Patients with heart failure are prone to infectious complications due to factors such as chronic ill-health, old age, malnutrition, multiorgan damage, metabolic abnormalities (hyperglycemia and uremia), and depressed immunity. They are also exposed to repeated hospital admission, invasive investigations, and therapy with blood derivatives. Infection compounds their heart failure. Influenza and hepatitis are among the most frequent community-acquired and nosocomial infections, respectively. Prophylaxis is available against each. Caution should be observed in heart failure due to histologically documented autoimmune myocardial disease.
In the absence of general guidelines, the risk/benefit ratio should be assessed in the individual patient. In normal subjects, influenza has a mortality of 1:5000, pneumonia 29:1000, and bronchitis 191:1000. Nichol et al showed the benefit of routine influenza vaccination in the elderly population and individuals with underlying chronic heart or lung disease. Heart failure increases the mortality of post-influenza pneumonia over 100-fold. Since 80% to 90% of deaths occur over the age of 65 years, vaccination should be offered to all individuals within this age group, and especially to those in heart failure. Patients must understand that vaccination is protective in only 80% to 90% of cases. The influenza virus may change and render vaccination ineffective. When patients are vaccinated for the first time, two doses should be administered 4 weeks apart, and subsequent vaccination repeated yearly. The use of viral fragments or surface purified antigens carries a lower risk of fever than the complete attenuated virus.
Hepatitis is a risk during the acute phase, but may also become chronic and lower resistance against other pathogens. Vaccination is recommended in hepatitis B seronegative heart failure, especially in patients with a serious prospect of joining a transplant program. It should be performed before further clinical deterioration as the patient is more likely to achieve a protective antibody threshold, immunodepression being a common cause of nonresponse. Vaccination is risk-free, 80% to 95% effective, and effective for over 10 years.
Pneumococcal vaccination lowers the risk of the respiratory infections that precipitate or worsen heart failure, especially in patients with chronic bronchitis.
management; vaccination; influenza; hepatitis; pneumococcal vaccination; prevention