The American Heart Association (AHA) and American College of Cardiology (ACC) recommend annual influenza vaccination as secondary prevention for individuals with coronary and other atherosclerotic vascular disease.1 This recommendation, published in 2006, reflects accumulating evidence that influenza vaccination protects against cardiovascular events for individuals with known cardiovascular disease.2-8

Who better to vaccinate against influenza, then, than patients undergoing cardiac rehabilitation (CR)? They are an audience eager to reduce their risk for future cardiovascular events. Furthermore, as indicated in the retrospective analysis by Bittner and Sanderson9 in this issue of Journal of Cardiopulmonary Rehabilitation of vaccination rates among CR patients in an academic medical center, they are just as unlikely to be vaccinated against influenza as other persons with cardiovascular disease in the US population who are at increased risk of the complications of influenza.

In other words, CR settings offer an opportunity-in many respects, an ideal opportunity-to reduce the health risks of patients with cardiovascular conditions by vaccinating them against influenza. As Bittner and Sanderson9 write, "Virtually all patients enrolled in CR are candidates for annual [influenza vaccination]. CR programs thus could play a major role in monitoring vaccination rates and educating patients and their families to improve these rates." Their suggested approach of monitoring and educating regarding influenza vaccine may not improve vaccination rates among persons with cardiovascular disease, however. In fact, current research suggests that the most effective approach may be to offer influenza vaccine right in CR settings. Before you dismiss this suggestion as improbable or impractical, consider the following points of evidence from recently published studies.

First, the most efficient approach to improving influenza vaccination rates among patients with cardiovascular disease is to maximize the availability of influenza vaccine and the strength of recommendations by cardiovascular healthcare providers in cardiology clinic settings.10 The main reason that improving the availability of influenza vaccine in cardiology clinics would be more efficient than, for instance, implementing standing orders for influenza vaccination in inpatient cardiac care settings or making more vaccine available in community locations (eg, supermarkets, pharmacies) is that only about one half of cardiology clinics nationwide have influenza vaccine on hand, and patients visit these clinics frequently.11

In the wake of the 2006 AHA/ACC recommendations for influenza vaccination, it is possible that more cardiovascular healthcare providers will decide to make influenza vaccination available in their practices. In the meantime, CR settings, which are almost always closely associated with the local cardiovascular care practices, attract the patients with cardiovascular disease at highest risk for recurrent events. Therefore, CR may be the most efficient location to administer influenza vaccine within a cardiovascular practice.

Second, consider the magnitude of risk reduction attributed to influenza vaccination in a recent randomized, controlled trial of influenza vaccination (Flu Vaccination in Acute Coronary Syndromes and Planned Percutaneous Interventions Study), in which 301 patients hospitalized either for myocardial infarction or planned angioplasty/stent were randomly assigned to receive influenza vaccination or remain unvaccinated.2 At 1 year, the relative risk of cardiovascular mortality in the vaccinated group was 0.25 (95% confidence interval, 0.07-0.86) compared with the unvaccinated group (overall event rates, 2% vs 8%, respectively), and the relative risk of a composite end point (cardiovascular death, nonfatal myocardial infarction, and severe ischemia) was 0.59 (95% confidence interval, 0.30-0.86; 11% vs 23%).2

Such profound reductions in the 1-year risk of cardiovascular mortality-and in the 1-year risk of death, nonfatal myocardial infarction, and severe ischemia-make a very strong argument for influenza vaccination to patients in CR settings. In fact, influenza vaccination may be one of the most efficient, easiest, and most familiar ways for patients to reduce their health risks in the short term.

Thus, why not just refer CR patients to other care settings for influenza vaccination, where vaccines would be more commonly administered? There are at least 2 strong arguments why referral would likely be less effective than having influenza vaccine immediately on hand in CR settings. First, patients in CR settings may not see other physicians very frequently during a key period when vaccination may be beneficial. Second, the CR care team can make a strong argument in support of influenza vaccination at a moment when a patient is eager to engage in behaviors, and behavior change, dedicated to reducing the future risk of cardiovascular events. Other providers may not be able to capitalize as effectively on those "teachable moments".

I recognize that there are likely barriers to administering influenza vaccination in CR settings, some of which may be common across many institutions and practices, and others that are more specific to certain locations. Nevertheless, the work of Bittner and Sanderson9 underscores the missed opportunity in CR settings to administer-or, at least, to offer and strongly recommend-influenza vaccine to a group of patients who may reduce their cardiovascular risks substantially by getting vaccinated. At a minimum, the undervaccination of CR patients against influenza can prompt CR care providers to consider strengthening their patient education and counseling materials about influenza vaccination, as Bittner and Sanderson recommend.

However, there is another, more active strategy that may be even more effective. Cardiac rehabilitation providers, in partnership with cardiovascular clinics, can decide to have influenza vaccine on hand, to recommend influenza vaccination strongly to all cardiovascular patients who do not have a contraindication (on the basis of an allergy or previous adverse reaction), and to offer vaccination at the time of CR care for patients who want to reduce their cardiovascular event risk through immunization against influenza. By reducing missed opportunities for influenza vaccination, CR providers may be able to further reduce the risk of cardiovascular events in the near term for their vulnerable patients.

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