COVID-19 vaccine prioritization should prioritize those with advanced cardiovascular (CVD) disease over well-managed CVD disease, according to an American College of Cardiology (ACC) health policy statement published in the Journal of the American College of Cardiology (JACC). All CVD patients face a higher risk of COVID-19 complications and should receive the vaccine quickly, but recommendations in this paper serve to guide clinicians in prioritizing their most vulnerable patients within the larger CVD group, while considering disparities in COVID-19 outcomes among different racial/ethnic groups and socioeconomic levels.
“A coherent vaccine allocation strategy will consider the exposure risks and clinical risks of given individuals and populations,” said Thomas M. Maddox, MD MSc, professor of cardiology at Washington University School of Medicine in St. Louis and co-chair of the health policy statement. “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.”
As of January 2021, there were almost 99 million COVID-19 cases and over 2 million deaths caused by the coronavirus worldwide. With the quick development of multiple vaccines, the Centers for Disease Control and Prevention (CDC) issued phased recommendations for which populations should get vaccinated first. Under Phase 1c of the 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. Although the guidance states that heart conditions, hypertension, diabetes, obesity and smoking are examples of such high-risk medical conditions, it was silent on varying levels of risk among the variety of CVD conditions that cardiovascular clinicians manage.
In response, the writing group developed a 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 CVD and COVID-19, and proposes a tiered schema of CVD risk to incorporate into vaccine allocation decisions. In addition, this policy statement highlights the large disparities in COVID-19 and CVD outcomes among racial and ethnic groups and different socioeconomic status levels and calls for consideration of these disparities in allocation decisions.
“Our proposed vaccine allocation schema outlines key CVD clinical risk considerations within the broader context of key overall risk considerations including exposure, disparities, health care access, advanced age and multimorbidity,” Maddox said. “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 CVD, may require long-term stays in nursing homes or rehabilitation centers, which increases their risk of COVID-19 exposure. Data shows 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 has 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 CVD-related risk associated with advanced age. However, this policy statement urges older patients with multiple comorbidities, including CVD 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.