The American College of Cardiology (ACC) has issued updated guidelines on adult immunization as part of cardiovascular care, incorporating recent evidence and current vaccine recommendations relevant to patients with cardiovascular disease (CVD). The guidelines address influenza, pneumococcal, COVID-19, respiratory syncytial virus (RSV), and zoster vaccination.
The 2026 summary clinical guidelines revise the ACC document issued in August 2025 to take into account results of recently published trials. In developing the update, the writing committee incorporated applicable recommendations from the ACC/American Heart Association (AHA) guidelines and national guidelines from the Advisory Committee on Immunization Practices, the American College of Physicians, and the Infectious Diseases Society of America.
Among the evidence added to the update are data supporting the 2025-2026 influenza, COVID-19, and RSV vaccines and randomized findings comparing high-dose and standard-dose influenza vaccination in older adults.
The strategies described in this guidance, including customized communications and materials developed by ACC’s CardioSmart, are intended to support the cardiovascular care community in improving vaccination coverage, reducing morbidity, and ultimately improving patient quality and length of life.
High-dose influenza vaccine is preferred for older adults
For patients ages 65 and older, the preferred influenza vaccine option is A High dosage formulation; Recombinant and adjuvanted vaccines are alternatives. Adults between the ages of 18 and 64 should get a standard dose of the vaccine. Current cardiovascular recommendations also call for annual influenza vaccination in chronic coronary artery disease and respiratory vaccination support in heart failure (HF) to reduce the risk of death.
Randomized trial data favored high-dose influenza vaccination in older adults, with fewer hospitalizations for respiratory disease, cardiovascular disease, or HF compared with standard-dose vaccination. The relative treatment effect was comparable by CVD status, but patients with CVD experienced a greater absolute reduction in hospitalizations because they entered the studies at higher baseline risk. For patients with HF, treating 105 with the high-dose combination instead of the standard dose would prevent a single hospitalization.
The evidence for cardiovascular protection with influenza vaccination extends beyond comparing doses. Across 6 randomized controlled trials totaling 6734 patients, vaccination was associated with a lower relative risk of major adverse cardiovascular events versus placebo or no vaccination (relative risk, 0.64; 95% CI, 0.48-0.96). Influenza Vaccination After Myocardial Infarction Trial (ClinicalTrials.gov Identifier: NCT02831608), which enrolled 2,571 patients after acute myocardial infarction (MI), found a 28% reduction in the composite risk of death from any cause, myocardial infarction, or stent thrombosis within 1 year of vaccination (hazard ratio [HR]0.72; 95% CI, 0.52-0.99).
Pneumococcal vaccination is recommended starting at age 50
To prevent pneumococcal pneumonia, guidelines call for vaccination starting at age 50 in adults without warning Pneumococcal conjugate vaccine Receipt (PCV). Vaccination is also recommended between the ages of 19 and 49 when certain chronic conditions are present. From a cardiovascular perspective, these include chronic heart disease, heart failure, and cardiomyopathy. High blood pressure alone is not a condition associated with an increased risk of pneumococcal pneumonia.
one PCV20 or sufficient PCV21 without subsequent pneumococcal conjugate vaccine. However, use of PCV15 requires a subsequent dose of pneumococcal polysaccharide vaccine 23-valent (PPSV23). It is acceptable to have the vaccine at the same visit as the influenza, COVID-19, or respiratory syncytial virus vaccination.
Clinical trial evidence has shown 75% efficacy against invasive disease caused by vaccine-covered pneumococcal serotypes and 45% efficacy against pneumococcal pneumonia among older adults receiving conjugate vaccine. In the more recent PPSV23 trial, the difference in MI or stroke did not reach statistical significance (HR, 0.90; 95% CI, 0.63-1.28; p =.57); Fewer events occurred than expected.
COVID-19 recommendations address immunocompromised adults
Vaccination against COVID-19 in patients with chronic coronary artery disease should follow public health recommendations, according to current ACC/AHA guidance. Respiratory immunization of patients with hepatitis C is also supported as a strategy to reduce mortality.
The specific dosing schedule for adults with moderate or severe immunosuppression depends on the former vaccination. Patients initiating vaccination should complete the initial multi-dose series first, followed by an additional dose after 6 months; The time interval can be shortened to at least two months. For patients who have already completed their primary series, it is recommended that two doses be administered 6 months apart, with 2 months again set as the minimum interval.
The guidelines also address myocarditis after mRNA vaccination. Although this event is uncommon and occurs mostly among younger men, the newer bivalent formulations have been associated with fewer cases of myocarditis/pericarditis than the original monovalent vaccines, at a rate of 1.2 versus 6.9 cases per million doses.
RSV vaccination is recommended for adults with cardiovascular disease starting at age 50 years
A history of cardiovascular disease qualifies adults for this Vaccination against RSV virus Starting at age 50, provided they have not already received the RSV vaccine. Nowadays, the recommendation is for a single dose for life rather than annually.
Cardiovascular outcomes were evaluated in a Danish randomized trial including approximately 130,000 adults. Respiratory syncytial virus vaccination had a 9.9% effectiveness against cardiorespiratory disease, and fewer cases of stroke and cardiovascular disease occurred with vaccination. The rate of protection against lower respiratory diseases across the three available vaccines is about 80% in the first year and about 70% in the second year. Although protection may be lower in patients with cardiovascular disease, available evidence has not determined when or whether another dose should be given.
Zoster vaccination is associated with cardiovascular benefits
Starting at age 50, adults should receive two doses Recombinant zoster vaccine series, with the second injection given 2 to 6 months after the first.
Observational studies cited by the ACC raise the possibility of cardiovascular protection through zoster vaccination. An analysis of more than 1 million individuals in South Korea linked vaccination to lower rates of myocardial infarction, stroke, heart failure, and arrhythmia over an 8-year period. Separate data among adults ages 50 and older found lower rates of acute cerebral infarction and stroke among those who completed both doses of the vaccine.
Beyond the vaccine guidelines, the ACCC also places the onus on us Cardiovascular Care teams to get to know Vaccination gaps During routine encounters, including visits after and during ongoing hospitalization or procedures Cardiovascular diseases administration. Vaccines can be integrated into cardiology practice when possible; Otherwise, patients may be directed to pharmacies, primary care practices or community vaccination sites. Physician reminders and conversations about immunization are among the methods identified to improve vaccine uptake.
“The strategies described in this guidance, including customized communications and materials developed by ACC’s CardioSmart, are intended to support the cardiovascular care community in improving vaccination coverage, reducing morbidity, and ultimately enhancing patient quality and length of life.” Administrative Coordination Committee That’s it.
Disclosure: Some study authors declared affiliations with biotechnology, pharmaceutical, and/or device companies. Please see the original reference for a complete list of disclosures.
This article originally appeared on Infectious disease consultant
