What vaccinations are recommended for patients with rheumatic heart disease?

Vaccination Recommendations for Patients with Rheumatic Heart Disease

Patients with rheumatic heart disease should receive influenza, pneumococcal, and recombinant varicella-zoster virus vaccinations as core preventive measures, regardless of immunosuppressive therapy status. 1

Core Vaccinations

Influenza Vaccination

• High-dose or adjuvanted influenza vaccination is conditionally recommended over regular-dose influenza for patients with rheumatic heart disease who are ≥65 years or between 18-65 years taking immunosuppressive medications 2
• Annual influenza vaccination should be administered regardless of timing of immunosuppressive therapies 2
• If high-dose or adjuvanted vaccines are unavailable, standard-dose influenza vaccine should be administered rather than delaying vaccination 2
• For patients on methotrexate, consider holding the medication for 2 weeks after influenza vaccination if disease activity permits 1

Pneumococcal Vaccination

• Pneumococcal vaccination is strongly recommended for patients with rheumatic heart disease who are <65 years and taking immunosuppressive medications 2
• Current CDC recommendations include either PCV15 followed by PPSV23 one year later, or a single dose of PCV20 for adults taking immunosuppressive medications 2
• Pneumococcal vaccination is particularly important as patients with cardiac conditions are at increased risk for pneumococcal infections 2, 3

Recombinant Varicella-Zoster Virus Vaccination

• Recombinant VZV vaccine is strongly recommended for patients with rheumatic heart disease >18 years who are taking immunosuppressive medication 2
• This non-live vaccine is safe for immunosuppressed patients and helps prevent herpes zoster, which occurs at higher rates in patients with rheumatic diseases 2

Medication Considerations for Vaccination

• For patients on rituximab, administer vaccinations on schedule regardless of rituximab timing, but consider delaying subsequent rituximab dosing for at least 2 weeks after vaccination if disease activity allows 1
• For patients taking prednisone ≥20 mg daily, administer influenza vaccination as scheduled, but consider deferring other non-live vaccinations until glucocorticoids are tapered to <20 mg daily 2
• Non-live vaccinations are conditionally recommended regardless of disease activity 2
• Multiple vaccinations can be administered on the same day rather than spacing them out on different days 1

Additional Preventive Measures

• Secondary prevention of rheumatic fever with antibiotic prophylaxis is indicated in all patients with rheumatic heart disease 2
• For patients with rheumatic heart disease and residual valvular disease, antibiotic prophylaxis should continue for at least 10 years or until age 40 (whichever is longer) 2
• Lifelong prophylaxis may be recommended if the patient is at high risk of group A streptococcus exposure 2
• Infective endocarditis prophylaxis should be provided to appropriate patients with rheumatic heart disease, especially those with prosthetic valves 2, 4

Practical Implementation

• Vaccination status should be assessed at every clinical encounter to maximize opportunities for vaccination 1
• Patients with rheumatic heart disease should receive standard age-appropriate vaccinations in addition to the specific recommendations above 2
• The maintenance of optimal oral health remains an important component of preventing infective endocarditis in patients with rheumatic heart disease 2
• Recent evidence shows that secondary antibiotic prophylaxis significantly reduces the risk of progression of latent rheumatic heart disease, highlighting the importance of comprehensive preventive care 5