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CLINICAL STATEMENTS AND GUIDELINES August 29, 2023 Circulation. 2023;148:e9–e119. DOI: 10.1161/CIR.0000000000001168 Virani et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline Prevention of Cardiovascular Disease) results among patients with clinically stable ASCVD who had shown a reduced risk of recurrent cardiovascular events in patients taking colchicine 0.5 mg daily compared with placebo.2,5 The primary endpoint was a composite of cardiovascular death, spontaneous MI, ischemic stroke, or ischemic-driven revascularization, which occurred in 6.8% of patients in the colchicine group compared with 9.6% in the placebo group (P<0.001). Despite the positive results, the study showed a trend toward increased risk of death from noncardiovascular causes in the colchicine group. The first trial to evaluate the efficacy of colchicine in secondary prevention in patients with ACS was the COLCOT trial.8,9 Of patients treated with colchicine, the primary endpoint of death from cardiovascular causes, MI, resuscitated cardiac arrest, stroke, or urgent hospitalization for angina leading to coronary revascularization occurred in 5.5% of patients compared with 7.1% in the placebo group (P=0.02). These results were driven primarily by reductions in the incidence of strokes and urgent hospitalizations for angina leading to coronary revascularization. Although studies evaluating colchicine in secondary prevention excluded patients with creatinine clearance of <50 mL/min, these studies were also limited to a duration of just over 2 years.1,2 Given its long half-life, narrow therapeutic window, and degree of dependence on renal function for clearance, use should be avoided in patients with advanced renal disease (eGFR, <30 mL/min/m2). Additionally, colchicine is metabolized by CYP3A4 and is a substrate for P-glycoprotein, which necessitates careful evaluation for drug-drug interactions.10 4.3.5 Immunizations Recommendations for Immunizations Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 1 A 1 In patients with CCD, an annual influenza vaccina- tion is recommended to reduce cardiovascular morbidity, cardiovascular death, and all-cause death.1–7 1 C-EO 2 In patients with CCD, coronavirus disease 2019 (COVID-19) vaccination is recommended per public health guidelines to reduce COVID-19 complications.8–10 2a B-NR 3 In patients with CCD, a pneumococcal vaccine is reasonable to reduce cardiovascular morbidity and mortality and all-cause death.11–13 Synopsis Infections such as influenza, pneumococcal pneumonia, and COVID-19 are a contributing factor to MACE and all-cause death, especially in patients with CCD.1,2,8,12 The mechanisms by which infections such as these increase cardiovascular events may be related to proinflammatory mediators, stimulation of the sympathetic system, and coagulation cascade activation, which may cause rupture of vulnerable atherosclerotic plaques.14 Vaccination against these respiratory infections may not only improve clinical outcomes but also potentially reduce hospitalization and health care costs. RCTs and nonrandomized clinical trials have concluded that vaccination for these infections offer the greatest benefit in the highest risk populations, which includes those with advanced age, CCD, or both. Vaccination promotion is the best defense in protecting those with CCD who may be exposed to these infections in the community and face potential adverse clinical outcomes as a result. Recommendation-Specific Supportive Text 1 Studies show a significant association between recent respiratory infection and acute MI.1 Metaanalyses and systematic reviews showed that influenza vaccination was associated with a lower risk of acute MI, cardiovascular death, MACE, and all-cause death in patients with CAD or HF.1-5,7 However, 1 study found no significant reduction in MI among those who received the influenza vaccine compared with control.7 In patients with previous stroke, there was a nonsignificant trend for reduction of recurrent stroke risk.3 No reduction was seen in all-cause death or cardiopulmonary hospitalization in high-risk patients with CCD who received high-dose trivalent influenza vaccine versus standard-dose quadrivalent influenza vaccine, although more vaccine-related adverse reactions occurred in the high-dose trivalent influenza vaccine group.6 2 Although outcome data about the benefit of the COVID-19 vaccination in patients with CCD are unavailable at the time of writing this guideline, the targeted population for whom this guideline is intended is among the highest risk for developing COVID-19– related complications and death.8 Therefore, the writing committee supports COVID-19 vaccination for patients with CCD and that the benefits of the COVID-19 vaccination outweigh the potential adverse events related to the vaccine itself.8–10 For reference, US Centers for Disease Control and Prevention (CDC) guidance may be accessed at https://www.cdc.gov/coronavirus/2019-ncov/communication/guidance.html.15 3 Limited data are available that evaluate pneumo- coccal polysaccharide vaccination in patients with CCD and its effect on cardiovascular outcomes and all-cause death. A population-based cohort study of 6171 patients (18% with ischemic heart disease) who were hospitalized for pneumonia within 90 days and received previous pneumococcal polysaccharide vaccination found a 58% reduction in ACS Downloaded from http://ahajournals.org by on October 7, 2026