Ankeet Bhatt, MD, MBA: NUDGE-FLU Analysis in Patients With and Without Myocardial Infarction

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Ankeet Bhatt, MD, MBA, discusses a NUDGE-FLU analysis from ACC.24 examining effect of the CV gain-framed nudge in patients with and without history of AMI.

Data from an analysis of the landmark NUDGE-FLU analysis offers insight into the effects of the study’s cardiovascular gains nudge on influenza vaccine uptake and outcomes based on history of acute myocardial infarction.

Presented by Ankeet Bhatt, MD, MBA, at the American College of Cardiology 2024 (ACC.24) Annual Scientific Session, results indicate the letter was associated with a positive effect on vaccination uptake regardless of history of myocardial infarction.1

“We know that influenza vaccination, given shortly after acute myocardial infarction improves major adverse cardiovascular events for the first time, the [European Society of Cardiology] guidelines have updated their recommendation to a class 1 recommendation—the way we think about beta blockers or aspirin and statins in patients that are post-myocardial infarction—to include yearly timely influenza vaccination,” explained Bhatt, a research scientist at Kaiser Permanente Northern California and associate physician at Kaiser San Francisco Medical Center, in an interview with HCPLive. “So, we thought it was a really important area to study to see if we can improve care in that in that group.”

The NUDGE FLU trial was originally presented a year prior at ACC 2023 and randomized all Danish citizens aged 65 years or older or turning 65 years by January 15, 2023 in a 9:1:1:1:1:1:1:1:1:1 ratio to usual care or 9 electronic letters designed with behavioral concepts. The primary endpoint of interest for the suited was receipt of flu vaccination. In total, the trial included 964,870 individuals from 691,280 households.1,2

Analysis of results indicated uptake of influenza vaccines was higher among those receiving an electronic letter highlighting potential cardiovascular benefits of vaccination (81.00% vs 80.12%; difference, 0.89 percentage points; 99.55% Confidence interval [CI], 0.29-1.48; <.0001) and the group receiving repeated letters at randomization and at day 14 (80.85% vs 80.12%; difference, 0.73 percentage points [0.13-1.34]; P = .0006).2

At ACC.24, Bhatt presented data from an analysis assessing the effects of these same letters in patient subgroups stratified by history of acute myocardial infarction. Among the 964,870 patients who underwent randomization, a cohort of 25,064 had a history of acute myocardial infarction.1

Initial analysis by Bhatt and colleagues revealed improved vaccination rates among those with (+3.09%; 99.55% CI, −0.3 to 6.5) and without a history of acute myocardial infarction (+0.82%, CI 0.2 to 1.4; P for interaction = .066). Analysis of secondary outcomes among patients with acute myocardial infarction suggested there was no difference in all-cause mortality (Hazard Ratio [HR], 0.98; 99.55% CI, 0.7 to 1.42) or a cardiovascular composite of acute myocardial infarction, stroke, revascularization, or cardiovascular death (HR, 1.05; 99.55% CI, 0.8 to 1.5) with the cardiovascular gain letter relative to usual care, with additional analysis indicating the repeat letter showed similar results.1

For more on the results of this study, check out our interview with Bhatt from the conference floor at ACC.24.

Relevant disclosures for Bhatt: Sanofi-Aventis.


  1. Bhatt AS, Johansen ND, Modin D, et al. ELECTRONIC NUDGES TO INCREASE INFLUENZA VACCINATION UPTAKE AMONG PARTICIPANTS WITH HISTORY OF ACUTE MYOCARDIAL INFARCTION: INSIGHTS FROM NUDGE-FLU. Presented at: American College of Cardiology (ACC.24) Annual Scientific Session. April 6 – 8, 2024. Atlanta, GA.
  2. Johansen ND, Vaduganathan M, Bhatt AS, et al. Electronic nudges to increase influenza vaccination uptake in Denmark: a nationwide, pragmatic, registry-based, randomised implementation trial. Lancet. 2023;401(10382):1103-1114. doi:10.1016/S0140-6736(23)00349-5