associated with increased risk of acute cardiovascular events
• CDC current recommendations: (1) All adults ≥50 years who have not received a PCV; (2) All adults 19–49 years with chronic medical conditions (CHD, HF, cardiomyopathies, CLD, smoking, DM); Hypertension alone does NOT qualify
• Two options that do not require subsequent vaccination: PCV20 (serotypes most common in invasive pneumococcal disease in children) and PCV21 (serotypes most common in adults) — preferred over PCV15 which must be followed by PPSV23
• Old PPSV23 reduced pneumonia risk 28% (RR 0.72; meta-analysis 6 trials, N=3,287)
• Conjugate vaccines more immunogenic than polysaccharide; prevent nasopharyngeal colonisation, reducing person-to-person transmission
• Dutch RCT (adults ≥65 years): PCV — 75% efficacy vs vaccine-type invasive pneumococcal disease; 45% efficacy vs pneumococcal pneumonia
• Adverse effects: local reactions in up to 10% (mild-moderate, resolve in 1–2 days); serious adverse reactions rare
• Can be given concurrently with influenza, COVID-19, and RSV vaccines

COVID-19 Vaccine

• COVID-19 pandemic caused a 2.7-year decline in US life expectancy through 2022; worse for those with heart disease
• Severe COVID-19 infection was 3-fold more likely for those with CVD
• Benefits include: reduced COVID-19 infection (RCT); reduced MI, pericarditis/myocarditis, stroke, and AF from COVID-19 (observational); reduced long-COVID symptoms (observational)
• Myocarditis from mRNA COVID-19 vaccine: 1–19 cases per 1,000,000 persons after first 2 doses; predominantly young males; course more benign than COVID-19 infection–related myocarditis; near-universal complete recovery
• 2024-2025 CDC ACIP recommendations:
  • No prior vaccination: initial series, 2 doses on Day 0 and at 6 months (minimum 2 months apart)
  • Adults <65 years (vaccinated before Fall 2024): at least 1 vaccination with 2024-2025 vaccine
  • Adults ≥65 years or moderate/severe immune deficiency: at least 2 vaccinations with 2024-2025 vaccine (6 months apart — one before winter COVID-19 peak, one before summer peak)
• AHA/ACC 2023 Chronic Coronary Artery Disease guideline: Class 1 recommendation per public health guidelines
• AHA/ACC/HFSA 2022 Heart Failure guideline: Class 2A recommendation for respiratory vaccination
• Continued COVID-19 vaccination likely to remain beneficial for CVD patients even if overall population recommendations evolve

Respiratory Syncytial Virus (RSV) Vaccine

• RSV causes 60,000–160,000 adult hospitalisations and 6,000–10,000 deaths annually among adults ≥65 years in the US — comparable seasonal impact to influenza in older adults
• Increased risk with chronic conditions: congestive HF, coronary disease, COPD, diabetes, long-term care facility residence
• As of June 2025: 2 subunit protein vaccines licensed for adults ≥50 years; 1 mRNA vaccine approved for adults ≥60 years (FDA review ongoing for <60 years)
• Efficacy: ~80% against lower respiratory tract disease in year 1; diminishing to ~70% in year 2
• Adverse effects: local injection site reactions, headache, fatigue; protein subunit vaccines associated with small Guillain-Barré syndrome risk (7–9 cases/million doses; not seen with mRNA vaccine)
• CDC current recommendations: (1) All adults ≥75 years not yet vaccinated; (2) Adults 50–74 years with chronic medical conditions
• RSV vaccine is NOT currently recommended annually; guidance on reimmunisation pending

Zoster (Shingles) Vaccine

• Herpes zoster infection induces an inflammatory state with increased risk of stroke and MI; CVD patients are more likely to contract zoster
• Multiple observational studies show reduced cardiovascular events with herpes zoster vaccination
• South Korean study (n>1 million individuals): zoster vaccination significantly reduced MI, stroke, HF, and arrhythmia; benefit lasted 8 years post-vaccination
• Randomised data indicate patients with CAD receive as good or greater effectiveness from vaccination vs other chronic conditions
• CDC recommendation: All adults ≥50 years — 2 doses of recombinant zoster vaccine (Shingrix), separated by 2–6 months

Implementation and Overcoming Barriers

Strategies to Improve Vaccination Rates

• Mailed letters modestly improved vaccination rates (228,000 Medicare beneficiaries); content of letter did not differentiate
• Text messages framing vaccine as "reserved for you" showed greatest absolute improvement in influenza vaccination
• NUDGE-FLU trial (n>960,000 Danish citizens ≥65 years): repeat letter strategy and letters highlighting cardiovascular benefits of vaccination produced the greatest improvements in influenza uptake — effects durable across subsequent season and confirmed in younger chronic-disease patients
• Cardiovascular-focused messaging underscores the role of the cardiologist as a key vaccination advocate

Vaccine Hesitancy

• Defined as "a state of indecision and uncertainty that precedes a decision to become (or not become) vaccinated" — distinct from vaccine resistance/antivaccination
• Significantly increased during COVID-19 pandemic due to rapidly evolving evidence and rapid vaccine development
• Influenced by socioeconomic status, misinformation, social norms, community distrust, and prior adverse vaccine experiences
• Most effective mitigation: education — especially one-on-one from clinicians; primary care physicians most influential for individual patients
• Key misconceptions to address: vaccines do not cause the disease they prevent; post-vaccination body aches/low-grade fever = immune response, not infection
• Group settings: facilitated discussions with community/spiritual leaders; social media and mobile apps for information dissemination

Access to Vaccination

• Cardiologists often see CVD patients before primary care (post-hospitalisation, post-MI) — vaccination should be included in secondary prevention protocols
• CDC-recommended vaccines must be provided under the Affordable Care Act without out-of-pocket cost
• Multiple vaccines can be given simultaneously on the same day (EXCEPT PCV15 + PPSV23, which should NOT be given concurrently)
• Access disparities: uninsured/under-insured patients and those with poor care access require specific focus

Limitations of the document

• Focus limited primarily to respiratory vaccines; other vaccines addressed only briefly
• RSV reimmunisation timing not yet established
• Evidence for influenza in HF patients is less robust than in stable CAD/post-MI populations
• COVID-19 vaccination recommendations will evolve as disease epidemiology changes
• Some observational data on zoster and cardiovascular benefit requires RCT confirmation
• Data on RSV vaccine and GBS risk is based on protein subunit vaccines; mRNA vaccine GBS data limited by fewer doses administered
• NUDGE-FLU generalisability to US settings not yet confirmed (ongoing validation)

Key Concepts Mentioned

• concepts/Adult-Immunization-CVD — core framework of this source; vaccine-specific evidence and recommendations in CVD
• concepts/Influenza-and-MI — 6-fold acute MI risk with influenza; IAMI trial
• concepts/Vaccine-Hesitancy-CVD — framework for addressing hesitancy in cardiovascular practice

Key Entities Mentioned

• entities/Influenza-Vaccine — annual vaccination; Class I Level A in chronic coronary disease
• entities/Pneumococcal-Vaccine — PCV20/PCV21 preferred; CVD qualifies for early vaccination
• entities/COVID-19-Vaccine — annual updated formulation; mRNA myocarditis risk context
• entities/RSV-Vaccine — one-time vaccination; protein subunit GBS risk
• entities/Zoster-Vaccine — Shingrix 2-dose regimen; 8-year CV benefit
• entities/Heart-Failure — vaccination recommendations for HF patients
• entities/Chronic-Coronary-Disease — Class I recommendation for influenza + COVID-19 vaccination

Wiki Pages Updated

• Created: wiki/sources/immunization-acc-2025.md
• Created: wiki/concepts/Adult-Immunization-CVD.md
• Updated: wiki/wikiindex.md
• Updated: wiki/sourceindex.md