A 69-year-old woman is evaluated for follow-up 3 months after a non–ST-elevation myocardial infarction. She was assessed to be at low risk, and she was treated medically. Since the acute event, the patient has done well. She has no chest discomfort or shortness of breath. She has hypercholesterolemia and hypertension. Medications are lisinopril, metoprolol, atorvastatin, aspirin, and clopidogrel. She has modified her diet and has begun performing physical activity 5 days a week.
On physical examination, the patient is afebrile, blood pressure is 125/80 mm Hg, pulse rate is 60/min, and respiration rate is 12/min. BMI is 26. A normal carotid upstroke without carotid bruits is noted, jugular venous pulsations are normal, and normal S1 and S2 heart sounds are heard without murmurs. Lung fields are clear, distal pulses are normal, and no peripheral edema is present.
Laboratory studies show adherence to her lipid therapy and are otherwise normal.
Which of the following will offer this patient the greatest reduction in her risk of future cardiovascular events?
3%
A Colchicine
8%
B Folic acid
77%
C Influenza vaccine
12%
D Vitamin E
Answer & Critique
Correct Answer: C
Educational Objective: Recommend influenza vaccination for the secondary prevention of ischemic heart disease.
Key Point
Influenza vaccine should be administered to patients with established cardiovascular disease to reduce the risk of future cardiovascular events.
Providing this patient with an annual influenza vaccination would significantly reduce her risk of future cardiovascular events. A meta-analysis of randomized trials demonstrated that use of the influenza vaccine was associated with a 36% lower risk of major adverse cardiovascular events compared with nonimmunized patients. Based on these data, the American Heart Association and American College of Cardiology recommend influenza vaccination for the secondary prevention of ischemic heart disease. In addition to influenza vaccination as a preventive measure for cardiovascular disease, this patient also qualifies for influenza vaccination according to Advisory Committee on Immunization Practices (ACIP) guidelines that recommend all persons aged 6 months or older receive the influenza vaccination.
Colchicine has anti-inflammatory properties, and observational studies of patients taking colchicine for gout or familial Mediterranean fever suggest a decreased risk of cardiovascular disease associated with treatment. However, its use for secondary prevention of cardiovascular disease has not been established.
Folic acid lowers homocysteine levels, which when elevated have been associated with increased cardiovascular disease in observational studies. However, clinical trials examining the effectiveness of lowering homocysteine levels by folic acid supplementation have failed to show a reduction in adverse cardiovascular events. Folic acid supplementation for this purpose is therefore not recommended as secondary prevention.
Because inflammation and oxidative stress are involved in atherosclerosis, the use of antioxidant agents, including vitamins E and C and β-carotene, has been proposed as both a primary and secondary preventive intervention for cardiovascular disease. Although supported by some basic science and observational data, several large, randomized controlled trials have failed to document benefit of antioxidant therapy for either purpose. Therefore, the use of vitamin E supplementation would not be appropriate in this patient.
Bibliography
Udell JA, Zawi R, Bhatt DL, et al. Association between influenza vaccination and cardiovascular outcomes in high-risk patients: a meta-analysis. JAMA. 2013 Oct 23;310(16):1711-20. PMID: 24150467
This content was last updated in March 2016.
