Saudi Heart Association Position Statement on Adult Vaccinations for Patients With Cardiovascular Diseases

Abstract

Background

Cardiovascular diseases (CVDs) remain the leading cause of mortality worldwide. Individuals with CVD are particularly vulnerable to severe complications from vaccine-preventable infections; however, adult vaccination continues to be underutilized.

Methods

A multidisciplinary expert panel from the Saudi Heart Association (SHA) conducted a comprehensive literature review and a series of consensus meetings to develop evidence-based recommendations for adult immunization in patients with CVD.

Results and conclusions

Evidence from randomized trials, observational studies, and real-world data supports the role of vaccines in reducing the risk of major adverse cardiovascular events in individuals with CVD. The SHA recommends the implementation of age-appropriate vaccinations against influenza, COVID-19, respiratory syncytial virus (RSV), herpes zoster, pneumococcal disease and meningococcal disease as an integral component of cardiovascular care. Recommendations emphasize routine vaccine assessment, integration into cardiology practice, healthcare provider engagement, patient education, and leveraging high-risk periods such as Hajj and Umrah for vaccination outreach.

1. Introduction

Cardiovascular diseases (CVDs) are largely preventable disorders and the leading cause of mortality worldwide, accounting for nearly 20 million deaths in 2022 [1]. With a third of these deaths occurring before the age of 70, it is estimated that most cases of premature CVD can be prevented by the adoption of preventative risk reduction [2]. The burden of CVDs is particularly high in Saudi Arabia, where prevalence of cardiovascular disease, its risk factors and mortality exceed global rates by far [3–5]. Notably, the age-standardized incidence and death rates of CVD in Saudi Arabia (1218.2 and 353.3 per 100,000, respectively) were about 1.5-fold higher than the corresponding global rates in 2021 [6].

Current cardiovascular prevention approaches primarily target conventional risk factors, including environmental, metabolic and behavioral factors [7,8]. However, acute viral illnesses have been shown to trigger cardiovascular events, and individuals with established CVD are at a higher risk for severe outcomes from these viral infections [9–13]. Given that serious illness from these infections is vaccine-preventable [13–16], immunization becomes a crucial but often overlooked component of CVD prevention that may be on par with pharmacologic therapy.

Despite this benefit and the strong recommendation of adult vaccination from major healthcare organizations and societies, adult immunization rates remain suboptimal around the world, including developed countries [17,18] and Saudi Arabia [19]. The rise in vaccine hesitancy following the coronavirus disease 2019 (COVID-19) pandemic is further compounded by limited public awareness of the need for vaccines beyond childhood, and frequently missed opportunities for adult vaccination due to inadequate assessment of adult patients’ vaccination status by healthcare professionals [20–27].

By harnessing the benefits of adult vaccination, healthcare providers can augment existing preventive strategies to alleviate the burden of CVDs. The Saudi Heart Association (SHA) thus undertook a comprehensive evaluation of available evidence within the unique context of Saudi Arabia to inform evidence-based recommendations and close existing gaps in practice related to adult vaccinations.

2. Methods

An extensive review of existing literature was conducted to gather relevant evidence on adult vaccinations and their impact on patients with CVDs. PubMed/MEDLINE was primarily used and was supplemented with other databases as needed, including Embase, Scopus, Web of Science, and the Cochrane Library. The search combined terms related to adult vaccination and immunization (“adult vaccination”, “adult immunization”), specific vaccines (“influenza vaccine”, “COVID-19 vaccine”, “respiratory syncytial virus vaccine”, “herpes zoster vaccine”, “pneumococcal vaccine”, “meningococcal vaccine”, “Hajj vaccination”, “Umrah vaccination”), as well as terms related to cardiovascular diseases/outcomes (“cardiovascular disease”, “cardiovascular prevention”, “cardiovascular outcomes”, “cardiovascular complications”). Reference lists of relevant articles and reviews were also screened to identify additional publications. No restrictions were placed on date of publication or language. All study types were considered, with preference given to randomized controlled trials and meta-analyses where available.

In this position statement, the term ‘cardiovascular disease (CVD)’ is used in its broadest sense to encompass all diseases of the cardiovascular system, including coronary artery disease, heart failure (HF), arrhythmias such as atrial fibrillation, valvular and congenital heart disease, and other structural or vascular conditions. We acknowledge that the level of evidence supporting vaccination may vary across these disease subsets.

Two online meetings were conducted comprising a panel of multidisciplinary experts from Saudi Arabia to evaluate the evidence and formulate preliminary recommendations. The panel included cardiologists, pulmonologists, infectious diseases specialists, and epidemiologists. Based on the insights and feedback from the initial discussions, the literature review was updated to include any additional relevant studies or data. A second online meeting was held to finalize the SHA recommendations, with the expert panel reviewing and refining them to ensure medical accuracy and applicability to the context of Saudi Arabia. The final recommendations were reviewed and approved by the expert panel to ensure the integrity and relevance of the content.

3. Pathophysiology of cardiovascular events and viral infections

The pathophysiology of cardiovascular events and viral infections is driven by complex interactions between pathogens and the cardiovascular system. The mechanisms by which viral infections precipitate cardiac events are diverse and result in vascular, myocardial, and systemic complications (Fig. 1). That being said, common respiratory infections generally act in a similar fashion, triggering cardiovascular events through immune system activation, the creation of a thrombogenic environment, the destabilization of existing plaques, and the disruption of endothelial and metabolic functions.

Fig. 1.

Cardiovascular complications of respiratory infections.

Abbreviations: COVID-19: Coronavirus Disease 2019; RSV: Respiratory Syncytial Virus.

Influenza, for instance, has been associated with several cardiovascular complications such as an increased risk of heart failure (HF) and stroke possibly mediated by acute plaque rupture, endothelial dysfunction and systemic inflammation [28]. Studies have also suggested that influenza virus replication may directly contribute to myocardial and vascular complications through inflammation-mediated plaque destabilization and myocardial dysfunction [28].

Similarly, various cardiovascular disorders have been documented to occur due to COVID-19, including myocarditis, arrhythmias, acute coronary syndrome, acute cardiac injury and thromboembolism [12]. The varied cardiovascular manifestations of COVID-19 can likely be explained by the reliance of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on the angiotensin-converting enzyme 2 (ACE2) receptor to gain entry into host cells. This interaction disrupts the normal function of ACE2, whose downregulation contributes to both lung injury and cardiovascular diseases [12].

Respiratory syncytial virus (RSV) also significantly impacts cardiovascular health. Hospitalization for RSV-related respiratory illness is frequently complicated by the onset of cardiovascular events in apparently healthy individuals (no prior CVD) and the worsening of existing conditions in those with established CVD [11,29]. The cardiovascular complications of RSV include worsening HF, increased risk of myocardial infarction and stroke, acute coronary syndrome, and arrhythmias [11,29].

Herpes zoster is another viral infection closely linked to cardiovascular diseases, causing severe complications such as vasculopathy, myocarditis, arrhythmia, and sudden death [10]. Not only is herpes zoster associated with acute cardiovascular events, studies including a meta-analysis have also shown that individuals with a history of herpes zoster infection (shingles) have an increased long-term risk of major cardiovascular events, including stroke and coronary heart disease [30–32].

Pneumococcal diseases are associated with a high risk of severe cardiovascular outcomes. Up to 30 % of hospitalized patients with community-acquired pneumonia experiencing major adverse cardiovascular events (i.e. HF, arrhythmia and myocardial infarction), resulting in doubled mortality rates [9,33–36]. The risk of these complications can persist for days and months following pneumonia, and possibly for years in the case of pneumonia with sepsis [37]. The cardiovascular complications associated with pneumococcal disease arise from different mechanisms, including plaque rupture and thrombus formation leading to vascular complications such as myocardial infarction [38,39]. Pneumococcal disease also causes inflammation and hypoxemia in addition to renal impairment, all of which can cause or exacerbate arrhythmias and HF through mechanisms like Renin-Angiotensin-Aldosterone System alteration and abnormal sympathetic nervous system responses [38,39].

Notably, underlying CVDs often exacerbate cardiovascular complications by increasing susceptibility to severe outcomes or mortality following viral illness. This has been noted in several studies and meta-analyses with influenza [40–42], COVID-19 [43], RSV [44–46], Zoster virus [47–49] and pneumococcal disease [34,50]. Other factors such as comorbidities and older age are also known to contribute to worsened clinical outcomes with viral infections, both in patients with established CVD and those without [34,40,44,45,47,51–55].

4. Mitigating cardiovascular disease risk: evidence and insights on adult immunization

The substantial burden of CVDs, coupled with the increased vulnerability to adverse outcomes from viral infections among individuals with CVD, positions this population as a key target for preventive interventions such as vaccination. The role of adult immunization in mitigating cardiovascular risk associated with viral illnesses is becoming increasingly evident, as demonstrated by randomized controlled trials (RCTs), observational studies and real-world data.

4.1. Influenza vaccination

Influenza vaccination has been consistently associated with a reduction in mortality and hospitalizations in both the general population and in individuals with chronic diseases including preexisting CVD [56,57]. The Influenza Vaccination after Myocardial Infarction (IAMI) trial reported a 28 % reduction in major adverse cardiovascular events (MACE) and a 41 % reduction in cardiovascular mortality when vaccination was administered within three days of hospitalization for myocardial infarction [58]. Likewise, a multinational RCT, including three centers from Saudi Arabia, demonstrated the clinical benefits of influenza vaccination in patients with HF [59]. These findings are consistent with broader evidence from both randomized and observational studies, which have shown reductions in all-cause and cardiovascular mortality, acute myocardial infarction, and MACE among patients with CVD, including coronary artery disease and HF [60–67]. Meta-analyses of RCTs further confirm that influenza vaccination reduces MACE in patients with CVD or at high risk for CVD by at least 25 %, with an even greater benefit (45 % reduction) observed in patients with a recent coronary syndrome [13,56,68].

Influenza vaccination is strongly recommended for patients with CVD by leading international and local cardiovascular medical societies such as the European Society of Cardiology, the American College of Cardiology and the SHA. In Saudi Arabia, the Ministry of Health (MOH) similarly advocates for annual influenza vaccination in patients with heart failure, CVD, or associated risk factors. While the standard-dose influenza vaccine is generally recommended for everyone aged six months and older, a high-dose version is preferred for older adults to provide stronger immune protection [69]. For patients aged 60 and above, particularly those at increased risk such as individuals with cardiovascular conditions, the high-dose influenza vaccine is preferred as it offers superior immunogenicity and effectiveness compared to the standard dose [70–72]. Lowering the eligibility age for high-dose vaccination to 60 years ensures enhanced protection in this vulnerable group.

Evidence from the DANFLU-1 trial has shown that the high-dose influenza vaccine reduces all-cause hospital admissions in people with chronic CVD [73]. Building on this, the ongoing DANFLU-2 trial (NCT05517174) aims to enroll approximately 339,700 participants across three influenza seasons to assess the comparative effectiveness of high-versus standard-dose influenza vaccines in older adult populations.

The cardiovascular benefits of influenza vaccination stem from various mechanisms, including prevention of infection-driven plaque rupture, lowering systemic inflammation, minimizing infection-related myocardial oxygen demand, and potential long-term immune modulation that reduces inflammation beyond the influenza season [74,75]. CVD management guidelines also support administering the vaccine during hospitalization for acute cardiovascular events, with data confirming it is safe and beneficial when given within 72 hours of an acute myocardial infarction [58,74].

Although the ideal window for influenza vaccination is in September and October, immunization efforts should continue throughout the flu season, as long as the virus is circulating. In the northern hemisphere, peak influenza activity usually occurs from December to March. However, in Saudi Arabia, an additional peak has been observed around the time of Umrah and Hajj pilgrimages, likely due to increased travel and crowding [76]. The coadministration of vaccines, such as influenza and COVID-19, is an effective strategy to improve coverage and ensure high-risk populations, including cardiovascular patients, are protected. This approach is particularly valuable before winter season and in preparation for Hajj or Umrah.

4.2. COVID-19 vaccination

Patients with CVD, particularly those with HF, experience a significantly more severe course of COVID-19 infection and face a higher risk of developing long COVID [77,78]. Several large-scale studies involving millions of adults have demonstrated the cardioprotective effects of COVID-19 vaccination, whether partial or complete. These include a 19–60 % reduction in the risk of MACE and myocardial infarction, a 27–55 % reduction in the risk of atrial fibrillation and HF, and a 31–78 % reduction in the risk of stroke [16,79–84]. Vaccination also substantially lowers the risk of long COVID, offering important protection for cardiovascular patients [85,86].

Importantly, available data continue to support the safety of COVID-19 vaccines in individuals with established CVD [87]. The clinical benefits of COVID-19 vaccination outweigh its exceedingly rare but recognized risks of cardiovascular manifestations, such as myocarditis, pericarditis, and thrombotic events. Among available vaccine platforms, protein-based vaccines offer a well-established safety profile and robust immune response [88,89] that may be particularly useful for individuals who are hesitant about mRNA vaccines or have precautions or contraindications.

Similar to seasonal influenza vaccines, COVID-19 vaccines are updated each season to match circulating strains. As such, updated COVID-19 vaccination should be considered part of routine care for patients with CVD.

4.3. RSV vaccination

RSV is a highly transmissible pathogen and a significant cause of hospitalization and mortality among high-risk adults, particularly those with cardiovascular, respiratory, metabolic, or immunological disorders [11,90]. While dedicated cardiovascular outcomes trials are lacking, current RSV vaccines have demonstrated high efficacy and favorable safety profiles in clinical studies [91–95].

Currently, two RSV vaccines are approved for adults aged 60 years and older. The RSV prefusion F protein vaccine (RSVPreF3) is the only available adjuvanted vaccine with an expanded age indication for adults aged 50 years or older who are at increased risk for RSV-related diseases, including chronic heart patients. In adults aged 60 years or older, a single dose of RSVpreF3 is routinely recommended, and has proven to be effective across three seasons [96]. This benefit was persistent in those with underlying chronic medical conditions such as HF [91,92,97]. RSVPreF3 also demonstrated 82.6 % efficacy against RSV-related lower respiratory tract disease (RSV-LRTD) in the first season, with a cumulative effectiveness of 67.2 % and 69.1 % across two and three seasons, respectively [92,96,98]. Effectiveness was even higher for severe RSV-LRTD (94.1 % for season 1 and 72.1 % across three seasons) [92,96], and in adults with cardiorespiratory conditions, including HF (92.1 % for RSV-LRTD and 88.1 % for RSV-related acute respiratoryillness [RSV-ARI]) [97].

Another approved vaccine against RSV is the protein-based vaccine RSVpreF, which is also routinely indicated for adults aged 60 or above. It has also been recently licensed for adults aged 18–59 years who are at increased risk for LRTD caused by RSV, including CVD. It showed vaccine efficacy of 88.9 % and 78.6 % against RSV-LRTI with 3 or more symptoms in high-risk individuals (including those with heart disease) in the first and second RSV seasons, respectively [93,94]. Real-world evidence supports the effectiveness of RSVpreF in significantly reducing hospitalization and emergency department visits among older individuals with underlying conditions, including for myocardial infarction and HF [99].

The third and most recently approved RSV vaccine is an mRNA-based vaccine (mRNA-1345) indicated for adults aged 60 years and older. This approval came following results from the ConquerRSV Phase 3 trial, which showed 83.7% efficacy against RSV-LRTD and 68.4% against RSV-ARI [95]. Although subgroup analysis indicated 88.4% efficacy in individuals with underlying conditions, only 1.1% of the trial participants had HF [95], warranting further investigation in high-risk CVD populations across multiple RSV seasons. The mRNA RSV vaccine is not yet approved in Saudi Arabia.

4.4. Herpes zoster vaccination

The recombinant subunit zoster vaccine (RZV, Shingrix) is currently the only available vaccine that is approved and recommended for all individuals 50 years and older, as well as for adults age 19 years and older with immunosuppressive conditions.

In a population-based cohort study of over 1.6 million individuals aged 66 years or older, the live attenuated zoster vaccine (Zostavax) was associated with a reduced risk of incident stroke compared to unvaccinated controls [100]. The reduction in the risk of stroke was sustained over a 5-year follow-up in adults with at-risk comorbid conditions and was observed along with a reduced risk of myocardial infarction [101]. However, the recombinant zoster vaccine demonstrates superior efficacy consistent across all age groups [102], leading to its preferential recommendation by the US Advisory Committee on Immunization Practices (ACIP) since 2017 [103].

The recombinant zoster vaccine offers more than 96% in preventing herpes zoster in adults aged 50 years or older [102], extending vaccination eligibility by a decade compared to the live attenuated vaccine. Moreover, there is more data to support the potential of the recombinant zoster vaccine in reducing cardiovascular risk, with reported reductions in the risk of CVD by 21%, and up to 39% when used with antiviral therapy [104]. Data from a large cohort of over 2 million patients showed an 18% reduction in myocardial infarction risk, and another study reported a 27% and 30% reduction in the 3-year risk of myocardial infarction and mortality, respectively [105,106]. Notably, the live vaccine showed minimal to no cardiovascular benefit in these studies compared to the recombinant zoster vaccine.

4.5. Pneumococcal vaccination

Two classes of pneumococcal vaccines are currently licensed and recommended, namely the 23-valent polysaccharide-based vaccine (PPSV23) and pneumococcal conjugate vaccines (PCVs: PCV13, PCV15, PCV20, and PCV21). These vaccines are effective in preventing invasive pneumococcal disease and pneumonia in older adults and those with high-risk conditions [107–109]. Their cardioprotective effects are well-documented and appear more pronounced in older individuals and those with elevated cardiovascular risk, as reported in a meta-analysis of cohort studies including over 332 thousand individuals [110].

A meta-analysis of data from over 700 thousand individuals found that pneumococcal vaccination significantly reduces the risk of acute myocardial infarction, particularly in individuals aged 65 years and older [111]. Another meta-analysis of observational studies including over 163 thousand individuals reported a 22 % reduction in all-cause mortality following pneumococcal vaccination (PCV13, PPSV23, or both) in adult patients with established CVD or at a very high cardiovascular risk [112]. Furthermore, pneumococcal vaccination is associated with reduced incidence of HF and HF-related hospitalizations in the elderly [113–116], and with lower risk of ischemic heart disease and cardiac arrest when co-administered with the influenza vaccine [115,117].

5. Optimizing cardiovascular outcomes through adult vaccination: Saudi Heart Association recommendations

5.1. Recommended vaccinations for adults with CVD

The burden of CVD in Saudi Arabia is profound, characterized by high mortality, earlier age of onset and high prevalence of cardiovascular risk factors [118–126]. CVD is the leading cause of mortality in the Kingdom, accounting for nearly half of all deaths [4,125,126,131,132]. Distinct patterns also differentiate Saudi Arabia from Western and international populations. Age-standardized mortality rates from CVD exceed the global average [3–6], and evidence from national registries shows that CVD events occur, on average, a decade earlier in Saudi patients compared with Western populations [118–124]. Diminished quality of life, significant losses in workforce productivity, and escalating healthcare costs are other far-reaching implications of CVD in Saudi Arabia [4], further emphasizing the need to attenuate the risks associated with this disease.

Based on the evidence presented in Section 3 and the substantial burden of CVD in Saudi Arabia, the SHA recommends that all adults with established CVD receive age-appropriate immunizations to mitigate the risk of future cardiovascular events and complications. Vaccinations recommended for individuals with established CVD include seasonal influenza, COVID-19, RSV, herpes zoster, pneumococcal and meningococcal vaccines (Table 1). Although vaccination is strongly recommended for adults with CVD, healthcare providers should rely on national guidelines and clinical judgment to account for contraindications and to determine the appropriateness of each vaccine for individual patients.

Table 1.

SHA Recommendations for adult vaccinations in patients with CVD.

Vaccine			Recommendation
COVID-19 vaccine			Annual routine vaccination against COVID-19 is recommended for all adult (≥18 years) patients with CVD, in accordance with local health authority guidelines. High-risk individuals include those aged 50 years and older, chronic disease patients, pregnant women, healthcare workers, and Hajj or Umrah pilgrims.
Inactivated Influenza Vaccine (IIV)			Annual routine vaccination against influenza is recommended with one dose of any available inactivated influenza vaccine for all adult (≥18 years) patients with CVD. High dose is preferable for those aged 60 and older.
Meningococcal ACWY conjugate vaccine			Meningococcal ACWY conjugate vaccination is recommended for individuals performing Umrah or Hajj. A booster dose is required every 5 years for individuals at continued risk, such as those planning repeated Umrah or Hajj, or those with ongoing medical or occupational risk factors (functional or anatomic asplenia, persistent complement component deficiency, HIV infection, during an outbreak caused by a vaccine serogroup, microbiologists, first-year college students and military personnel).
Respiratory Syncytial Virus (RSV) Vaccine			Vaccination with a single dose of any available RSV vaccine (Arexvy® or Abrysvo™) should be considered for all individuals aged 60 years and older. For patients at increased risk for RSV disease, including those with CVD, Arexvy® is approved for use in individuals 50 to 59 years of age, while Abrysvo® is approved for individuals aged 18 to 59 years old.
Recombinant Zoster Vaccine (RZV)*			Vaccination with a two-dose series of the recombinant zoster vaccine (RZV, Shingrix) should be considered for patients with CVD aged 50 years or older.
Pneumococcal vaccine			PCV20 or PCV21 are recommended for adults age 50 or older, and either vaccine is recommended for adults age 19 through 49 who are at increased risk for invasive pneumococcal disease, including chronic heart disease. If PCV13 or PCV15 has been administered, a dose of PPSV23 should also be given with at least 1-year interval if immune-competent or minimum of 8 weeks between doses for those with an immunocompromising condition.
Live attenuated Influenza vaccine (LAIV, intranasal)			Annual vaccination with one dose of a live attenuated influenza vaccine may be considered for patients with CVD aged 19–49 years. Caution advised in accordance with local health authority guidelines.
	Recommended for all adults (≥18 years)		Should be considered for some adults based on either age OR increased risk for or severe outcomes from disease		Precaution: Might be indicated if benefit of protection outweighs risk of adverse reaction

^*live attenuated zoster vaccine not available in Saudi Arabia.

Abbreviations:

COVID-19: Coronavirus Disease 2019; CVD: cardiovascular disease; HIV: human immunodeficiency virus; PCV: Pneumococcal Conjugate Vaccine; PPSV23: 23-Valent Polysaccharide-Based Vaccine; RSV: Respiratory Syncytial Virus

5.2. Patient perspectives: barriers and opportunities for intervention

In Saudi Arabia, uptake of recommended vaccinations among adults is generally low. Influenza vaccine coverage in the general population rarely exceeds one-third of surveyed individuals [27,127–132]. Although somewhat higher influenza rates (27.6 %–61.2 %) have been reported in high-risk groups (i.e., older adults and people with chronic conditions) [133–137], these figures still fall short of the World Health Organization’s recommended 75 % target coverage rate for these populations. Data on other non-COVID-19 vaccines such as pneumococcal and herpes zoster vaccines, are limited, but available evidence suggests even lower uptake (<20 %) [132,133,137–139].

This pattern reflects a global challenge: even patients with CVD often remain hesitant to receive vaccinations despite their increased vulnerability and the availability of robust clinical evidence and clear clinical recommendations in support of immunization [140–143]. In Saudi Arabia, decision-making is particularly shaped by perceptions of benefit and risk. Patients citing a lack of perceived benefit [27,136] are less likely to accept vaccination, whereas those who express confidence in vaccine efficacy and safety show higher uptake [130,131,133,139]. Similarly, limited knowledge and awareness are key barriers [132,134,136], yet better-informed patients and those who recognize their own risk of disease are more willing to get vaccinated [127–129,132]. Fear of side effects discourages uptake [134], whereas reassurance through recommendations from the Ministry of Health or healthcare professionals can mitigate such concerns and encourage acceptance [132,134,136,139]. Accessibility also plays a role, as awareness that vaccines are available free of charge enhances uptake [130].

Improving patient education is central to overcoming hesitancy [144,145]. Patients should be informed of the protective role of vaccinations in preventing cardiovascular complications and disease progression. This can be approached through different platforms, including social media accounts of local health authorities. Trusted healthcare professionals should be equipped with communication strategies that directly address perceived risks, highlight personal vulnerability, and reinforce the safety and efficacy of vaccines. Clearly disclosing vaccine availability and accessibility is also central to promoting vaccination among Saudi patients.

5.3. Gaps in clinical practice and the role of healthcare providers

It is clear that engagement and advocacy by healthcare professionals are essential to improving vaccine uptake among this high-risk population in Saudi Arabia [20,132,134,136,139,146]. However, they also represent a source of barriers: despite generally positive attitudes and adequate knowledge, many Saudi healthcare providers continue to express reluctance in initiating conversations about vaccinations with their patients [148,147]. Furthermore, some remain hesitant to be vaccinated themselves, citing concerns about contracting illness, doubts about vaccine efficacy, or a perception of being healthy and therefore not in need of vaccination [149–152].

To strengthen the role of Saudi healthcare professionals, targeted interventions are needed to ensure availability of vaccines, improved awareness of vaccination guidelines through structured awareness campaigns and training programs, as well as deployment of vaccine champions to encourage vaccination [149,151]. Gaps in knowledge regarding appropriate timing and indications, especially for newer vaccines, highlight the need for interventions beyond targeted continuing medical education, particularly the development of clear and contextual guidelines [147,153].

In this regard, it is recommended that cardiologists and other healthcare providers dealing with cardiac patients routinely evaluate the vaccination status of their patients and ensure timely administration of all indicated vaccines (Table 1). To optimize vaccine delivery and reduce delays or loss to follow-up, adult vaccination is recommended to be integrated into routine practice. Where this is not feasible, a structured referral pathway to adult vaccination services or family medicine and internal medicine clinics is recommended to be established.

Furthermore, empowering nurses through training in adult immunization protocols, including team-based care models, standardized clinical protocols and standing orders, can enhance vaccination efforts within appropriate clinical settings [154].

5.4. Hajj and Umrah: harnessing mass gatherings for adult vaccinations

In the context of Saudi Arabia, it is particularly important to advise patients to consult their healthcare provider prior to Hajj or Umrah in order to assess their medical fitness and reduce the risk of infection during these mass gatherings. The Hajj and Umrah pilgrimages, as annual religious mass-gathering events in Saudi Arabia, are recognized as high-risk settings for the transmission of infectious diseases [155–157]. In line with this, the Saudi Ministry of Health mandates specific vaccinations for pilgrims as part of national infection prevention efforts [158,159]. Accordingly, Hajj and Umrah represent valuable opportunities for the assessment and updating of adult vaccinations [160], cardiologists and other healthcare providers dealing with cardiac persons are encouraged to proactively recommend all relevant immunizations for patients intending to perform pilgrimage.

According to the latest Saudi Ministry of Health annual vaccination recommendations, influenza, COVID-19, and meningococcal (quadrivalent ACWY) vaccination is mandatory for Hajj and is a prerequisite for obtaining a permit. Two quadrivalent conjugate vaccines are currently approved and available: MenACWY-TT, which can be administered from 2 months of age, and MenACWY-DT, approved from 9 months of age. A booster dose is required every 5 years if the risk persists, including for individuals undertaking repeated pilgrimages for Hajj or Umrah. Additionally, the meningococcal serogroup B vaccine (MenB) is available and recommended for individuals at increased risk, such as those with functional or anatomic asplenia or persistent complement component deficiencies [161,162].

6. Conclusion

Adult vaccination is a critical yet underutilized strategy in preventing cardiovascular complications. A substantial body of evidence confirms the efficacy and safety of vaccines in reducing cardiovascular morbidity and mortality among adults with CVD. The SHA strongly advocates for systematic evaluation and timely administration of recommended vaccines in patients with established CVD (influenza, COVID-19, RSV, herpes zoster, pneumococcal and meningococcal vaccines. Integration of vaccination protocols and trainings into cardiology clinics and other clinics dealing with cardiac patients, structured referral pathways, and multidisciplinary team-based delivery models are essential. Moreover, patient and provider education, particularly in preparation for high-exposure scenarios such as Hajj and Umrah, can significantly improve vaccine uptake and enhance cardiovascular outcomes in Saudi Arabia.

Abbreviations

CVD

Cardiovascular Disease

COVID-19

Coronavirus Disease 2019

HF

Heart Failure

MACE

Major Adverse Cardiovascular Events

PCV

Pneumococcal Conjugate Vaccine

PPSV23

23-Valent Polysaccharide-Based Vaccine

RCT

Randomized Controlled Trial

RSV

Respiratory Syncytial Virus

RSV-ARI

Respiratory Syncytial Virus-Related Acute Respiratory Illness

RSV-LRTD

Respiratory Syncytial Virus-Related Lower Respiratory Tract Disease

SHA

Saudi Heart Association

Funding Statement

There was no financial reward associated with writing the paper. Konoz Retaj (Saudi Arabia) provided editorial assistance for preparing this manuscript based on the Good Publication Practice (GPP 2022) and the ICMJE requirements. This work was funded by Tabuk Pharmaceuticals, Moderna Inc. and Sanofi. The views and opinions expressed are those of the authors. Tabuk Pharmaceuticals, Moderna Inc. and Sanofi had no role in the decision to publish, or preparation of the manuscript