Not All Heart Disease Is Equal for COVID Vaccine Prioritization

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“Heart disease” covers a lot of ground. Should patients with certain types be prioritized to receive COVID-19 vaccines ahead of others? The American College of Cardiology says yes, and offers recommendations in a new policy statement.

The CDC’s phased approach to vaccine distribution puts all patients ages 16 to 64 with medical conditions that increase the risk for severe COVID-19 infection in the 1c category, citing heart conditions, hypertension, diabetes, and obesity among the examples.

However, the CDC made no attempt to stratify by levels of risk among those conditions.

“A coherent vaccine allocation policy promoting the greatest benefit for the greatest number would prioritize individuals with the highest risk for adverse outcomes of COVID-19 ahead of lower-risk populations,” wrote Elissa Driggin, MD, of NewYork-Presbyterian Hospital/Columbia University Irving Medical Center in New York City, and colleagues on the ACC Solution Set Oversight Committee writing group in the Journal of the American College of Cardiology.

The group proposed “a schema of CV risk to incorporate into vaccine allocation decisions.”

“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,” Driggin’s group wrote.

The top tier of risk for severe COVID-19 outcomes comprised people with:

  • An unplanned cardiovascular disease hospitalization within the prior 6 months
  • Class III or IV pulmonary hypertension
  • Adult congenital heart disease patients with physiological stage C or D
  • High-grade pulmonary arterial disease
  • Obstructive coronary artery disease (triple vessel or left main cases, or one- or two-vessel disease with angina)
  • Advanced heart failure or heart transplant
  • Morbid obesity
  • Two or more comorbid, poorly controlled risk factors, such as hypertension and diabetes
  • Poorly controlled insulin-dependent diabetes

The next tier included people with a high burden of malignant tachyarrhythmia; those with less advanced stages of pulmonary hypertension, congenital heart disease, peripheral or coronary disease, or heart failure; and people with obesity, poorly controlled hypertension, or well-controlled but insulin-dependent diabetes.

Overweight, hypertension, and non-insulin-dependent diabetes got the lowest risk categorization.

The statement acknowledged that cardiovascular risk category is just one piece of the bigger context of age, exposure risk, socioeconomic and minority group disparities, and other factors.

With limited vaccine supply and chaotic rush for vaccine slots, distribution has turned away from a careful adherence to strict prioritization of the most essential workers and nursing home residents and largely blown open to the older population.

In January, HHS Secretary Alex Azar blamed restrictive eligibility criteria for delays in vaccine rollout, calling it “heavy-handed micromanagement,” and told states to expand into vaccinating younger people with comorbidities.

Despite the emphasis on getting shots in arms, it’s taking much longer than expected to move into vaccinating people with high-risk conditions, noted Claire Hannan, MPH, executive director of the Association of Immunization Managers.

Stratifying high-risk conditions is less efficient than simply checking someone’s age, she told MedPage Today in discussing another high-risk group, the dialysis population. “It’s more difficult to prioritize limited doses to specific groups that way.”

For heart disease patients, Driggin’s group cautioned that their risk-stratification schema shouldn’t discourage anyone from taking their shot at the vaccine, writing that it “does not suggest that individuals with lower-risk CV conditions should delay or avoid receiving the vaccine.”

“Rather, its intent is to emphasize that those with relatively higher-risk CV conditions should prioritize their receipt of the vaccine. Accordingly, their care teams should encourage prompt vaccination and proactively address any barriers or hesitancy that the patient may be facing,” the group argued.

Disclosures

Driggin disclosed no relevant relationships with industry.

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