Influenza infection and heart failure-vaccination may change heart failure prognosis?

Viral intruders in the heart: A review of RNA viruses and their role in cardiac disorders

Viral cardiac diseases have a significant impact on global health, and RNA viruses play a crucial role in their pathogenesis. This literature review aims to provide a comprehensive understanding of the complex relationship between RNA viruses and cardiac diseases, focusing on the molecular processes and clinical implications of these interactions. The paper begins by discussing the various RNA viruses that have been linked to cardiac infections. Subsequently, the study explores the mechanisms through which RNA viruses can cause cardiac injury, including direct viral invasion, immune-mediated responses, and molecular mimicry. The review extensively examines the intricate interplay between the host immune system and RNA viruses, shedding light on both protective and harmful immune responses. Additionally, it investigates the role of viral persistence and chronic inflammation in the long-term effects on cardiac health. The thorough analysis presented not only enhances our scientific understanding of how RNA viruses contribute to the development of cardiac diseases but also highlights potential avenues for future research and breakthroughs in this field. Given the significant global health threat posed by viral cardiac disorders, unraveling the molecular foundations of these diseases is essential for advancing diagnostic capabilities and therapeutic interventions.

The role of patient-oriented mHealth interventions in improving heart failure outcomes: A systematic review of the literature

Heart failure (HF) is a debilitating disease with 26 million patients worldwide. Consistent and complex self-care is required on the part of patients to adequately adhere to medication and to the lifestyle changes that the disease necessitates. Mobile health (mHealth) is being increasingly incorporated in patient interventions in HF, as smartphones prove to be ideal platforms for patient education and self-help assistance. This systematic review aims to summarize and report on all studies that have tested the effect of mHealth on HF patient outcomes. Our search yielded 17 studies, namely 11 randomized controlled trials and six non-randomized prospective studies. In these, patients with the assistance of an mHealth intervention regularly measured their blood pressure and/or body weight and assessed their symptoms. The outcomes were mostly related to hospitalizations, clinical biomarkers, patients' knowledge about HF, quality of life (QoL) and quality of self-care. QoL consistently increased in patients who received mHealth interventions, while study results on all other outcomes were not as ubiquitously positive. The first mHealth interventions in HF were not universally successful in improving patient outcomes but provided valuable insights for patient-oriented application development. Future trials are expected to build on these insights and deploy applications that measurably assist HF patients.

Influenza Myopericarditis and Pericarditis: A Literature Review

Myopericarditis is a rare complication of influenza infection. The presentation may range from mild and frequently unrecognized, to fulminant and potentially complicated by cardiogenic and/or obstructive shock (tamponade), which is associated with high mortality. We performed a review of literature on all influenza pericarditis and myopericarditis cases according to PRISMA guidelines using the PubMed search engine of the Medline database. Seventy-five cases of influenza myopericarditis and isolated pericarditis were identified from 1951 to 2021. Influenza A was reported twice as often as influenza B; however, influenza type did not correlate with outcome. Men and elderly patients were more likely to have isolated pericarditis, while women and younger patients were more likely to have myopericarditis. All included patients had pericardial effusion, while 36% had tamponade. Tamponade was more common in those with isolated pericarditis (41.2%) than myopericarditis (13.8%). Cardiogenic shock was more common in patients with myopericarditis (64%), with an overall mortality rate of 14.7%. Nearly 88% of the recovered patients remained without long-term complications reported. Conclusion: Influenza A appears a more common cause of pericarditis and myopericarditis. Isolated pericarditis was more commonly associated with tamponade but without reported deaths, whereas myopericarditis was more commonly associated with cardiogenic shock and death (19%).

Heart Failure after Laboratory Confirmed Influenza Infection (FLU-HF)

Background:

Influenza has been shown to exacerbate heart failure (HF). Importantly, no study to date has examined the relationship between HF hospitalizations (HFH) with laboratory confirmed influenza infections. This study evaluated the association between laboratory confirmed influenza infection and HFH in the two largest hospitals in Saskatchewan, Canada.

Methods:

We used a retrospective self-controlled case series design to evaluate the association between laboratory-confirmed influenza infection and HFH. We compared the incidence ratio for HFH during the influenza risk interval with the control interval. We defined the influenza risk interval as the seven days after a laboratory confirmed influenza result and the control interval as one year before and after the risk interval.

Results:

We identified 114 HFH that occurred within one year before and after a positive test result for influenza between April 1, 2010, and April 30, 2018. Of these, 28 (28 admissions per week) occurred during the risk interval and 86 (0.853 admissions per week) occurred during the control interval. The incidence ratio of a HFH during the risk interval as compared with the control interval was 33.53 (95% confidence interval [CI], 21.89 to 51.36). A decline in incidence was observed after day seven; between days 8 to 14 and 14 to 28 incidence ratios was 0.91 (95% CI, 0.13 to 6.52) and 0.91 (95% CI, 0.22 to 3.68) respectively.

Conclusion:

We have observed a significant association between acute influenza infection and HFH. However, further research with a larger sample size and involving a multicenter setting is warranted.

Highlights

Effectiveness of the influenza vaccine at reducing adverse events in patients with heart failure: A systematic review and meta-analysis

BACKGROUND

The association between influenza and adverse vascular events in patients with heart failure is well documented. The effect of the influenza vaccine on preventing such adverse events is uncertain. This systematic review and meta-analysis addressed whether vaccination against influenza reduces adverse vascular events and mortality in heart failure patients.

METHODS

MEDLINE and EMBASE databases were comprehensively searched, study screening and quality assessment were completed, and data was synthesized. Eligible studies investigated heart failure patients who received the influenza vaccine, and reported outcomes within 12 months, compared to heart failure patients who did not receive the influenza vaccine. The following 6 outcomes were assessed: all-cause mortality, cardiovascular-related mortality, all-cause hospitalization, cardiovascular-related hospitalization, non-fatal myocardial infarction, and non-fatal stroke. Risk of bias was assessed using the Newcastle-Ottawa Scale and a GRADE assessment was completed. A random-effects meta-analysis was performed to estimate the pooled risk ratio (RR), 95% confidence intervals (CIs), and heterogeneity using I² statistics.

RESULTS

After synthesizing data from 7 non-randomized studies (247,842 patients), the results demonstrate the risk of all-cause mortality is significantly reduced within 12 months of a heart failure patient receiving the influenza vaccine (RR = 0.75, 95% CI 0.71-0.79; P<0.0001); very low certainty of evidence. The risk of cardiovascular-related mortality was significantly reduced (RR = 0.77, 95% CI 0.73-0.81; P<0.0001); low certainty of evidence. The pooled risk of all-cause hospitalization was higher among vaccinated heart failure patients (RR = 1.24, 95% CI 1.13-1.35; P<0.0001), based on two studies; very low certainty of evidence and considerable heterogeneity (I² = 90%). No eligible studies assessed cardiovascular-related hospitalization, non-fatal myocardial infarction, or non-fatal stroke.

CONCLUSIONS

Influenza vaccination appears to reduce adverse cardiovascular events, although the certainty of the evidence is low or very low. Rigorous randomized controlled trial evidence is needed to further examine the protective effect of the influenza vaccine in heart failure patients.

Vaccine-preventable disease hospitalized patients with heart failure with reduced ejection fraction

Background

Over five million Americans suffer from heart failure (HF), and this is associated with multiple chronic comorbidities and recurrent decompensation. Currently, there is an increased incidence in vaccine‐preventable diseases (VPDs). We aim to investigate the impact of HF with reduced ejection fraction (HFrEF) in patients hospitalized with VPDs.

Hypothesis

Patient with HFrEF are at higher risk for VPDs and they carry a higher risk for in‐hospital complications.

Methods

Retrospective analysis from all hospital admissions from the 2016‐2018 National Inpatient Sample (NIS) using the ICD‐10CM codes for patients admitted with a primary diagnosis of VPDs with HFrEF and those without reduced ejection fraction. Outcomes evaluated were in‐hospital mortality, length of stay (LOS), healthcare utilization, frequency of admissions, and in‐hospital complications. Multivariate regression analysis was conducted to adjust for confounders.

Results

Out of 317 670 VPDs discharges, we identified 12 130 (3.8%) patients with HFrEF as a comorbidity. The most common admission diagnosis for VPDs was influenza virus (IV) infection (75.0% vs. 64.1%; p < .01), followed by pneumococcal pneumonia (PNA) (13% vs. 9.4%; p < .01). After adjusting for confounders, patients with HFrEF had higher odds of having diagnosis of IV (adjusted [aOR], 1.42; p < .01) and PNA (aOR, 1.27; p < .01). Patients with VPDs and HFrEF had significantly higher odds of mortality (aOR, 1.76; p < .01), LOS, respiratory failure requiring mechanical ventilation, and mechanical ventilation for less than 96 h.

Conclusion

Influenza and PNA were the most common VPDs admitted to the hospital in patients with a concomitant diagnosis of HFrEF. They were associated with increased mortality and in‐hospital complications.

Preventing heart failure: a position paper of the Heart Failure Association in collaboration with the European Association of Preventive Cardiology

The heart failure epidemic is growing and its prevention, in order to reduce associated hospital readmission rates and its clinical and economic burden, is a key issue in modern cardiovascular medicine. The present consensus document aims to provide practical evidence-based information to support the implementation of effective preventive measures. After reviewing the most common risk factors, an overview of the population attributable risks in different continents is presented, to identify potentially effective opportunities for prevention and to inform preventive strategies. Finally, potential interventions that have been proposed and have been shown to be effective in preventing HF are listed.

Acute Bacterial Infections and Longitudinal Risk of Readmissions and Mortality in Patients Hospitalized with Heart Failure

Aims: Infections are associated with worse short-term outcomes in patients with heart failure (HF). However, acute infections may have lasting pathophysiologic effects that adversely influence HF outcomes after discharge. Our objective was to describe the impact of acute bacterial infections on longitudinal outcomes of patients hospitalized with a primary diagnosis of HF. Methods and Results: This paper is based on a retrospective cohort study of patients hospitalized with a primary diagnosis of HF with or without a secondary diagnosis of acute bacterial infection in Optum Clinformatics DataMart from 2010–2015. Primary outcomes were 30 and 180-day hospital readmissions and mortality, intensive care unit admission, length of hospital stay, and total hospital charge, compared between those with or without an acute infection. Cohorts were compared after inverse probability of treatment weighting. Multivariable logistic regression was used to examine relationship to outcomes. Of 121,783 patients hospitalized with a primary diagnosis of HF, 27,947 (23%) had a diagnosis of acute infection. After weighting, 30-day hospital readmissions [17.1% vs. 15.7%, OR 1.11 (1.07–1.15), p < 0.001] and 180-day hospital readmissions [39.6% vs. 38.7%, OR 1.04 (1.01–1.07), p = 0.006] were modestly greater in those with an acute infection versus those without. Thirty-day [5.5% vs. 4.3%, OR 1.29 (1.21–1.38), p < 0.001] and 180-day mortality [10.7% vs. 9.4%, OR 1.16 (1.11–1.22), p < 0.001], length of stay (7.1 ± 7.0 days vs. 5.7 ± 5.8 days, p < 0.001), and total hospital charges (USD 62,200 ± 770 vs. USD 51,100 ± 436, p < 0.001) were higher in patients with an infection. Conclusions: The development of an acute bacterial infection in patients hospitalized for HF was associated with an increase in morbidity and mortality after discharge.

Preventing heart failure: a position paper of the Heart Failure Association in collaboration with the European Association of Preventive Cardiology

The heart failure epidemic is growing and its prevention, in order to reduce associated hospital readmission rates and its clinical and economic burden, is a key issue in modern cardiovascular medicine. The present position paper aims to provide practical evidence-based information to support the implementation of effective preventive measures. After reviewing the most common risk factors, an overview of the population attributable risks in different continents is presented, to identify potentially effective opportunities for prevention and to inform preventive strategies. Finally, potential interventions that have been proposed and have been shown to be effective in preventing heart failure are listed.

Associations of heart failure with susceptibility and severe complications of COVID-19: A nationwide cohort study

Infection is associated with occurrence and worsening of heart failure (HF). However, studies on the association of susceptibility and severe complications of coronavirus disease 2019 (COVID-19) with HF history are limited. From the Korean nationwide COVID-19 data set, 212,678 participants with at least one severe acute respiratory syndrome coronavirus 2 real-time reverse transcription polymerase chain reaction (RT-PCR) test were included between January 1 and June 4, 2020. To investigate the association of HF with susceptibility and severe complications of COVID-19, 1:4 ratio propensity score matching (PSM) and logistic regression analysis were performed. The primary outcome was a composite outcome of mechanical ventilation, intensive care unit (ICU) admission, and death. After PSM, COVID-19 PCR positivity did not show a significant difference according to HF history in multivariable analysis (odds ratio [OR]: 0.91, 95% confidence interval (CI) (0.79-1.04), p = 0.146). Of 7630 individuals with confirmed COVID-19 infection, 310 (4.1%) had HF history. The overall primary outcome occurred in 426 (5.6%) individuals, including 159 (2.1%) cases of mechanical ventilation, 254 (3.3%) cases of ICU admission, and 215 (2.8%) cases of death. In multivariate logistic analysis, presence of HF history was associated independently with primary outcome (OR: 1.99, 95% CI: 1.42-2.79, p < 0.001), particularly mortality (OR: 2.02, 95% CI: 1.36-3.00, p < 0.001). Our study demonstrated that HF history is associated poor prognosis, particularly mortality, in COVID-19. Patients with HF can have severe complication if infected with COVID-19; therefore, careful management are necessary.

Viruses in the Heart: Direct and Indirect Routes to Myocarditis and Heart Failure

Viruses are an underappreciated cause of heart failure. Indeed, several types of viral infections carry cardiovascular risks. Understanding shared and unique mechanisms by which each virus compromises heart function is critical to inform on therapeutic interventions. This review describes how the key viruses known to lead to cardiac dysfunction operate. Both direct host-damaging mechanisms and indirect actions on the immune systems are discussed. As viral myocarditis is a key pathologic driver of heart failure in infected individuals, this review also highlights the role of cytokine storms and inflammation in virus-induced cardiomyopathy.

Tachycardia and Pre-existing Chronic Kidney Disease Are Predictors of the Worse Clinical Outcomes in Patients Recently Hospitalized With Acute Heart Failure

Background: This study aimed to assess the factors contributing to the outcomes of recently hospitalized patients with heart failure (HF).

Methods: A prospective data of 76 adults who were admitted due to acute HF between October 1, 2019 and June 30, 2020 at our center were analyzed. Endpoints included survival and rehospitalization within six months after discharge.

Results: The mean age was 64.9 ± 13.8 years, with a male preponderance (68.4%). Approximately 60.5% of patients had the left ventricular ejection fraction (LVEF) <40%, whereas 26.3% of patients had LVEF ≥50%. Coronary artery disease (75%), arterial hypertension (72.4%), chronic kidney disease (46.1%), and diabetes mellitus (46.1%) were the most frequent comorbidities. Poor compliance (40.8%) and non-cardiac infection (21.1%) were the common precipitating factors for hospitalization. The majority of subjects had severe symptoms, indicated by the frequent need of intensive care unit (43%), high N-terminal prohormone brain natriuretic peptide levels [NT-proBNP; median, 4765 (1539.7-11782.2) pg/mL], and presence of either atrial fibrillation, severe mitral regurgitation, or significant pulmonary hypertension in approximately one-third of cases. Even though in-hospital mortality was relatively low (2.6%), the all-cause mortality and rehospitalization rates in the next six months after discharge were still high, reaching 22.54% and 19.72%, respectively. Further survival analysis showed that tachycardia on admission and pre-existing chronic kidney disease (CKD) resulted in low six-month survival rates among these patients.

Conclusion: After hospital discharge, patients with HF were still exposed to higher risks of death and readmission albeit with the medication addressed. Tachycardia on admission and pre-existing CKD might predict worse outcomes.

The impact of COVID-19 on hospital admissions and emergency department visits: A population-based study

Background

As a result of the novel coronavirus disease 2019 (COVID-19), there have been widespread changes in healthcare access. We conducted a retrospective population-based study in Alberta, Canada (population 4.4 million), where there have been approximately 1550 hospital admissions for COVID-19, to determine the impact of COVID-19 on hospital admissions and emergency department (ED visits), following initiation of a public health emergency act on March 15, 2020.

Methods

We used multivariable negative binomial regression models to compare daily numbers of medical/surgical hospital admissions via the ED between March 16-September 23, 2019 (pre COVID-19) and March 16-September 23, 2020 (post COVID-19 public health measures). We compared the most frequent diagnoses for hospital admissions pre/post COVID-19 public health measures. A similar analysis was completed for numbers of daily ED visits for any reason with a particular focus on ambulatory care sensitive conditions (ACSC).

Findings

There was a significant reduction in both daily medical (incident rate ratio (IRR) 0.86, p<0.001) and surgical (IRR 0.82, p<0.001) admissions through the ED in Alberta post COVID-19 public health measures. There was a significant decline in daily ED visits (IRR 0.65, p<0.001) including ACSC (IRR 0.75, p<0.001). The most common medical/surgical diagnoses for hospital admissions did not vary substantially pre and post COVID-19 public health measures, though there was a significant reduction in admissions for chronic obstructive pulmonary disease and a significant increase in admissions for mental and behavioral disorders due to use of alcohol.

Conclusions

Despite a relatively low volume of COVID-19 hospital admissions in Alberta, there was an extensive impact on our healthcare system with fewer admissions to hospital and ED visits. This work generates hypotheses around causes for reduced hospital admissions and ED visits which warrant further investigation. As most publicly funded health systems struggle with health-system capacity routinely, understanding how these reductions can be safely sustained will be critical.

Immune Cells and Immunotherapy for Cardiac Injury and Repair

Cardiac injury remains a major cause of morbidity and mortality worldwide. Despite significant advances, a full understanding of why the heart fails to fully recover function after acute injury, and why progressive heart failure frequently ensues, remains elusive. No therapeutics, short of heart transplantation, have emerged to reliably halt or reverse the inexorable progression of heart failure in the majority of patients once it has become clinically evident. To date, most pharmacological interventions have focused on modifying hemodynamics (reducing afterload, controlling blood pressure and blood volume) or on modifying cardiac myocyte function. However, important contributions of the immune system to normal cardiac function and the response to injury have recently emerged as exciting areas of investigation. Therapeutic interventions aimed at harnessing the power of immune cells hold promise for new treatment avenues for cardiac disease. Here, we review the immune response to heart injury, its contribution to cardiac fibrosis, and the potential of immune modifying therapies to affect cardiac repair.

Clinical efficacy of ceftazidime combined with levofloxacin on heart failure complicated with pulmonary infection and its influence on cardiopulmonary function

OBJECTIVE

This study was designed to analyze the clinical efficacy of ceftazidime combined with levofloxacin on heart failure complicated with pulmonary infection and its influence on cardiopulmonary function.

METHODS

A total of 124 patients with heart failure and pulmonary infection admitted to our hospital from June 2018 to October 2019 were divided into groups according to different treatment schemes. Thereinto, 60 patients who were given ceftazidime intravenous drip on the basis of routine treatment were included in group A, and 64 who were given levofloxacin hydrochloride injection based on intravenous drip in group A were included in group B. The clinical efficacy, cardiac and lung function, pathogenic bacteria, infection, immune indexes and adverse reactions before and after treatment were compared.

RESULTS

After treatment, the adjusted levels of LVEF, LVEDD and LA in group B after treatment were greater than those in group A (P<0.05); the levels of MMV, TLC and FEV1 in group B were increased more than those in group A (P<0.05). After treatment, the levels of BNP, PCT and CRP in groups A and B decreased compared with those before treatment (P<0.05). Furthermore, the down-regulated levels of BNP, PCT and CRP in group B were higher than those in group A after treatment (P<0.05). After treatment, the levels of serum CD3⁺, CD4⁺, CD4⁺/CD8⁺ in group B increased more and CD8⁺ decreased more. The clinical efficacy of group B after 7 days was higher than that of group A (P<0.01). Patients were followed up for one month, and there was no marked difference in their adverse drug reaction rates (P>0.05).

CONCLUSION

To sum up, ceftazidime combined with levofloxacin on patients with heart failure and pulmonary infection can improve the immune function while optimizing the clinical efficacy and cardiopulmonary function.

A Patient-Oriented App (ThessHF) to Improve Self-Care Quality in Heart Failure: From Evidence-Based Design to Pilot Study

Background

Heart failure (HF) remains a major public health challenge, while HF self-care is particularly challenging. Mobile health (mHealth)–based interventions taking advantage of smartphone technology have shown particular promise in increasing the quality of self-care among these patients, and in turn improving the outcomes of their disease.

Objective

The objective of this study was to co-develop with physicians, patients with HF, and their caregivers a patient-oriented mHealth app, perform usability assessment, and investigate its effect on the quality of life of patients with HF and rate of hospitalizations in a pilot study.

Methods

The development of an mHealth app (The Hellenic Educational Self-care and Support Heart Failure app [ThessHF app]) was evidence based, including features based on previous clinically tested mHealth interventions and selected by a panel of HF expert physicians and discussed with patients with HF. At the end of alpha development, the app was rated by mHealth experts with the Mobile Application Rating Scale (MARS). The beta version was tested by patients with HF, who rated its design and content by means of the Post-Study System Usability Questionnaire (PSSUQ). Subsequently, a prospective pilot study (THESS-HF [THe Effect of a Specialized Smartphone app on Heart Failure patients’ quality of self-care, quality of life and hospitalization rate]) was performed to investigate the effect of app use on patients with HF over a 3-month follow-up period. The primary endpoint was patients’ quality of life, which was measured with the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the 5-level EQ-5D version (EQ-5D-5L). The secondary endpoints were the European Heart Failure Self-care Behavior Scale (EHFScBS) score and the hospitalization rate.

Results

A systematic review of mHealth-based HF interventions and expert panel suggestions yielded 18 separate app features, most of which were incorporated into the ThessHF app. A total of 14 patients and 5 mHealth experts evaluated the app. The results demonstrated a very good user experience (overall PSSUQ score 2.37 [SD 0.63], where 1 is the best, and a median MARS score of 4.55/5). Finally, 30 patients (male: n=26, 87%) participated in the THESS-HF pilot study (mean age 68.7 [SD 12.4] years). A significant increase in the quality of self-care was noted according to the EHFScBS, which increased by 4.4% (SD 7.2%) (P=.002). The mean quality of life increased nonsignificantly after 3 months according to both KCCQ (mean increase 5.8 [SD 15] points, P=.054) and EQ-5D-5L (mean increase 5.6% [SD 15.6%], P=.06) scores. The hospitalization rate for the follow-up duration was 3%.

Conclusions

The need for telehealth services and remote self-care management in HF is of vital importance, especially in periods such as the COVID-19 pandemic. We developed a user-friendly mHealth app to promote remote self-care support in HF. In this pilot study, the use of the ThessHF app was associated with an increase in the quality of self-care. A future multicenter study will investigate the effect of the app use on long-term outcomes in patients with HF.

Effects of Influenza Vaccine on Mortality and Cardiovascular Outcomes in Patients With Cardiovascular Disease: A Systematic Review and Meta-Analysis

Background

Influenza infection causes considerable morbidity and mortality in patients with cardiovascular disease. We assessed the effects of the influenza vaccine on mortality and cardiovascular outcomes in patients with cardiovascular disease.

Methods and Results

We searched PubMed, Embase, and the Cochrane Library through January 2020 for randomized controlled trials and observational studies assessing the effects of influenza vaccine on mortality and cardiovascular outcomes in patients with cardiovascular disease. Estimates were reported as random effects risk ratios (RRs) with 95% CIs. Analyses were stratified by study design into randomized controlled trials and observational studies. A total of 16 studies (n=237 058), including 4 randomized controlled trials (n=1667) and 12 observational studies (n=235 391), were identified. Participants' mean age was 69.2±7.01 years, 36.6% were women, 65.1% had hypertension, 31.1% had diabetes mellitus, and 23.4% were smokers. At a median follow‐up duration of 19.5 months, influenza vaccine was associated with a lower risk of all‐cause mortality (RR, 0.75; 95% CI, 0.60–0.93 [P=0.01]), cardiovascular mortality (RR, 0.82; 95% CI, 0.80–0.84 [P<0.001]), and major adverse cardiovascular events (RR, 0.87; 95% CI, 0.80–0.94 [P<0.001]) compared with control. The use of the influenza vaccine was not associated with a statistically significant reduction of myocardial infarction (RR, 0.73; 95% CI, 0.49–1.09 [P=0.12]) compared with control.

Conclusions

Data from both randomized controlled trials and observational studies support the use of the influenza vaccine in adults with cardiovascular disease to reduce mortality and cardiovascular events, as currently supported by clinical guidelines. Clinicians and health systems should continue to promote the influenza vaccine as part of comprehensive secondary prevention.

Factors associated with seasonal influenza immunization in people with chronic diseases

Annually, at a global level, 3 to 5 million people present severe clinical forms of seasonal influenza and up to 650 000 people die of influenza-related complications. People with chronic diseases, such as cardiovascular, pulmonary, renal, hepatic, neurologic, hematologic and metabolic diseases or those reciveing immunosuppressive therapy, constitute a high-risk population group for the development of influenza-related complications, more severe clinical course and poorer health-related outcomes. Due to all of the above, people with chronic diseases are of high priority to receive the influenza vaccine. Immunization represents the key strategy to prevent influenza both in terms of effectiveness and health care costs. Based on the World Health Organization (WHO) recommendations, adequate seasonal influenza immunization coverage among people with chronic diseases is set at 75%. However, few countries achieve this threshold. Understanding predictive factors of vaccination, at different levels of health care delivery (such as individuals, service providers, health policy), is essential to secure acceptance of influenza immunization and achieve the recommended level of vaccination coverage. In this mini review, all the available evidence regarding seasonal influenza vaccination coverage is summarized, alongside factors associated with vaccine uptake in people with chronic diseases as a whole, as well as according to specific diseases such as: cardiovascular and pulmonary disorders, diabetes and cancer. Based on the reviewed empirical evidence, a wide spectrum of factors associated with immunization against influneza was found in people who have chronic diseases. Although diverse, these factors can be systematized into 4 distinctive groups: socio-demographic characteristics, individual attitudes and beliefs, health promoting behaviors and factors related to the health care system. Further efforts are needed to improve the seasonal influenza vaccination coverage. The immunization strategy needs to include the health care system and the community to support people with chronic diseases to continously accept the influenza vaccine.

Adverse effects of non-steroidal anti-inflammatory drugs in patients with viral respiratory infections: rapid systematic review

OBJECTIVES

To assess the effects of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with viral respiratory infections on acute severe adverse outcomes, healthcare utilisation, quality of life and long-term survival.

DESIGN

Rapid systematic review.

PARTICIPANTS

Humans with viral respiratory infections, exposed to systemic NSAIDs.

PRIMARY OUTCOMES

Acute severe adverse outcomes, healthcare utilisation, quality of life and long-term survival.

RESULTS

We screened 10 999 titles and abstracts and 738 full texts, including 87 studies. No studies addressed COVID-19, Severe Acute Respiratory Syndrome or Middle East Respiratory Syndrome; none examined inpatient healthcare utilisation, quality of life or long-term survival. Effects of NSAIDs on mortality and cardiovascular events in adults with viral respiratory infections are unclear (three observational studies; very low certainty). Children with empyema and gastrointestinal bleeding may be more likely to have taken NSAIDs than children without these conditions (two observational studies; very low certainty). In patients aged 3 years and older with acute respiratory infections, ibuprofen is associated with a higher rate of reconsultations with general practitioners than paracetamol (one randomised controlled trial (RCT); low certainty). The difference in death from all causes and hospitalisation for renal failure and anaphylaxis between children with fever receiving ibuprofen versus paracetamol is likely to be less than 1 per 10 000 (1 RCT; moderate/high certainty). Twenty-eight studies in adults and 42 studies in children report adverse event counts. Most report that no severe adverse events occurred. Due to methodological limitations of adverse event counts, this evidence should be interpreted with caution.

CONCLUSIONS

It is unclear whether the use of NSAIDs increases the risk of severe adverse outcomes in patients with viral respiratory infections. This absence of evidence should not be interpreted as evidence for the absence of such risk. This is a rapid review with a number of limitations.

PROSPERO REGISTRATION NUMBER

CRD42020176056.

Influenza Vaccination to Reduce Cardiovascular Morbidity and Mortality in Patients With COVID-19: JACC State-of-the-Art Review

Viral respiratory infections are risk factors for cardiovascular disease (CVD). Underlying CVD is also associated with an increased risk of complications following viral respiratory infections, including increased morbidity, mortality, and health care utilization. Globally, these phenomena are observed with seasonal influenza and with the current coronavirus disease 2019 (COVID-19) pandemic. Persons with CVD represent an important target population for respiratory virus vaccines, with capacity developed within 3 large ongoing influenza vaccine cardiovascular outcomes trials to determine the potential cardioprotective effects of influenza vaccines. In the context of COVID-19, these international trial networks may be uniquely positioned to redeploy infrastructure to study therapies for primary and secondary prevention of COVID-19. Here, we describe mechanistic links between influenza and COVID-19 infection and the risk of acute cardiovascular events, summarize the data to date on the potential cardioprotective effects of influenza vaccines, and describe the ongoing influenza vaccine cardiovascular outcomes trials, highlighting important lessons learned that are applicable to COVID-19.

Risk of Severe Influenza Among Adults With Chronic Medical Conditions

BACKGROUND

Severe influenza illness is presumed more common in adults with chronic medical conditions (CMCs), but evidence is sparse and often combined into broad CMC categories.

METHODS

Residents (aged 18-80 years) of Central and South Auckland hospitalized for World Health Organization-defined severe acute respiratory illness (SARI) (2012-2015) underwent influenza virus polymerase chain reaction testing. The CMC statuses for Auckland residents were modeled using hospitalization International Classification of Diseases, Tenth Revision codes, pharmaceutical claims, and laboratory results. Population-level influenza rates in adults with congestive heart failure (CHF), coronary artery disease (CAD), cerebrovascular accidents (CVA), chronic obstructive pulmonary disease (COPD), asthma, diabetes mellitus (DM), and end-stage renal disease (ESRD) were calculated by Poisson regression stratified by age and adjusted for ethnicity.

RESULTS

Among 891 276 adults, 2435 influenza-associated SARI hospitalizations occurred. Rates were significantly higher in those with CMCs compared with those without the respective CMC, except for older adults with DM or those aged <65 years with CVA. The largest effects occurred with CHF (incidence rate ratio [IRR] range, 4.84-13.4 across age strata), ESRD (IRR range, 3.30-9.02), CAD (IRR range, 2.77-10.7), and COPD (IRR range, 5.89-8.78) and tapered with age.

CONCLUSIONS

Our findings support the increased risk of severe, laboratory-confirmed influenza disease among adults with specific CMCs compared with those without these conditions.

Vaccination coverage of recommended vaccines and determinants of vaccination in at-risk groups

Upon exposure to vaccine-preventable diseases, certain individuals are at increased risk for complications due to preexisting diseases, age or immunosuppressive treatment. Vaccination against influenza, pneumococcal disease and hepatitis B (for some groups) is advised in addition to standard vaccination against diphtheria, tetanus and pertussis. We estimated the vaccination coverage and determinants of recommended vaccinations in patients with diabetes mellitus type 1 (n = 173) and type 2 (n = 177), chronic kidney disease (CKD) (n = 138), heart failure (n = 200), chronic obstructive pulmonary disease (COPD) (n = 187), HIV (n = 201) or solid organ transplantation (SOT) (n = 201) in a monocentric study. Vaccination data were retrieved from documents provided by patients and general practitioners, and from the Flemish vaccination register. Less than 10% had received all recommended vaccines. Overall, 29% of subjects were vaccinated against diphtheria-tetanus, 10% against pertussis, 44% against influenza, 32% against pneumococcal disease and 24% of HIV patients and 31% of CKD patients against hepatitis B. Age was positively associated with vaccination against influenza (OR:2.0, p < .01) and pneumococcal disease (OR:2.6, p < .001). Patients with COPD, HIV and SOT were more likely to be vaccinated against influenza (OR:2.8, p < .001, OR:1.8, p < .05; OR:2.0, p < .001, respectively) and pneumococcal disease (OR:2.9, p < .001, OR:25.0, p < .001; OR:2.6, p < .001, respectively) than patients with heart failure. Reason for non-vaccination were concerns about effectiveness, necessity and side effects of influenza vaccines, and not being aware of the recommendation for pneumococcal disease. Initiatives to monitor the vaccination status of vulnerable patients are needed, which is why we advocate systematic vaccination registration and frequent communication about vaccination.

What's in a prick? Vaccines and the cardiovascular system

Evidence suggests a crucial role for vaccines in cardiovascular disease, mediated not only by disease prevention but also by immunomodulatory effects. This review attempts to briefly present the effects of pathogens and vaccines on the cardiovascular system and potential mechanisms for the development of vaccines against cardiovascular diseases per se. Current epidemiological evidence regarding vaccine effectiveness in different categories of heart disease is discussed, as well as current international guidelines' recommendations. In summary, cardiologists should strive to promote vaccination against specific pathogens with proven beneficial effects on cardiovascular diseases.

Influenza vaccine and cardiac protection: a study from a tertiary care center

Patients with heart disease (HD) are at increased risk of developing cardiac complications if they acquire the influenza virus. The objective of this study was to determine whether the influenza vaccine has a primary role in preventing newly diagnosed HD in patients who have no history of HD and who were being followed up at the American University of Beirut Medical Center (AUBMC). The study is a retrospective cohort, with 2-years follow up, which was conducted using electronic medical records between the years of 2011-2013 in a tertiary care center. All patients 60 years and older (n = 698) who have taken the flu vaccine were randomly selected from the University Health Service records (UHS) and compared to a group who has not taken the flu vaccine during the same period. The odds of developing HD among vaccinated people with cofactors are 0.97 times the odds of that among non-vaccinated. This odds ratio is not significantly different than that of people vaccinated without cofactors (OR = 1.74). The occurrence of HD in the presence of vaccination revealed a non-significant decrease trend with the increase in a number of risk factors (OR = 1.61 vs 0.97). Our results suggest that there was a non-significant difference between the effect of the vaccine for influenza on patients who had cofactors for HD and those who had not. Similarly, the effect of vaccine showed a non-significant increase in protective effect as the number of comorbidities increase. The potential effects of the vaccine may be related to the protection against flu.

Klug S, Gensichen J. Increasing Influenza Vaccination Rates in People With Chronic Illness

BACKGROUND

The safety and efficacy of influenza vaccination for the chronically ill are clearly supported by the evidence, yet vaccination rates in this vulnerable popu- lation remain low. This leads to many avoidable hospitalizations and deaths in Germany every year. The goal of this systematic review is to identify measures in primary care medicine that can be used to increase influenza vaccination rates among the chronically ill.

METHODS

This review was carried out as recommended in the PRISMA statement. A systematic literature search was performed. Only randomized, controlled trials were included in the analysis. Details can be found in the study protocol (PROSPERO, CRD42018114163).

RESULTS

15 trials were included in the analysis. Training sessions for medical practice teams focusing on a particular disease raised the vaccination rates by as much as 22%. A financial incentive had the greatest effect (relative risk [RR]: 2.79; 95% confidence interval: [1.18; 6.62]). Reminders via text message yielded a maximum 3.8% absolute increase in vaccination rates. Complex interventions were not found to be of any greater benefit than simple ones.

CONCLUSION

A variety of approaches can be effective. Focusing training sessions for medical practice teams on certain diseases may be of greater benefit than vacci- nation-centered training sessions. Reminder systems for doctors should be more reliably implemented. Simple strategies are perhaps the most suitable ones in the heterogeneous population of chronically ill persons. The limitations of this system- atic review include the heterogeneity of the studies that we examined and the small number of studies in each category.

Influenza virus-related critical illness: pathophysiology and epidemiology

Influenza virus affects the respiratory tract by direct viral infection or by damage from the immune system response. In humans, the respiratory epithelium is the only site where the hemagglutinin (HA) molecule is effectively cleaved, generating infectious virus particles. Virus transmission occurs through a susceptible individual's contact with aerosols or respiratory fomites from an infected individual. The inability of the lung to perform its primary function of gas exchange can result from multiple mechanisms, including obstruction of the airways, loss of alveolar structure, loss of lung epithelial integrity from direct epithelial cell killing, and degradation of the critical extracellular matrix.Approximately 30-40% of hospitalized patients with laboratory-confirmed influenza are diagnosed with acute pneumonia. These patients who develop pneumonia are more likely to be < 5 years old, > 65 years old, Caucasian, and nursing home residents; have chronic lung or heart disease and history of smoking, and are immunocompromised.Influenza can primarily cause severe pneumonia, but it can also present in conjunction with or be followed by a secondary bacterial infection, most commonly by Staphylococcus aureus and Streptococcus pneumoniae. Influenza is associated with a high predisposition to bacterial sepsis and ARDS. Viral infections presenting concurrently with bacterial pneumonia are now known to occur with a frequency of 30-50% in both adult and pediatric populations. The H3N2 subtype has been associated with unprecedented high levels of intensive care unit (ICU) admission.Influenza A is the predominant viral etiology of acute respiratory distress syndrome (ARDS) in adults. Risk factors independently associated with ARDS are age between 36 and 55 years old, pregnancy, and obesity, while protective factors are female sex, influenza vaccination, and infections with Influenza A (H3N2) or Influenza B viruses.In the ICU, particularly during the winter season, influenza should be suspected not only in patients with typical symptoms and epidemiology, but also in patients with severe pneumonia, ARDS, sepsis with or without bacterial co-infection, as well as in patients with encephalitis, myocarditis, and rhabdomyolysis.

Seasonality in Mortality in a Cardiology Department: A Five-Year Analysis in 500 Patients

BACKGROUND

Previous studies have indicated that cardiovascular mortality follows a seasonal trend. The aim of this work was to determine the evolution of mortality throughout the year in a cardiology department.

METHODS

All admissions and deaths occurring in our Cardiology Department over a 5-year period (2013-2017) were recorded retrospectively.

RESULTS

From a total of 17,829 hospital admissions, 500 patients died (2.8%, 0.3 patients/day). The mean age of deceased patients was 74.2 ± 13.1 years, and 186 (37.2%) were women. Mortality ranged from 0.17 deaths/day in August to 0.40 deaths/day in February (p = 0.03), and from 0.20 deaths/day in summer to 0.36 deaths/day in winter (p = 0.001). There was also a trend towards a variation in hospitalizations, with a peak in January (10.5 admissions/day) and the lowest figure in August (7.0 admissions/day), p = 0.047. We found no significant seasonal trend regarding mortality rate with respect to the number of hospital admissions (p = 0.89). The most common cause of death was refractory heart failure (267 patients [65.8%]). A noncardiac cause of death was observed in 134 patients (26.8%).

CONCLUSIONS

In a cardiology department, there are twice as many deaths in winter as in summer. Hospitalizations also tend to be more frequent in winter than in summer.

The Effect of Influenza Vaccination on Mortality and Risk of Hospitalization in Patients With Heart Failure: A Systematic Review and Meta-analysis

BACKGROUND

Influenza is a major cause of morbidity and mortality in patients diagnosed with heart failure. The aim of this study was to evaluate the effectiveness of influenza vaccination in this population in terms of reduction in all-cause mortality and rate of hospitalization.

METHODS

We conducted a systematic review and meta-analysis using PubMed and EMBASE entries from January of 2000 through April 2018. Publication bias was examined using the Egger's regression test. Statistical heterogeneity was examined using the Higgins I 2 statistic. Subgroup analyses were performed to examine the effect of vaccination during the influenza and noninfluenza seasons.

RESULTS

We identified 8 studies that included a total of 82 354 patients with heart failure. In patients with heart failure who were vaccinated against influenza, we found a reduced risk of all-cause mortality (hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.51-0.87). No evidence of publication bias was found, and the effect was more pronounced during influenza season (HR, 0.49; 95% CI, 0.30-0.69), compared with noninfluenza season (HR, 0.79; 95% CI, 0.68-0.89). In terms of heart failure hospitalizations, we did not identify a statistically significant difference between the cohorts (HR, 0.62; 95% CI, 0.00-1.23).

CONCLUSIONS

Influenza vaccination was associated with a decreased risk of all-cause mortality in patients with heart failure, and this effect was more prominent during the influenza season.

Management protocols for chronic heart failure in India

Heart failure is a common clinical syndrome and a global health priority. The burden of heart failure is increasing at an alarming rate worldwide as well as in India. Heart failure not only increases the risk of mortality, morbidity and worsens the patient's quality of life, but also puts a huge burden on the overall healthcare system. The management of heart failure has evolved over the years with the advent of new drugs and devices. This document has been developed with an objective to provide standard management guidance and simple heart failure algorithms to aid Indian clinicians in their daily practice. It would also inform the clinicians on the latest evidence in heart failure and provide guidance to recognize and diagnose chronic heart failure early and optimize management.