Table 8.2. Recommendations for immunizations for HFrEF patients.

Recommendations	Class	LE	Comment	Table 2018	Ref.
Influenza vaccine to prevent influenza-related morbidity and mortality in HF.	I	B	MODIFIED: New retrospective studies have shown benefits in reducing mortality rates.	Item 6.7 (page 454)	117–120
Pneumococcal vaccine to prevent pneumococcal-related morbidity and mortality in HF.	I	C	2018 recommendation remains current.	Item 6.7 (page 454)	See 2018
Until recently, there was no data on the impact of influenza on outcomes for patients with HF. However, recent population-based studies have shown the relationship between seasonality and a higher number of hospitalizations for HF, evident on four consecutive periods.117 In a subanalysis of the Paradigm trial, 21% of participants were vaccinated against influenza, leading to a 19% decrease in overall mortality after adjusting for propensity.118 A Danish cohort study of 134,038 HF patients receiving ≥1 vaccinations between 2003 and 2015, resulted in an 18% decrease in all-cause mortality; more importantly, greater cumulative number of vaccinations was associated with an 28% reduced risk in total mortality and a 29% decrease in cardiovascular mortality.119 A database study of 6,435 HF patients, out of which 695 had been vaccinated before or during the 2017/2018 winter seasons, found a 22% decrease in total mortality and a 17% decrease in cardiovascular death or hospitalizations for HF. The benefits from vaccination on total mortality were greater for patients over the age of 70, with an over 25% decrease.120 There are no studies on the impact of pneumococcal vaccines on outcomes. Several prospective studies are currently recruiting patients

HF: heart failure.