ACC Statement Urges COVID-19 Vaccine Prioritization For Highest Risk CVD Patients

COVID-19 vaccine prioritization should prioritize those with advanced cardiovascular disease over well-managed cardiovascular disease, according to an ACC health policy statement published Feb. 12 in the Journal of the American College of Cardiology. All cardiovascular disease patients face a higher risk of COVID-19 complications and should receive the vaccine quickly, but recommendations in the paper serve to guide clinicians in prioritizing their most vulnerable patients within the larger cardiovascular disease group, while considering disparities in COVID-19 outcomes among different racial/ethnic groups and socioeconomic levels.

Under Phase 1c of the Centers for Disease Control and Prevention (CDC) guidance, all patients from 16-64 years old with medical conditions that increase the risk for severe COVID-19 infection should receive the vaccine – including heart conditions, hypertension, diabetes, obesity and smoking. However, the guidance was silent on varying levels of risk among the variety of cardiovascular disease conditions that cardiovascular clinicians manage.

In response, an ACC writing committee, led by Co-Chairs Elisa Driggin, MD, and Thomas M. Maddox, MD, MSc, FACC, developed a health policy statement that provides overall considerations of both exposure and clinical risk needed for vaccine allocation efforts. It presents the specific evidence and risk considerations related to cardiovascular disease and COVID-19, and proposes a tiered schema of cardiovascular disease risk to incorporate into vaccine allocation decisions. In addition, the statement highlights the large disparities in COVID-19 and cardiovascular disease outcomes among racial and ethnic groups and different socioeconomic status levels and calls for consideration of these disparities in allocation decisions.

"A coherent vaccine allocation strategy will consider the exposure risks and clinical risks of given individuals and populations," said Maddox. "In addition, it will take into account those demographic populations that, for a variety of reasons, have additional risks that lead to higher rates of COVID-19 infection and severe health outcomes."

Maddox adds that the "proposed vaccine allocation schema outlines key cardiovascular disease clinical risk considerations within the broader context of key overall risk considerations including exposure, disparities, health care access, advanced age and multimorbidity. Patients' risk categorization is determined by highest tier in which meet one or more of its criteria."

Some examples in the proposed vaccine allocation schema include patients with poorly controlled hypertension, insulin-dependent diabetes or diabetes with microvascular and/or macrovascular complications as a result of poor glycemic control should be considered higher risk compared to patients who are medically optimized. Similarly, patients with morbid obesity should be considered higher risk compared to patients who are overweight.

Patients with severe medical conditions, such as advanced cardiovascular disease, may require long-term stays in nursing homes or rehabilitation centers, which increases their risk of COVID-19 exposure. Data show that the clinical risk for severe COVID-19 infection is associated with both advanced age and preexisting medical conditions, especially when two or more co-occur. In addition to multimorbidity, data have found adverse effects of frailty in patients with COVID-19. The CDC's phased vaccine allocation recommendations prioritize patients with advanced age, which is in accordance with the cardiovascular disease-related risk associated with advanced age. However, this policy statement urges older patients with multiple comorbidities, including cardiovascular disease conditions and/or frailty should be prioritized for COVID-19 vaccination.

"We hope that this document can be used to guide COVID-19 vaccine allocation and patient outreach in the context of prolonged demand-supply mismatch as we enter Phase 1c," Maddox said.