It is therefore recommended that ARBs be substituted for ACE inhibitors in patients with SIHD and hypertension who are intolerant of ACE inhibitors.563,565,792,804,805 4.4.2.4. Influenza Vaccination Class I 1. An annual influenza vaccine is recommended for patients with SIHD.806 810 (Level of Evidence: B) In patients with chronic medical conditions such as cardio- vascular disease, influenza contributes to a higher risk for mortality and hospitalization and exacerbates underlying medical conditions. The World Health Organization and the AHA/ACCF recommend annual vaccination with inactivated vaccine (administered intramuscularly) against seasonal in- fluenza to prevent all-cause mortality and morbidity in patients with underlying cardiovascular conditions.806,807 A cohort study in 1340 elderly (ie, 65 years of age) patients with heart failure or IHD showed that annual influenza vaccinations reduced the risk of mortality by 37% during the winter period (January through April), but not the summer period (June through September), resulting in a number needed to treat to prevent 1 death during 1 influenza period of 122 annual vaccinations.808 Further mechanistic and confir- Trandolapril was further tested in the PEACE (Prevention of Events matory studies in heart failure and other cardiovascular disease are needed to confirm these findings. Evidence from 2 prospective randomized clinical studies in patients $65 years of age who were medically stable supports increasing influenza vaccine doses to achieve higher serum antibody titers and potentially improved protection from influenza infection.809,810 This dosing scheme was associated with higher injection site reactions, including pain and myalgias. Currently, it is recommended that patients with SIHD receive an annual influenza vaccination in the standard dose. 4.4.2.5. Additional Therapy to Reduce Risk of MI and Death Class III: No Benefit 1. 