Sage Journals: Discover world-class research

Abstract

Introduction

Individuals with chronic cardiac conditions are at increased risk for developing pneumococcal diseases. In this study, we aim to develop an evidence-based consensus document on the use of pneumococcal vaccines in individuals with cardiac conditions.

Methods

Modified Delphi consensus methodology was used to establish consensus. A committee of seven cardiologists from India formed the panel. Questions were drafted across three domains: (a) the risk of pneumococcal disease in patients with cardiac conditions, (b) evidence and optimal timing of pneumococcal vaccination, and (c) barriers to vaccination in cardiology settings. The consensus level was categorized into three groups: (a) low (<60%), (b) moderate (60%-79%), and (c) high (≥80%).

Results

Experts agreed that immunocompetent individuals with cardiac conditions, adults with a medical history of myocardial infarction/coronary artery disease, heart failure, individuals who fall under the coronary artery disease spectrum, older adults (>50 years of age) with chronic hypertension, and adults with chronic hypertension or a history of acute coronary syndrome/myocardial infarction, with multiple comorbidities, can benefit from pneumococcal vaccination.

Conclusion

This document will guide clinicians on the optimal timing for pneumococcal vaccination in patients with cardiac conditions and highlight specific patient subgroups that can benefit from it.

Keywords

Cardiovascular disease consensus Delphi pneumococcal infections vaccines

Introduction

Pneumococcal diseases (PDs) caused by Streptococcus pneumoniae significantly contribute to morbidity and mortality, especially among individuals with chronic underlying cardiac conditions.^1–3 Clinically, PDs manifest across a broad spectrum, ranging from noninvasive infections (otitis media and sinusitis) to invasive forms (pneumonia with bacteremia and meningitis).^{1, 4–6} S. pneumoniae is a common cause of community-acquired bacterial pneumonia in adults.^{1, 3, 7} Cardiovascular (CV) events, such as myocardial infarction (MI), heart failure (HF), or arrhythmias, have been reported in patients with community-acquired pneumonia (CAP) due to S. pneumoniae.⁸ Furthermore, patients hospitalized with invasive pneumococcal disease (IPD) are at an increased risk of major adverse CV events, including new/worsening HF, arrhythmia, and MI.⁹ Individuals with preexisting cardiac conditions are at increased risk of developing these cardiac complications after pneumonia (all-cause CAP), which are associated with both short-term (e.g., within the first 24 h or 30 days) and long-‍term mortality risks (after hospital discharge extending over 10 years).¹⁰ As a preventive measure, pneumococcal vaccination can be crucial in mitigating the burden of PD in patients with underlying cardiac conditions. Pneumococcal vaccination is associated with a reduced risk of all-cause mortality among adults with cardiovascular disease (CVD) or very high CV risk (N = 5 studies; 163,756 adult participants) versus no vaccination.¹¹ Herein, we aimed to review (a) the risks and consequences of CAP and IPD in patients with cardiac conditions; (b) the efficacy of pneumococcal vaccines (PVs) in patients with cardiac conditions; (c) recommendations for the administration of PVs in patients with cardiac conditions and risk factors; and (d) barriers to the administration of PVs in cardiology settings. We summarize expert opinions and practical consensus recommendations on vaccine sequencing, highlight patient subgroups with cardiac conditions that can benefit from PVs, and discuss the optimal timing of pneumococcal vaccination in cardiac conditions.

Methodology

A panel of seven cardiologists with significant experience in the field (Figure 1) participated in developing the consensus manuscript. A chair/moderator led and facilitated the consensus process. An evidence review was conducted using the PubMed database to identify relevant articles (published from January 2000 to June 2024). Keywords such as “risk,” “barriers,” “heart disease,” “chronic,” “cardiac,” “pneumococcal infections,” “pneumococcal disease,” “community-acquired pneumonia,” “pneumococcal pneumonia,” “invasive pneumococcal disease,” “pneumococcal vaccine,” “efficacy,” “effectiveness,” “safety,” “pediatric,” “adult,” “immunization,” “prevention,” and “guidelines” were used. Original research articles, review articles, systematic literature reviews, meta-analyses, surveys, guidelines, and consensus recommendations were included. In total, 26 clinically relevant statements and questions (statements: n = 19; other survey-type questions: n = 7) were drafted and finalized after discussions with the chair. An electronic survey link to these questions was sent to all the participants to gather their responses.

Figure 1.

Note: PD, pneumococcal disease; PV, pneumococcal vaccine.

Expert consensus was achieved through the modified Delphi process.¹² The consensus level (Table 1) was categorized into three groups: (a) low (<60%), (b) moderate (60%-79%), and (c) high (≥80%).¹³ The process involved two rounds of Delphi surveys and one round of discussion. A virtual meeting was conducted to review the Delphi round one survey results and to discuss the questions and statements receiving near or no consensus. The statements that did not attain consensus were modified and presented for voting in the second round. Experts arrived at the modifications based on the current scientific evidence, guideline recommendations, and real-world practice. In November 2024, another round of basic literature search was performed in PubMed to check for any updates. Consensus statements were formulated based on the opinions and agreements of the majority. The consensus report was shared with the expert panel for approval.

Table 1.

Consensus Criteria.¹³

“High”	“When ≥80% of participants agree/strongly agree or disagree/strongly disagree with a statement.”
“Moderate”	“When 60%-79% of participants agree/strongly agree or disagree/strongly disagree with a statement.”
“Low”	“When <60% of participants agree/strongly agree or disagree/strongly disagree with a statement.”

Results

In round one, a consensus was reached for 10 out of 19 statements (52.63%). Two statements that did not achieve consensus were excluded, whereas the remaining seven statements were modified and presented for voting in the second round. The seven statements were finalized after the Delphi survey round two. In this article, we first review the evidence for each study objective, followed by expert opinions and consensus recommendations.

Risk and Consequences of Community-acquired Pneumonia and Invasive Pneumococcal Disease in Patients with Cardiac Conditions

Community-acquired pneumonia (majorly caused by S. pneumoniae and influenza virus) poses a significant health risk to patients with preexisting cardiac conditions.^{1, 3, 8, 10, 14} Corrales-Medina et al. reported that individuals with CAP and preexisting HF, cardiac arrhythmias, coronary artery disease (CAD), or arterial hypertension were at an increased risk for developing cardiac complications.¹⁴ Specifically, the odds ratios (ORs) for cardiac complications were 4.3 for HF, 1.8 for cardiac arrhythmias, 1.5 for CAD, and 1.5 for arterial hypertension.¹⁴ However, the study did not specify the specific causative organism causing pneumonia (S. pneumoniae or influenza virus).¹⁴ In the “PARADIGM-HF” (“Prospective Comparison of Angiotensin Receptor Neprilysin Inhibitor [ARNI] With Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in HF”) and “PARAGON-HF” (“Prospective Comparison of ARNI with Angiotensin Receptor Blocker Global Outcomes in HF with Preserved Ejection Fraction”) trials, the incidence of pneumonia (all-cause) was 6.3% and 10.6%, respectively, translating to incidence rates of 29 and 39 per 1,000 patient-years.¹⁵ The incidence of pneumonia was notably high in patients with HF, especially HF with preserved ejection fraction, at approximately three times higher than the expected rate, and a first episode of pneumonia was associated with a 4-fold mortality risk.¹⁵ Torres et al. reported that individuals with chronic heart disease (CHD), including congestive HF, CVD, and valvular diseases, have up to a 3.3-fold risk of CAP and a 9.9-fold risk of IPD compared with those without CHD.³ Mor et al. reported that patients with chronic HF with cardiomyopathy (OR: 2.05) and heart valve disease (OR: 2.19) were at an increased risk of hospitalization due to pneumonia.¹⁶ The risk of pneumonia-related hospitalization was lower in patients with HF associated with previous acute MI (OR: 1.69) or atrial fibrillation (OR: 1.72).¹⁶ Heart failure in combination with a history of heart valve disease or atrial fibrillation has also been associated with an increased mortality risk due to pneumonia.¹⁷ These findings highlight that pneumococcal and influenza vaccinations are crucial preventative measures for adults with cardiac conditions to prevent pneumonia and associated complications, regardless of the specific causative organism.

Expert Opinions

In our study, the experts opined that patients with HF, CAD, and MI are at risk of PD based on their clinical practice. Acute coronary syndrome (ACS) and chronic hypertension (CH) may confer some degree of increased susceptibility to PD. Experts mentioned that, based on their clinical practice, 30%-70% of patients with underlying cardiac conditions show worsening of primary illness or cardiac complications after developing CAP, and 10%-50% after developing IPD. Furthermore, 10%-30% of patients with CHD who develop pneumococcal infections require hospitalization during the course of illness. Early identification and prompt management of PD are important for reducing mortality in this at-risk patient subgroup.

Evidence and Optimal Timing of Pneumococcal Vaccinations in Patients with Cardiac Conditions

Two recent systematic reviews reported that pneumococcal conjugate vaccine 13 (PCV13) and pneumococcal polysaccharide vaccine 23 (PPSV23) protected against ‍vaccine type (VT)-IPD and VT-pneumococcal pneumonia in adults.^{18, 19} Pneumococcal vaccination may provide economic benefits by lowering the hospitalization risk, as it plays a role in preventing PD.^{2, 20, 21} Pneumococcal vaccination offers significant protective effects for adults, especially those with underlying CV conditions (such as MI, ACS, HF, and CAD), and patients with high CV risk (Table 2).^{2, 11, 22–24} Ignatova et al. found that vaccinating patients (with PCV13) with chronic obstructive pulmonary disease (COPD), alongside chronic HF and ischemic heart disease, reduced healthcare costs by 74%-84%.²⁵ A meta-analysis by Vlachopoulos et al. reported that the protective effect of PPSV23 was particularly significant in individuals with elevated CV risk profiles.²³ This finding underscores the importance of pneumococcal vaccination in mitigating CV events in high-risk populations, as the analysis demonstrated a statistically significant reduction in both MI and cerebrovascular events among the elderly.²³ The benefit was most notable within the first year after vaccination, with a 28% reduction in CV events, though it waned beyond 1 year. Additionally, the protective effect was amplified in patients with CV and pulmonary comorbidities, further supporting its role in reducing risk in vulnerable populations.²³ Similarly, a study by Antunes et al. supports this finding, showing a 22% reduction in all-cause mortality in patients with CVD or those classified as having very high CV risk after pneumococcal vaccination (PCV13 and/or PPSV23).¹¹ Conversely, the absence of pneumococcal vaccination has been linked to a higher relative risk of developing HF and CAD, with older adults (between the ages of 80 and 89 years) facing an increased risk of hospitalization due to pneumococcal pneumonia in the absence of vaccination.²⁶ The use of PPSV was associated with a significantly lower risk of ACS events in older adults aged ≥65 years but not a significantly lower risk of stroke.²² Local injection site and systemic reactions, such as fever and fatigue, were reported.²² Jaiswal et al. reported that pneumococcal vaccination is associated with a decreased risk of all-cause mortality and MI in adult patients.² However, the study did not analyze the outcomes by PV type.² Tong et al. highlighted that sequential pneumococcal vaccination with PCV13 and PPSV23 was associated with lower CVD risk (ACS, congestive HF, or stroke), CVD-related deaths, and all-cause pneumonia versus single vaccination with either PCV13 or PPSV23 in older adults (≥65 years).²⁷

Children with cyanotic congenital heart disease and HF are at an increased risk of infections. Impaired nutrition and pulmonary congestion predispose one to pneumonia and other lower respiratory tract infections.^{28, 29} Pneumococcal conjugate vaccine can be considered in immunocompetent children with CHD (particularly cyanotic congenital heart disease and HF), who are at an increased risk of PD.^30–32Table 3 provides a breakdown of pneumococcal vaccination schedules according to various global versus national guidelines for patients with cardiac conditions (CHD, pulmonary arterial hypertension, HF, and CAD).^33–39

Expert Opinions/Consensus Recommendations

Table 4 lists the statements that achieved consensus (A) and the statements that were excluded (B). In our study, the experts agreed that, whether treated or untreated, pediatric patients with CHD (cyanotic congenital heart disease/impaired nutrition/pulmonary congestion/complex congenital anomalies) should be evaluated for pneumococcal vaccination status, and recommendations should be made based on the individual patient profile (Table 4A; high consensus). Experts came to a consensus that pneumococcal vaccination can lower the risk of acute CV events (ACS and MI) in adults with a history of CVD (high consensus). Experts recommended administering pneumococcal conjugate vaccine (PCV) followed by PPSV23 (≥8 weeks later) in vaccine-naïve adult patients (aged 19-49 years) with cardiac conditions, after the assessment of medical history, immune status, and risk factors (high consensus).

There was a moderate consensus on the administration of PCV13, followed by PPSV23 (≥8 weeks later), in elderly individuals (aged >50 years) with CH.

Experts agreed that administering PCV13 followed by PPSV23 after ≥8 weeks can be considered in adult patients under the CAD spectrum (high consensus).

The presence of multiple risk factors, such as smoking, type 2 diabetes mellitus (T2DM), and obesity, increases the susceptibility to pneumococcal infections. There was a low consensus on the clinical applicability of PCV13 in patients with ACS and arrhythmia alone. Hence, those two statements were excluded (Table 4B). The experts opined that patients with ACS and CH are at an increased risk of PD when complicated by additional multiple risk factors. Considering this, the panel also recommended administering PCV13 followed by PPSV23 after ≥8 weeks in adults (19 years and above) with CH/history of ACS/MI who had multiple comorbidities (left ventricular dysfunction, T2DM, obesity, COPD, chronic kidney disease [CKD], and/or chronic liver disease) (high consensus).

Immunocompetent individuals (aged >19 years) with cardiac conditions, adults (aged >19 years) with a medical history of MI/CAD, elderly individuals with cardiac conditions (≥65 years), individuals with moderate and high CV risk, and patients with HF (aged >19 years) could benefit from PCV13 vaccination (high consensus).

Table 2.

Summary of Studies Reporting the Efficacy of Pneumococcal Vaccination for Cardiac Conditions.^{2, 11, 22–24}

Author and Year	Study Details (Type/Population/Outcomes)	Key Findings
Jaiswal et al. (2022)²	Systematic review and meta-analysis. Adults (history of MI/CAD, hypertension, HF, stroke) with or without comorbidities (CRF, liver disease, diabetes). The high CV risk group: At least 50% of patients had established atherosclerotic CV diseases (CAD, cerebrovascular diseases, or peripheral vascular diseases), HF, end-stage CKD or requiring dialysis, and diabetes mellitus with target end-organ damage. All-cause mortality, risk of MI, stroke, and CV mortality. The study did not analyze the outcomes by PV type.	Pneumococcal vaccination was associated with a significant decrease in the incidence of MI (N = 8 studies; 193,940 participants). No significant reduction in CV mortality (N = 5 studies; 157,708 participants) or stroke (N = 5 studies; 179,649 participants). The benefit of reduction in all-cause mortality was only in the high CV risk group compared with that in the low-to-moderate CV risk group.
Ren et al. (2015)²²	Systematic review and meta-‍analysis. Adults (risk/first diagnosis of MI, CAD, hypertension, or prior cerebrovascular accident). ACS events (230,426 study participants; N = 8 studies) and stroke (192,210 study participants; N = 4 studies).	PPSV was associated with significantly lower odds of ACS events in older adults (aged ≥65 years). However, it was not associated with a lower risk of stroke.
Vlachopoulos et al. (2015)²³	Systematic review and meta-analysis. Adults (MI, ACS). Total CV events (CV death, MI, CAD, revascularization, cerebrovascular events, peripheral vascular disease, and unstable angina, HF and CV hospitalizations). In total, 11 studies were included, with 332,267 study participants.	The protective role of PPSV for total CV events was noted in patients with high CV risk and older adults.
Marra et al. (2020)²⁴	Systematic review and meta-analysis. Adults (ACS, prior cerebrovascular accident, MI, or CAD). Any CV events (e.g., MI, congestive HF, transient ischemic attack, or stroke) and mortality (N = 18 studies; 716,108 study participants).	Vaccination with PPSV was associated with a decreased risk of any CV event and MI in adults, with a significant effect in adults aged ≥65 years. Significant risk reduction in all-cause mortality in adults aged ≥65 years was reported.
Antunes et al. (2020)¹¹	Systematic review and meta-analysis. Adults (HF, history of MI, history of cerebrovascular disease, hemodialysis patients, history of known vascular disease, or diabetes with end-organ damage). All-cause mortality. In total, five studies were included, with 163,756 study participants.	Pneumococcal vaccination (PCV and/or PPSV) was associated with a 22% decrease in all-cause mortality in patients with CVD (HF, history of MI, or a history of cerebrovascular disease) or those at very high CV risk (hemodialysis patients). A non-significant difference in MACE was reported.

Note: ACS, acute coronary syndrome; CAD, coronary artery disease; CKD, chronic kidney disease; CRF, chronic renal failure; CV, cardiovascular; CVD, cardiovascular disease; HF, heart failure; MACE, major adverse cardiovascular events; MI, myocardial infarction; PCV, pneumococcal conjugate vaccine; PPSV, pneumococcal polysaccharide vaccine; PV, pneumococcal vaccine.

Table 3.

Recommendations for the Administration of Pneumococcal Vaccinations for Patients with Cardiac Conditions and Risk Factors.^33–39

Guidelines	Patient Population	Recommendations
CDC (2024)³³	“Adults 19-49 years old with medical conditions or other risk factors, including CHD, chronic lung/liver disease, CRF, diabetes.”	“Not previously received a PCV13, PCV15, PCV20, or PCV21, or previous vaccination history is unknown: 1D of PCV20 or 1D of PCV21 or 1D of PCV15, followed by 1D of PPSV23 ≥1YL.” “Previously received only PCV13: 1D of PCV20 or 1D of PCV21 ≥1YL after PCV13.” “Previously received only PPSV23: 1D of PCV15 or 1D of PCV20 or 1D of PCV21 ≥1YL.”
CDC (2024)³³	“Adults 50 years or older, lack documentation of vaccination, or lack evidence of immunity.”	“Not previously received a PCV13, PCV15, PCV20, or PCV 21, or whose previous vaccination history is unknown: 1D of PCV20 or 1D of PCV21, or 1D of PCV15 followed by 1D of PPSV23 ≥1YL.” “Previously received only PCV13: 1D of PCV20 or 1D of PCV21 ≥1YL after PCV13.” “Previously received only PPSV23: 1D of PCV15 or 1D of PCV20 or 1D of PCV21 ≥1YL.”
API Indian consensus guideline on adult immunization (2024)³⁴	“Heart disease in adults aged 18-49 years.”	At-risk: “PCV13 followed by PPSV23, 1YL.” High-risk: “PCV13 followed by PPSV23, 8WL.”
	“Elderly aged 18-49 years.”	“PCV13 followed by PPSV23, 1YL.”
ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension (2022)³⁵	“Patients with PAH.”	“Recommends patients with PAH be vaccinated against Streptococcus pneumoniae.”
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure (2021)³⁶	“Patients with HF.”	“Influenza and pneumococcal vaccinations should be considered to prevent HF hospitalizations.”
ICS-NCCP (2019)³⁷	“Immunocompetent adults (aged 19-64 years) with chronic conditions such as CHD, chronic liver disease, poorly controlled diabetes mellitus, and chronic lung disease.”	“PCV13 followed by PPSV23 ≥8WL is recommended.”
ICS-NCCP (2019)³⁷	“Immunocompetent adults (≥65 years) with chronic conditions such as CHD, chronic liver disease, poorly controlled diabetes mellitus, and chronic lung disease.”	“The decision to administer a dose of PCV13 preceding PPSV23 should be taken jointly by the physician and the patient, on a case-by-case basis.Revaccination with PPSV23 must be based only on clinical judgment.”
IMA (2018)³⁸	“Immunocompetent children (aged 24-71 months) with CHD (cyanotic congenital heart disease and cardiac failure).” “Adults aged 19-64 years with CHD, chronic lung, kidney, or liver disease.”	“PCV13 followed by PPSV23 after 8 weeks.”
GSI (2015)³⁹	“Adults (≥50 years) with underlying medical conditions such as CAD, congestive HF, cardiomyopathy, diabetes mellitus, cirrhosis of the liver, and CRF.”	“PCV13 may be preferred in vaccine-naïve or previously vaccinated adults.” “If previously unvaccinated, PCV13 is recommended, followed by PPSV23 8WL.”

Note: API, The Association of Physicians of India; CAD, coronary artery disease; CDC, Centers for Disease Control and Prevention; CHD, chronic heart disease; CRF, chronic renal failure; ERS, European Respiratory Society; ESC, European Society of Cardiology; 8WL, 8 weeks later; GSI, Geriatric Society of India; HF, heart failure; ICS/NCCP, Indian Chest Society/National College of Chest Physicians; IMA, Indian Medical Association; 1D, one dose; 1YL, one year later; PAH, pulmonary arterial hypertension; PCV, pneumococcal conjugate vaccine; PPSV, pneumococcal polysaccharide vaccine; PV: pneumococcal vaccine.

Table 4.

A Summary of Statements that Achieved Consensus (A) and were Excluded (B).

(A) Consensus Statements	Round 1 Vote (%)	Round 2 Vote (%)
Whether treated or untreated, pediatric patients with chronic heart disease (cyanotic/impaired nutrition/pulmonary congestion/complex congenital anomalies) should be evaluated for pneumococcal vaccination status, and recommendations should be made based on the individual patient profile.	Consensus was not reached in round one. The statement was modified for round two voting.	100%
Pneumococcal vaccination can lower the risk of acute CV events (ACS and MI) in adults with a history of CVD.	Consensus was not reached in round one. The statement was modified for round two voting.	100%
PCVs have an acceptable safety and tolerability profile in patients with underlying cardiac conditions.	100%	NA
1D of PCV followed by 1D of PPSV23 (≥8WL) is the optimum strategy to sequence pneumococcal vaccination in vaccine-naive adult patients (aged 19-‍49 years) with cardiac conditions.	Consensus was not reached in round one. The statement was modified for round two voting.	100%
Patient subgroups with cardiac conditions/risk that can benefit from PCV13: 1. CV risk:
a. Individuals with low CV risk, particularly those over 65 years, who are willing to receive it, can benefit from PCV13 vaccination.	100%	NA
b. Individuals with moderate CV risk, designated as having a likelihood of adverse cardiac events, can benefit from PCV13 vaccination.	85.7%	NA
c. Individuals with high CV risk with a high likelihood of adverse cardiac events stand to benefit significantly from the administration of PCV13.	100%	NA
2. Patients in the age group (19-64 years, ≥65 years) with cardiac conditions:
a. 19-64 years	85.7%	NA
b. ≥65 years	100%	NA
3. Immunocompetent adults with cardiac conditions	85.7%	NA
4. Adults with a history of MI	100%	NA
5. Adults with a history of CAD	85.7%	NA
6. Patients with HF	100%	NA
PCV13 followed by PPSV23 (≥8WL) should be recommended for adult patients under the CAD spectrum.	Consensus was not reached in round one. The statement was modified for round two voting.	100%
PCV13 followed by PPSV23 (≥8WL) can be considered for elderly individuals (>50 years) with CH.	Consensus was not reached in round one. The statement was modified for round two voting.	71.43%
In adults with a history of ACS/MI with multiple comorbidities (left ventricular dysfunction, T2DM, obesity, COPD, CKD, or chronic liver disease), PCV13 followed by PPSV23 (≥8WL) is recommended.	Consensus was not reached in round one. The statement was modified for round two voting.	100%
In adults with CH with multiple comorbidities (left ventricular dysfunction, T2DM, obesity, COPD, CKD, or chronic liver disease), PCV13 followed by PPSV23 (≥8WL) is recommended.	Consensus was not reached in round one. The statement was modified for round two voting.	100%
(B) Statements that did not Achieve Consensus and were Excluded
Clinical applicability of PCV13 in patients with arrhythmia alone. Clinical applicability of PCV13 in patients with ACS alone.

Note: ACS, acute coronary syndrome; CAD, coronary artery disease; CH, chronic hypertension; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; CV, cardiovascular; CVD, cardiovascular disease; 8WL, 8 weeks later; HF, heart failure; MI, myocardial infarction; NA, not applicable; 1D, one dose; PCV, pneumococcal conjugate vaccine; PPSV, pneumococcal polysaccharide vaccine; T2DM, type 2 diabetes mellitus.

Barriers to Pneumococcal Vaccination in Cardiology Settings and the Recommended

Approach for Administering Pneumococcal Vaccines for Cardiac Conditions

Studies have highlighted that concerns about vaccine efficacy, lack of awareness about PD, and its complications, and poor understanding of vaccination schemes contribute to the lower uptake of pneumococcal vaccination.^40–43 For patients with cardiac conditions, strategies such as patient education and direct physician recommendations for pneumococcal vaccination during clinical visits can play a major role in reducing vaccine hesitancy.⁴⁴

Expert Opinions

In our study, lack of awareness of PD and risk factors, lack of awareness of vaccine availability, and vaccine hesitancy (due to fear of adverse events) were identified as the most common perceived barriers to pneumococcal vaccination among patients with cardiac conditions. The most perceived barriers at the healthcare professional level were a lack of awareness regarding the burden of PD in cardiac conditions and uncertainty regarding clinical data on vaccine efficacy and recommendations (timing and schedule) for the use of pneumococcal vaccination in cardiac conditions. Experts agreed that counseling about the risk of PD early in the patient journey and the addition of flu and pneumococcal vaccination to the protocol for the management of cardiac conditions can decrease vaccine hesitancy and promote vaccination, especially among high-risk individuals.

Discussion

Pneumococcal diseases pose a significant public health concern in India, especially among older adults (>50 years of age) and those with preexisting cardiac conditions and/or chronic comorbidities (e.g., diabetes, chronic lung disease, obesity, and severe CKD).^{9, 42, 45, 46} Studies have reported that S. pneumoniae is one of the primary causes of IPD and CAP in India.^{47, 48} Furthermore, S. pneumoniae is the most frequently identified pathogen in studies of CAP etiology among adults, accounting for about 32.8%-55% of cases.^49–52 Two studies from India reported a case fatality rate for IPD to be from 17.8% to 30%.^{48, 53}

In 2017, PCV was introduced into the pediatric national immunization schedule in India.⁵⁴ Pneumococcal conjugate vaccine 13 offers broader protection, covering three additional prevalent serotypes (3, 6A, and 19A), than PCV10.^55–57 Currently, both are licensed and available in the private sector in India. Solanki et al. confirmed PCV13’s immunogenicity and safety, with significant increases in opsonophagocytic assay geometric mean titers across all 13 vaccine serotypes, underscoring its suitability for addressing the PD burden among Indian adults aged 50-65 years.⁵⁸ Considering this, the experts reached a consensus that PCV13, followed by PPSV23, is recommended for vaccine-naive adult patients with various cardiac conditions in Indian settings. Experts further identified specific subgroups of patients who benefit significantly from pneumococcal vaccination, such as adults with a history of MI or CAD, patients with HF, older adults with CH, and those with a history of ACS/MI with multiple comorbidities. However, barriers to pneumococcal vaccination uptake persist in cardiology settings in India. Limited awareness of the burden of PD in individuals with cardiac conditions and vaccine hesitancy, driven by concerns over potential adverse events, exacerbates the gap (Figure 2). Addressing these barriers requires a multifaceted approach, including educational initiatives, collaboration, and integration of vaccination protocols into routine cardiac care pathways (Figure 3). Cardiologists, general practitioners, and primary care physicians should take an active role in improving vaccination awareness among this vulnerable patient population.

Figure 2.

Barriers to Pneumococcal Vaccination in Cardiology Settings.

Figure 3.

The Recommended Approach for Administering Pneumococcal Vaccines (PVs) for Cardiac Conditions.

Strengths and Limitations

Strengths: Our modified Delphi study provides a thorough synthesis of expert opinions. The panelists were selected based on their clinical expertise and in-depth knowledge of the field to ensure a fair and unbiased selection process. The questionnaire was designed after a thorough review of evidence to increase the study’s rigor. Furthermore, anonymity during the Delphi survey encouraged honest and unbiased input from panel members.

Limitation: The study did not include any patients’ opinions or views.

Conclusion

This expert consensus provides practical recommendations for clinicians, emphasizing the importance of pneumococcal vaccination for at-risk subgroups, such as individuals with HF, CAD, and a history of ACS/MI with comorbidities (notably diabetes and severe CKD). Addressing the barriers to vaccination necessitates coordinated efforts to raise awareness, reduce vaccine hesitancy, and implement customized vaccination protocols within cardiology practices. Although existing data emphasize the benefits of vaccination, more robust evidence is needed to refine strategies for at-risk subgroups with complex cardiac conditions. Future research should explore the long-term CV outcomes of pneumococcal vaccination and assess its cost-‍effectiveness in the adult population with/without multiple comorbidities in Indian settings.

Footnotes

Acknowledgment

The authors would like to thank BioQuest Solutions Pvt. Ltd. for its editorial support.

Authors Contribution

All authors contributed to data curation, formal analysis, methodology, validation, visualization, writing—original draft, and writing—review & editing. Additionally, conceptualization, investigation, resources, software, and supervision were carried out by Santosh Taur and Namrata Kulkarni. Funding acquisition was managed by Santosh Taur, while project administration was handled by Namrata Kulkarni. All authors have reviewed and approved the final version of the manuscript for publication and agree to take responsibility for all aspects of the work, ensuring that any concerns regarding its accuracy or integrity are thoroughly investigated and appropriately addressed.

Informed Consent

Informed consent was taken before answering the survey from all experts.

Data Availability

The datasets used during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest regarding the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Tiny Nair

References

Scelfo

, Menzella

, Fontana

, . Pneumonia and invasive pneumococcal diseases: the role of pneumococcal conjugate vaccine in the era of multi-drug resistance. Vaccines (Basel) . 2021;9(5):420. doi:10.3390/vaccines9050420

Jaiswal

, Ang

, Lnu

, . Effect of pneumococcal vaccine on mortality and cardiovascular outcomes: a systematic review and meta-analysis. J Clin Med . 2022;11(13):3799. doi:10.3390/jcm11133799

Torres

, Blasi

, Dartois

, . Which individuals are at increased risk of pneumococcal disease and why? Impact of COPD, asthma, smoking, diabetes, and/or chronic heart disease on community-acquired pneumonia and invasive pneumococcal disease. Thorax . 2015;70(10):984–989.

Centers for Disease Control and Prevention. Pneumococcal Disease . 2024. https://www.cdc.gov/vaccines/pubs/pinkbook/pneumo.html. Accessed January 10, 2025.

Centers for Disease Control and Prevention. Pneumococcal Vaccination . 2024. https://www.cdc.gov/pneumococcal/vaccines/index.html. Accessed January 10, 2025.

World Health Organization. Pneumococcal Disease . https://www.who.int/teams/health-product-policy-and-standards/standards-and-specifications/norms-and-standards/vaccine-standardization/pneumococcal-disease. Accessed January 10, 2025.

Tralhão

, Póvoa

Cardiovascular events after community-acquired pneumonia: a global perspective with systematic review and meta-analysis of observational studies. J Clin Med . 2020;9(2):414. doi:10.3390/jcm9020414

Feldman

, Normark

, Henriques-Normark

, . Pathogenesis and prevention of risk of cardiovascular events in patients with pneumococcal community-acquired pneumonia. J Intern Med . 2019;285(6):635–652. doi:10.1111/joim.12875

Africano

, Serrano-Mayorga

, Ramirez-Valbuena

, . Major adverse cardiovascular events during invasive pneumococcal disease are serotype dependent. Clin Infect Dis . 2021;72(11):e711–e719.

10.

Feldman

Cardiac complications in community-acquired pneumonia and COVID-19. Afr J Thorac Crit Care Med . 2020;26(2). doi:10.7196/AJTCCM.2020.v26i2.077

11.

Antunes

, Duarte

, Brito

, . Pneumococcal vaccination in adults at very high risk or with established cardiovascular disease: systematic review and meta-analysis. Eur Heart J Qual Care Clin Outcomes . 2021;7(1):97–106. doi:10.1093/ehjqcco/qcaa030

12.

Nasa

, Jain

, Juneja

Delphi methodology in healthcare research: how to decide its appropriateness. World J Methodol . 2021;11(4):116–129. doi:10.5662/wjm.v11.i4.116

13.

Jünger

, Payne

, Brearley

, . Consensus building in palliative care: a Europe-wide Delphi study on common understandings and conceptual differences. J Pain Symptom Manage . 2012;44(2):192–205. doi:10.1016/j.jpainsymman.2011.09.009

14.

Corrales-Medina

, Musher

, Wells

, . Cardiac complications in patients with community-acquired pneumonia: incidence, timing, risk factors, and association with short-term mortality. Circulation . 2012;125(6):773–781. doi:10.1161/CIRCULATIONAHA.111.040766

15.

Shen

, Jhund

, Anand

, . Incidence and outcomes of pneumonia in patients with heart failure. J Am Coll Cardiol . 2021;77(16):1961–1973.

16.

Mor

, Thomsen

, Ulrichsen

, . Chronic heart failure and risk of hospitalization with pneumonia: a population-based study. Eur J Intern Med . 2013;24(4):349–353.

17.

Thomsen

, Kasatpibal

, Riis

, . The impact of pre-existing heart failure on pneumonia prognosis: population-based cohort study. J Gen Intern Med . 2008;23(9):1407–1413.

18.

Berild

, Winje

, Vestrheim

, . A systematic review of studies published between 2016 and 2019 on the effectiveness and efficacy of pneumococcal vaccination on pneumonia and invasive pneumococcal disease in an elderly population. Pathogens . 2020;9(4):259. doi:10.3390/pathogens9040259

19.

Farrar

, Childs

, Ouattara

, . Systematic review and meta-analysis of the efficacy and effectiveness of pneumococcal vaccines in adults. Pathogens . 2023;12(5):732. doi:10.3390/pathogens12050732

20.

Krishnamoorthy

, Eliyas

, Nair

, . Impact and cost effectiveness of pneumococcal conjugate vaccine in India. Vaccine . 2019;37:623–630. doi:10.1016/j.vaccine.2018.12.004

21.

Smith

, Wateska

, Nowalk

, . Cost-effectiveness of adult vaccination strategies using pneumococcal conjugate vaccine compared with pneumococcal polysaccharide vaccine. JAMA . 2012;307(8):804–812. doi:10.1001/jama.2012.169

22.

Ren

, Newby

, Li

, . Effect of the adult pneumococcal polysaccharide vaccine on cardiovascular disease: a systematic review and meta-analysis. Open Heart . 2015;2(1):e000247. doi:10.1136/openhrt-2015-000247

23.

Vlachopoulos

, Terentes-Printzios

, Aznaouridis

, . Association between pneumococcal vaccination and cardiovascular outcomes: a systematic review and meta-analysis of cohort studies. Eur J Prev Cardiol . 2015;22(9):1185–1199. doi:10.1177/2047487314549512

24.

Marra

, Zhang

, Gillman

, . The protective effect of pneumococcal vaccination on cardiovascular disease in adults: a systematic review and meta-analysis. Int J Infect Dis . 2020;99:204–213. doi:10.1016/j.ijid.2020.07.038

25.

Ignatova

, Antonov

VN.

Efficiency of vaccine prophylaxis concentrated pneumococcal vaccine in patients with chronic obstructive lung disease and chronic heart failure. Ter Arkh . 2018;90(8):53–62. doi:10.26442/terarkh201890853-62

26.

Ahmed

, Patel

, Fonarow

, . Higher risk for incident heart failure and cardiovascular mortality among community-dwelling octogenarians without pneumococcal vaccination. ESC Heart Fail . 2016;3(1):11–17. doi:10.1002/ehf2.12056

27.

Tong

, Gao

, Wong

ICK

, . Effects of sequential vs single pneumococcal vaccination on cardiovascular diseases among older adults: a population-based cohort study. Int J Epidemiol . 2024;53(1):dyae005. doi:10.1093/ije/dyae005

28.

Sadoh

, Osarogiagbon

WO.

Underlying congenital heart disease in Nigerian children with pneumonia. Afr Health Sci . 2013;13(3):607–612. doi:10.4314/ahs.v13i3.13

29.

Jat

, Bhagwani

, Bhutani

, . Assessment of the prevalence of congenital heart disease in children with pneumonia in tertiary care hospital: a cross-sectional study. Ann Med Surg (Lond) . 2021;73:103111. doi:10.1016/j.amsu.2021.103111

30.

Reyburn

, Tsatsaronis

, von Mollendorf

, . Systematic review on the impact of the pneumococcal conjugate vaccine ten valent (PCV10) or thirteen valent (PCV13) on all-cause, radiologically confirmed and severe pneumonia hospitalisation rates and pneumonia mortality in children 0-9 years old. J Glob Health . 2023;13:05002. doi:10.7189/jogh.13.05002

31.

Solórzano-Santos

, Espinoza-García

, Aguilar-Martínez

, Beirana-Palencia

, Echániz-Avilés

, Miranda-Novales

Pneumococcal conjugate vaccine and pneumonia prevention in children with congenital heart disease. Rev Invest Clin . 2017;69(5):270–273. doi:10.24875/ric.17002241

32.

CDC. Summary of Risk-based Pneumococcal Vaccination Recommendations . https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/risk-indications.html. Accessed January 15, 2025.

33.

CDC. Recommended Adult Immunization Schedule for Ages 19 Years or Older . https://www.cdc.gov/vaccines/hcp/imz-schedules/downloads/adult/adult-combined-schedule.pdf. Accessed November 22, 2024.

34.

Indian Consensus Guideline on Adult Immunization . https://www.apiindia.org/activities/other-publications. Accessed November 22, 2024.

35.

Humbert

, Kovacs

, Hoeper

, . 2022 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension [published correction appears in Eur Heart J . 2023;44(15):1312. doi:10.1093/eurheartj/ehad005]. Eur Heart J. 2022;43(38):3618-3731.

36.

McDonagh

, Metra

, Adamo

, . 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: developed by the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail . 2022;24(1):4–131. doi:10.1002/ejhf.2333

37.

Dhar

, Ghoshal

, Guleria

, . Clinical practice guidelines 2019: Indian consensus-based recommendations on pneumococcal vaccination for adults. Lung India . 2020;37(Supplement): S19–S29. doi:10.4103/lungindia.lungindia_272_20

38.

Tandon

, Ravindra

, Monga

. Life Course Immunization Guidebook. A Quick Reference Guide . Indian Medical Association. http://www.ima-india.org/ima/pdfdata/IMA_LifeCourse_Immunization_Guide_2018_DEC21.pdf. Accessed November 24, 2024.

39.

Geriatric Society of India. Indian Guidelines for Vaccination in Older Adults . In: Sharma

, ed. 2015. https://www.geriatricindia.in/. Accessed November 24, 2024.

40.

Huang

, Mak

, Wong

, . Enabling factors, barriers, and perceptions of pneumococcal vaccination strategy implementation: a qualitative study. Vaccines . 2022;10(7):1164. doi:10.3390/vaccines10071164

41.

Mieczkowski

, Wilson

SA.

Adult pneumococcal vaccination: a review of physician and patient barriers. Vaccine . 2002;20(9-10):1383–1392. doi:10.1016/s0264-410x(01)00463-7

42.

Koul

, Chaudhari

, Chokhani

, . Pneumococcal disease burden from an Indian perspective: need for its prevention in pulmonology practice. Lung India . 2019;36(3):216–225. doi:10.4103/lungindia.lungindia_497_18

43.

Seazzu

, Mueller

, Day

, . Pneumococcal pure polysaccharide vaccination in pediatric patients with chronic heart disease. J Pediatr Health Care . 2023;37(6):710–717. doi:10.1016/j.pedhc.2023.05.008

44.

Ekin

, Kış

, Güngören

, . Awareness and knowledge of pneumococcal vaccination in cardiology outpatient clinics and the impact of physicians’ recommendations on vaccination rates. Vaccines (Basel) . 2023;11(4):772. doi:10.3390/vaccines11040772

45.

Fukuda

, Onizuka

, Nishimura

, Kiyohara

Risk factors for pneumococcal disease in persons with chronic medical conditions: results from the LIFE Study. Int J Infect Dis . 2022;116:216–222. doi:10.1016/j.ijid.2021.12.365

46.

Koul

, Vora

, Jindal

, . Expert panel opinion on adult pneumococcal vaccination in the post-COVID era (NAP-EXPO Recommendations-2024). Lung India . 2024;41(4):307–317. doi:10.4103/lungindia.lungindia_8_24

47.

Ghia

, Dhar

, Koul

, . Streptococcus pneumoniae as a cause of community-acquired pneumonia in Indian adolescents and adults: a systematic review and meta-analysis. Clin Med Insights Circ Respir Pulm Med . 2019;13:1179548419862790. doi:10.1177/1179548419862790

48.

Thomas

, Mukkai Kesavan

, Veeraraghavan

, . Invasive pneumococcal disease associated with high case fatality in India. J Clin Epidemiol . 2013;66(1):36–43. doi:10.1016/j.jclinepi.2012.04.006

49.

Dey

, Nagarkar

, Kumar

Clinical presentation and predictors of outcome in adult patients with community-acquired pneumonia. Natl Med J India . 1997;10(4):169–172.

50.

Bansal

, Kashyap

, Pal

, Goel

Clinical and bacteriological profile of community acquired pneumonia in Shimla, Himachal Pradesh. Indian J Chest Dis Allied Sci . 2004;46(1):17–22.

51.

Oberoi

, Aggarwal

Bacteriological profile, serology and antibiotic sensitivity pattern of micro-organisms from community acquired pneumonia. JK Sci . 2006;8(2):79–82.

52.

Capoor

, Nair

, Aggarwal

, . Rapid diagnosis of community-acquired pneumonia using the BacT/Alert 3D system. Braz J Infect Dis . 2006;10(5):352–356.

53.

Jayaraman

, Varghese

, Kumar

, . Invasive pneumococcal disease in Indian adults: 11 years’ experience. J Microbiol Immunol Infect . 2019;52(5):736–742. doi: 10.1016/j.jmii.2018.03.004

54.

National Health Mission. National Operational Guidelines on the Introduction of Pneumococcal Conjugate Vaccine, India . 2017. https://nhm.gov.in/New_Updates_2018/NHM_Components/Immunization/Guildelines_for_immunization/Operational_Guidelines_for_PCV_introduction.pdf. Accessed November 24, 2024.

55.

Singh

, Sundaresan

, Manoharan

, . Serotype distribution and antimicrobial susceptibility pattern in children ≤5 years with invasive pneumococcal disease in India—a systematic review. Vaccine . 2017;35(35 Pt B):4501–4509. doi:10.1016/j.vaccine.2017.06.079

56.

Nagaraj

, Govindan

, Ganaie

, . Streptococcus pneumoniae genomic datasets from an Indian population describing pre-vaccine evolutionary epidemiology using a whole genome sequencing approach. Microb Genom . 2021;7(9):000645. doi:10.1099/mgen.0.000645

57.

Abu Seir

, Azmi

, Hamdan

, . Comparison of early effects of pneumococcal conjugate vaccines: PCV7, PCV10 and PCV13 on Streptococcus pneumoniae nasopharyngeal carriage in a population based study; The Palestinian-Israeli Collaborative Research (PICR). PLoS One . 2018;13(11):e0206927.

58.

Solanki

, Juergens

, Chopada

, . Safety and immunogenicity of a 13-valent pneumococcal conjugate vaccine in adults 50 to 65 years of age in India: An open-label trial. Hum Vaccin Immunother . 2017;13(9):2065–2071.

Pneumococcal Disease Risk and Vaccination Consensus in Cardiac Conditions: Expert Group Recommendations Based on Modified Delphi Consensus Method

Abstract

Introduction

Methods

Results

Conclusion

Keywords

Introduction

Methodology

Consensus Criteria. 13

Results

Risk and Consequences of Community-acquired Pneumonia and Invasive Pneumococcal Disease in Patients with Cardiac Conditions

Expert Opinions

Evidence and Optimal Timing of Pneumococcal Vaccinations in Patients with Cardiac Conditions

Expert Opinions/Consensus Recommendations

Summary of Studies Reporting the Efficacy of Pneumococcal Vaccination for Cardiac Conditions.2, 11, 22–24

Recommendations for the Administration of Pneumococcal Vaccinations for Patients with Cardiac Conditions and Risk Factors.33–39

A Summary of Statements that Achieved Consensus (A) and were Excluded (B).

Barriers to Pneumococcal Vaccination in Cardiology Settings and the Recommended

Approach for Administering Pneumococcal Vaccines for Cardiac Conditions

Expert Opinions

Discussion

Barriers to Pneumococcal Vaccination in Cardiology Settings.

The Recommended Approach for Administering Pneumococcal Vaccines (PVs) for Cardiac Conditions.

Strengths and Limitations

Conclusion

Footnotes

Acknowledgment

Authors Contribution

Informed Consent

Data Availability

Declaration of Conflicting Interests

Funding

ORCID iD

References

Consensus Criteria.¹³

Summary of Studies Reporting the Efficacy of Pneumococcal Vaccination for Cardiac Conditions.^{2, 11, 22–24}

Recommendations for the Administration of Pneumococcal Vaccinations for Patients with Cardiac Conditions and Risk Factors.^33–39