At 1 year of follow-up, the risk of MI and cardiovascu- lar death was significantly lower among patients who received the vaccine. These results were subsequently confirmed in other inpatient and outpatient CAD populations.445,446 In a ran- domized trial of 439 patients admitted with acute coronary syndrome, influenza vaccine significantly lowered the com- posite end point of death or hospitalization for CAD, heart failure, or stroke (vaccine versus placebo, 9.5% versus 19.3%; Most recently, a meta-analysis of 6 randomized trials involving 6735 patients at high risk for cardiovascu- lar disease demonstrated that influenza vaccine significantly lowered the risk of cardiovascular events (RR, 0.64; 95% CI, 0.48 0.86; P=0.003), with the greatest treatment benefit seen among the highest-risk patients with more active CAD.435 These findings provide support for the current recommenda- tions for influenza vaccination of all patients admitted with acute coronary syndrome.2,447 Within the general population, the Centers for Disease Control and Prevention currently recommends routine annual influenza vaccination for all people >6 months of age unless specific contraindications are For patients undergoing CABG, there is justification based on the evidence in the cardiology literature to provide influ- enza vaccination for those in whom no contraindication exists. Hospitalization for cardiac surgery provides an opportunity to vaccinate those people who are not immunized and to potentially lower the risk of subsequent adverse cardiovascu- lar events. However, no studies exist regarding the safety or effectiveness of influenza vaccination in reducing periopera- tive morbidity or mortality after CABG. Furthermore, peri- operative immunological alterations may reduce a patient s ability to respond to and to develop immunity after a vaccina- Thus, the optimal timing of perioperative influenza vaccination in patients undergoing cardiac surgery remains unclear. 