BACKGROUND AND AIMS:Abdominal aortic calcification (AAC) reflects subclinical atherosclerotic cardiovascular disease (ASCVD), but its lifestyle determinants remain uncertain. We investigated how a Healthy Lifestyle Score (HLS) relates to AAC and whether AAC mediates the HLS-ASCVD association. METHODS AND RESULTS:Participants from the UK Biobank Imaging study were assessed for AAC from DXA images. A Healthy Lifestyle Score (HLS), based on smoking, physical activity, diet quality, alcohol consumption, sleep, and BMI was developed, and categorised as low, moderate and high. Cross-sectional associations with (i) any AAC (AAC≥1) and (ii) high AAC (AAC≥6) were analysed using multivariable-adjusted logistic regression models. The association between HLS and incident ASCVD over 6 years was assessed using Cox regression models. Mediation analysis examined the extent to which the HLS-ASCVD association was mediated by AAC. Among 27,818 participants (52% female; median age 65y), 33.5% had any AAC and 4.4% had high AAC. Compared to participants with a low HLS, those with moderate or high scores had 21% (95%CI: 60%-105%) and 66% (33%-59%) lower odds of having high AAC, respectively, and 10% (78%-104%) and 18% (0.71%-95%) lower odds of having any AAC, respectively. These associations were strongest in women and those younger than 65 years. During follow-up, a one-point increment in the HLS was associated with a 4% (0%-8%) lower rate of incident ASCVD. High AAC accounted for 20% (10%-48%) of this association. CONCLUSION:These findings suggest targeting specific modifiable lifestyle factors, especially earlier in life, may help prevent high AAC levels and subsequent risk of ASCVD.

Background: Abdominal aortic calcification (AAC) is a subclinical measure of atherosclerotic cardiovascular disease (ASCVD). AAC can be captured on lateral spine images obtained from bone density machines during routine osteoporosis screening. Identifying individuals with AAC provides a new opportunity to prevent disease progression. Objectives: The aim of the study was to externally validate a machine learning-derived AAC 24-point algorithm (ML-AAC24) with incident ASCVD. Methods: Middle-aged individuals from the UK Biobank Imaging Study with lateral spine images, obtained via dual-energy x-ray absorptiometry, were included. ML-AAC24 scores were grouped as low (<2), moderate (2 to <6), and high (≥6). Linked health records were used to identify ASCVD-associated events, including hospitalizations and death. Results: Among 53,611 participants (52% female; mean age 65 years), 78.2% had low, 16.4% had moderate, and 5.4% had high ML-AAC24. After excluding people with prevalent ASCVD or missing data, 1,163 (2.3%) of 50,923 people had an incident ASCVD event over a median follow-up of 4.1 [3.0-5.5] years. In age- and sex-adjusted analysis, compared to those with low ML-AAC24, those with moderate (HR: 1.80 [95% CI: 1.57-2.08]) and high ML-AAC24 (HR: 2.87 [95% CI: 2.39-3.44]) had a higher HR for incident ASCVD. Results remained comparable after adjustment for established ASCVD risk factors. Consistent patterns were observed when considering incident coronary artery disease, myocardial infarction, and stroke. Conclusions: Assessing ML-AAC24 on lateral spine images offers a new and promising screening method to identify people with higher risk of incident ASVD events.

Aims:The role of clinical quality registries is to collect structured observational data in routine clinical practice to monitor the quality of care provided to specific patient populations. There is currently no standardized methodology of how to establish registry platforms. The objective of this scoping review is to provide an overview of the methodology and characteristics of established national acute coronary syndrome registries. Methods and results:Three electronic databases were searched to identify national registries in high-income countries collecting routine clinical data on adult patients with suspected and/or diagnosed acute coronary syndrome. Articles published from the year 2000 onwards that described the protocol and/or quantitative results of such registries located in 25 countries with the largest gross domestic product were included. There were 24 countries with an established national registry, of which nine are currently active. Inclusion criteria varied across these registries, with a predominant focus on either a suspected or confirmed diagnosis of acute coronary syndrome or myocardial infarction. The primary clinical outcomes measured were all-cause mortality and major adverse cardiovascular events during hospitalization, as well as at 30-day and/or 1 year time points. The main sources of follow-up data were hospital discharge records and administrative data. Conclusion:Globally, acute coronary syndrome clinical quality registries share similar fundamental objectives of monitoring and improving or sustaining the highest quality of care. However, there is considerable variation in the design of national registries and better harmonization of fundamental issues, such as who is included, core data, and key outcomes, would be beneficial.

Despite the nexus between cardiovascular health and frailty, the relevance of high-sensitivity cardiac troponin I (hs-cTnI), a biomarker of myocardial injury, to frailty is poorly understood. We examined whether hs-cTnI concentrations were associated with frailty in a well-characterized cohort of older women. A total of 1151 community-dwelling women from the Perth Longitudinal Study of Aging Women (mean age ± SD = 75.2 ± 2.7 years) were included. Frailty was operationalized using a validated frailty index (FI) of cumulative deficits and a modified Fried phenotype. Plasma hs-cTnI were categorized into quartiles. Cross-sectional associations between hs-cTnI quartiles and frailty were assessed using multivariable-adjusted logistic regression models. A total of 235 (20.4%) women were classified as frail using the FI, while 74 (6.4%) were considered frail by Fried's phenotype. In a multivariable-adjusted model, compared to women in the lowest hs-cTnI quartile (Q1), those in Q3 and Q4 had 1.38 (95% CI, 1.00-1.90) and 1.79 (1.20-2.67) greater odds for frailty when classified by the FI. When classified according to Fried's phenotype, women in Q2, Q3, and Q4 had 2.25 (1.10-4.09), 2.64 (1.19-5.21), and 2.44 (1.10-5.33) greater odds for frailty, compared to Q1. Associations remained largely unchanged when further adjusted for daily protein intake or systemic inflammation (lipocalin-2) and restricted to those with subclinical hs-cTnI levels (<15.6ng/L). Higher hs-cTnI levels are associated with greater odds for frailty, classified using an FI or Fried's phenotype, among older women. hs-cTnI may have applications beyond its typical use in cardiology, offering insight into the implications of underlying cardiovascular dysfunction relating to frailty.

Older adults often require permanent pacemaker (PPM) insertion. Delays to PPM insertion may associate with poor health outcomes. To investigate the association between delayed PPM insertion and adverse outcomes in older adults. Patients aged ≥65 years who underwent non-elective inpatient PPM insertion at Royal Perth Hospital between April 2019 and January 2022 were included in this retrospective cohort study. The relationship between time from admission to PPM insertion (exposure) and death or residential aged care facility (RACF) admission was examined using Cox modelling. In 375 patients, with a mean age of 80.8±7.5 years, the median [25th – 75th ] duration from admission to PPM insertion was 47 [22–90] hours. Time from admission to PPM insertion (days) was associated with an increased risk of death at 1635 [1048–1931] days follow-up in univariate regression models (HR 1.05, 95

BACKGROUND:Both coronary atherosclerotic plaque activity and low endothelial shear stress (ESS) are predictive of adverse cardiovascular events. We aimed to investigate their association and relationship with high-risk plaque features. METHODS:Coronary computed tomography angiography (CCTA) based flow simulations were used to compute ESS in patients presenting with acute coronary syndrome proceeding percutaneous coronary intervention. Associations between ESS, CCTA plaque features and coronary plaque activity, measured by 18F-sodium fluoride (18F-NaF) positron emission tomography (PET), were investigated at the coronary segment and vessel level. RESULTS:ESS and coronary plaque activity were both analyzed in 330 coronary segments and 123 vessels. The area of low ESS (<0.4 ​Pa), termed low shear area (LSA), was larger in 18F-NaF positive regions increasing from median 11.7 ​mm2 (IQR: 4.6-27.4) to 29.0 ​mm2 (IQR: 14.1-55.2) at the segment level (P ​< ​0.0001) and from median 27.3 ​mm2 (IQR: 8.6-65.3) to 57.8 ​mm2 (26.6-108.2) at the vessel level (P ​= ​0.0049). The maximum tissue-to-background ratio of 18F-NaF activity positively correlated with LSA at the segment level (rs ​= ​0.27; P ​< ​0.0001) and at the vessel level (rs ​= ​0.38; P ​< ​0.0001). LSA was associated with spotty calcification at both the segment (P <0.0001) and vessel level (P ​= ​0.0042) and positive remodeling at the vessel level (P ​= ​0.025). CONCLUSIONS:In patients with acute coronary syndrome, LSA is associated with increased coronary atherosclerotic plaque activity, as measured by 18F-NaF PET.

Background A pathway incorporating an option for early discharge based on a single low level of high-sensitivity cardiac troponin I (hs-cTnI) at presentation increases the proportion of patients presenting with a potential acute coronary syndrome (ACS) that can be discharged directly from the emergency department (ED), reducing length of stay without any increase in adverse events at 30 days. Here, we report the 1-year outcomes of patients managed using this pathway. Methods We recruited two cohorts of patients with a potential ACS, without high-risk features. The ‘standard’ cohort was managed according to the Australian national guidelines and the Single Troponin Accelerated Triage (‘STAT’) cohort was managed using the study pathway. 12-month outcomes were assessed using linked administrative data. Results Between May 2018 and October 2019, we recruited 2255 patients (1131 standard vs 1124 STAT), mean age 55 years, 53% male. 709 (63%) patients managed using the STAT pathway were discharged directly from ED, compared with 403 (38%) patients using the standard pathway, with a 47 min reduction in median hospital length of stay. At 12 months, there were no significant differences in unadjusted all-cause death (STAT 0.62% vs standard 0.97%, p=0.35) or myocardial infarction (MI) (STAT 0.62% vs standard 1.24%, p=0.13). Conclusions A clinical pathway which incorporates early discharge based on a single low serum hs-cTnI is associated with an increased proportion of patients with a potential ACS discharged directly from the ED and reduced length of stay, without an increase in death or MI at 1 year.

BACKGROUND:Cardiac magnetic resonance (CMR) may radiologically identify or confirm underlying pathophysiologies in myocardial infarction with non-obstructive coronary arteries (MINOCA), however, there are scant prospective data evaluating the impact on routine clinical care. METHODS:In a multicentre international cohort study of MINOCA, clinical diagnosis, diagnostic certainty and intended clinical management were prospectively determined before and again after CMR. The primary outcome was a composite of change in clinical diagnosis and/or management. Secondary outcomes were individual components of the primary outcome, change in diagnostic certainty and number-needed-to-test for deprescription of dual antiplatelet therapy (DAPT). Predictors of the primary outcome were evaluated by multivariable logistic regression analysis. RESULTS:In 320 patients, CMR was associated with change in diagnosis and/or management in 63% (95% CI 57% to 68%, p<0.001) and significantly increased diagnostic certainty (8/10 post-CMR (5-9) vs 6/10 pre-CMR (4-7), p<0.0001). Relevant predictors of the primary outcome on multivariable analysis were early CMR (≤14 days), absence of atheroma on coronary angiography and significant pre-CMR diagnostic uncertainty (≤5/10); CMR changed diagnosis and/or management in 80% of individuals with all three predictors versus 40% in those with none. In individuals where treating physicians initially chose to prescribe DAPT despite no obstructive culprit lesion, number-needed-to-test by CMR for DAPT deprescription was 3. CONCLUSIONS:CMR in MINOCA is associated with significant changes in clinical diagnosis, diagnostic certainty and management. The impact on deprescription of unnecessary DAPT could have important implications for patient safety and costs and warrants further evaluation. Early CMR should be considered to augment diagnosis and management in MINOCA. TRIAL REGISTRATION NUMBER:ISRCTN75233845.

Vitamin K refers to a group of lipid-soluble vitamins that exist in two natural isoforms; phylloquinone (PK, vitamin K1) and menaquinones (MKs, vitamin K2). Phylloquinone, the primary dietary source, is found abundantly in green vegetables and plant oils. Menaquinones (MK-4 through MK-13) are synthesized by anaerobic bacteria and may be obtained through the diet from fermented foods and animal products (e.g., meats, dairy and eggs). Originally recognized for its role in blood coagulation, vitamin K is an essential cofactor for the posttranslational carboxylation of vitamin K-dependent proteins (VKDPs), which are implicated in various physiological processes including; blood coagulation, calcium homeostasis, as well as metabolic and inflammatory pathways. Therefore, vitamin K has attracted considerable research interest for its potential implications in several diseases. While promising, the specific roles of vitamin K in various health conditions, the quantity of vitamin K (both PK and MKs) required for the function of various VKDPs, and the influence of genetics on vitamin K metabolism, remain unclear. This review aims to (i) provide an overview of the structure, dietary sources, metabolism, and physiological roles of vitamin K, including those relating to; cardiovascular diseases, type 2 diabetes, respiratory conditions, musculoskeletal health and cancer; (ii) discuss the impact of genetic factors on vitamin K status and how such factors modulate the role of vitamin K in the aforementioned chronic diseases; and (iii) outline key directions for future research.

[18F]NaF is a potential biomarker for assessing cardiac risk. Automated analysis of [18F]NaF positron emission tomography (PET) images, specifically through quantitative image analysis (“radiomics”), can potentially enhance diagnostic accuracy and personalised patient management. However, it is essential to evaluate the reproducibility and reliability of radiomic features to ensure their clinical applicability. This study aimed to (i) develop and evaluate an automated model for coronary artery segmentation using [18F]NaF PET and calcium scoring computed tomography (CSCT) images, (ii) assess inter- and intra-observer radiomic reproducibility from manual segmentations, and (iii) evaluate the radiomics reliability from AI-derived segmentations by comparison with manual segmentations. 141 patients from the “effects of Vitamin K and Colchicine on vascular calcification activity” (VikCoVac, ACTRN12616000024448) trial were included. 113 were used to train an auto-segmentation model using nnUNet on [18F]NaF PET and CSCT images. Reproducibility of inter- and intra-observer radiomics and reliability of radiomics from AI-derived segmentations was assessed using lower bound of intraclass correlation coefficient (ICC). The auto-segmentation model achieved an average Dice Similarity Coefficient of 0.61 ± 0.05, having no statistically significant difference compared to the intra-observer variability (p = 0.922). For the unfiltered images, 47(12.6 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368825 .

Vitamin K may inhibit vascular calcification, a common attribute of atherosclerotic vascular diseases (ASVDs). We examined associations between dietary vitamin K1 intakes and both subclinical atherosclerosis and ASVD events, including hospitalisations and mortality, in older women. 1,436 community-dwelling women (mean ± SD age 75.1 ± 2.7 years) were included. Vitamin K1 intakes were calculated from a validated food frequency questionnaire at baseline (1998), utilising a region-matched vitamin K food database. Common carotid artery intima–media thickness (CCA-IMT), a measure of subclinical atherosclerosis, was measured in 2001 (n = 1,090). Differences in CCA-IMT by quartiles (Q) of vitamin K1 intake were examined using multivariate analysis of variance. Associations between vitamin K1 intakes and ASVD outcomes (hospitalisations and/or deaths), obtained from linked health records over 14.5 years, were analysed using restricted cubic splines within multivariable-adjusted Cox-proportional hazard models. Women with higher vitamin K1 intakes had a 5.6

BACKGROUND:Elevated high-sensitivity cardiac troponin (hs-cTn) levels are linked with cardiovascular disease and cognitive impairment, both of which are strong risk factors for late-life dementia (LLD). This study examined the association between hs-cTnI levels below the sex-specific 99th percentile for myocardial injury and the incidence of LLD in older women. METHODS:986 community-dwelling women aged ≥70 years without prior LLD and with hs-cTnI <15.6 ng/L (stratified into quartiles) were included from the Perth Longitudinal Study of Ageing Women. The primary outcome was incident LLD events, including LLD hospitalisation or death, over 14.5 years obtained from linked health records. Associations between hs-cTnI and LLD outcomes were explored using multivariable-adjusted Cox models, as part of restricted cubic splines. RESULTS:At baseline, participants' mean (±SD) age was 75.2±2.7 years. Over 14.5 years of follow-up, LLD events (n=174, 17.7%), hospitalisations (n=155, 15.7%) and deaths (n=68, 6.9%) were recorded. Compared with those in the lowest quartile (Q1, median 3.1 ng/L), women in the highest quartile of hs-cTnI (Q4, median 7.3 ng/L) had a greater risk of developing LLD-related events (adjusted HR: 1.88, 95% CI: 1.22 to 2.91), hospitalisation (adjusted HR: 1.65, 95% CI: 1.04 to 2.64) and death (adjusted HR: 2.27, 95% CI: 1.13 to 4.59), after adjusting for established cardiovascular and dementia risk factors, including apolipoprotein E (APOE) genotype. CONCLUSION:Among older women, hs-cTnI levels below the sex-specific 99th percentile for myocardial injury were associated with an increased risk of LLD events over 14.5 years. These findings suggest that hs-cTnI may identify older women at higher risk of LLD, capturing both cardiovascular and brain health vulnerability in older age. TRIAL REGISTRATION NUMBER:ACTRN12617000640303.

BACKGROUND: Leaflet calcification contributes to the development and progression of aortic valve stenosis. Vitamin K activates inhibitors of vascular calcification and may modulate inflammation and skeletal bone loss. Therefore, we aimed to determine whether higher dietary intakes of vitamin K 1 are associated with a lower incidence of aortic stenosis. METHODS: In the Danish Diet, Cancer and Health study, participants aged 50 to 64 years completed a 192-item food frequency questionnaire at baseline, from which habitual intakes of vitamin K 1 were estimated. Participants were prospectively followed using linkage to nationwide registers to determine incident aortic valve stenosis (primary outcome) and aortic stenosis with subsequent complications (aortic valve replacement, heart failure, or cardiovascular disease–related mortality; secondary outcome). RESULTS: In 55 545 participants who were followed for a maximum of 21.5 years, 1085 were diagnosed with aortic stenosis and 615 were identified as having subsequent complications. Participants in the highest quintile of vitamin K 1 intake had a 23% lower risk of aortic stenosis (hazard ratio, 0.77 [95% CI, 0.63–0.94]) and a 27% lower risk of aortic stenosis with subsequent complications (hazard ratio, 0.73 [95% CI, 0.56–0.95]), compared with participants in the lowest quintile after adjusting for demographics and cardiovascular risk factors. CONCLUSIONS: In this study, a high intake of vitamin K 1 –rich foods was associated with a lower incidence of aortic stenosis and a lower risk of aortic stenosis with subsequent complications.

Abstract Background Higher cruciferous vegetable intake is associated with lower cardiovascular disease risk in observational studies. The pathways involved remain uncertain. We aimed to determine whether cruciferous vegetable intake (active) lowers 24-h brachial systolic blood pressure (SBP; primary outcome) compared to root and squash vegetables (control) in Australian adults with mildly elevated BP (SBP 120–160 mmHg inclusive). Methods In this randomized, controlled, crossover trial, participants completed two 2-week dietary interventions separated by a 2-week washout. Cruciferous vegetables were compared to root and squash vegetables (~ 300 g/day) consumed with lunch and dinner meals. Participants were blinded to which interventions were the active and control. Adherence was assessed using food diaries and biomarkers (S-methyl cysteine sulfoxide (SMCSO, active) and carotenoids (control)). Twenty-four-hour brachial ambulatory SBP and secondary outcomes were assessed pre- and post each intervention. Differences were tested using linear mixed effects regression. Results Eighteen participants were recruited (median (IQR) age: 68 (66–70); female: n = 16/18; mean ± SD clinic SBP: 135.9 ± 10.0 mmHg). For both interventions, 72% participants had 100% adherence (IQR: 96.4–100%). SMCSO and carotenoids were significantly different between interventions (mean difference active vs. control SMCSO: 22.93 mg/mL, 95%CI 15.62, 30.23, P < 0.0001; carotenoids: − 0.974 mg/mL, 95%CI − 1.525, − 0.423, P = 0.001). Twenty-four-hour brachial SBP was significantly reduced following the active vs. control (mean difference − 2.5 mmHg, 95%CI − 4.2, − 0.9, P = 0.002; active pre: 126.8 ± 12.6 mmHg, post: 124.4 ± 11.8 mmHg; control pre: 125.5 ± 12.1 mmHg, post: 124.8 ± 13.1 mmHg, n = 17), driven by daytime SBP (mean difference − 3.6 mmHg, 95%CI − 5.4, − 1.7, P < 0.001). Serum triglycerides were significantly lower following the active vs. control (mean difference − 0.2 mmol/L, 95%CI − 0.4, − 0.0, P = 0.047). Conclusions Increased intake of cruciferous vegetables resulted in reduced SBP compared to root and squash vegetables. Future research is needed to determine whether targeted recommendations for increasing cruciferous vegetable intake benefits population health. Trial registration Clinical trial registry ACTRN12619001294145. https://www.anzctr.org.au

Abstract Introduction Despite increasing use of bioprosthetic surgical aortic valve replacement (bAVR) in patients ≤70 years [1, 2], the relative benefits compared to mechanical valve replacement (mAVR) remain uncertain [3, 4]. Purpose The current study aims to compare mortality and other important clinical endpoints by prosthesis type for patients aged 50-70 years who received an AVR in a well-characterised Australian cohort. Methods A retrospective cohort study was designed utilising the WAVES Patient Registry and incorporating linked administrative outcome data including all patients who had an AVR in Western Australian public hospitals between 2010-2020. The primary endpoint was all-cause mortality. Secondary endpoints included cardiovascular (CV) mortality, separately and combined with non-fatal myocardial infarction and non-fatal stroke (MACE), major bleeding, and days alive and out of hospital (DAOH). Outcomes were compared based on a propensity-matched analysis (including demographics, biometrics, and clinical characteristics). Results Within the initial cohort of 727 patients undergoing surgical AVR (mean age = 63 ± SD 6), a propensity-matched cohort identified 151 patients each with bAVR (mean age = 61 ± 4) and mAVR (mean age = 60 ± 5). Patients who received mAVR versus bAVR had improved all-cause survival (Hazard Ratio [HR] 0.50; 95% CI 0.25-0.99) but increased risk of major bleeding (HR 4.85; 95% CI 1.57-14.98). There were no significant differences in CV mortality (HR 0.58; 95% CI 0.19-1.74), MACE (HR 0.59; 95 % CI 0.32-1.07), or DAOH by prosthesis type (P = 0.452). Conclusions Patients aged 50-70 years who underwent mAVR had lower risk of all-cause mortality compared with bAVR, despite higher bleeding risk. Although risks of CV mortality and MACE were lower in mAVR, statistical significance was not reached, likely due to the small sample size. Larger studies are necessary to confirm these findings, which have important clinical implications.

Summary Health-related behaviours contribute to the global burden of cardiovascular disease (CVD). Cardiovascular imaging can be used to screen asymptomatic individuals for increased risk of CVD to enable earlier interventions to promote health-related behaviours to prevent or reduce CVD risk. Some theories of behaviour and behaviour change assume that engagement in a given behaviour is a function of individual threat appraisals, beliefs regarding the performance of behaviour, self-efficacy for performing the desired behaviour and/or dispositions to act (e.g. behavioural intentions). To date, little is known about the impact of cardiovascular imaging interventions on these constructs. This article summarises evidence related to perceived threat, efficacy beliefs, and behavioural intentions after CVD screening. We identified 10 studies (2 RCTs and 8 non-randomised studies, n = 2498) through a combination of screening citations from published systematic reviews and meta-analyses and searching electronic databases. Of these, 7 measured behavioural intentions and perceived susceptibility and 3 measured efficacy beliefs. Findings showed largely encouraging effects of screening interventions on bolstering self-efficacy beliefs and strengthening behavioural intentions. Imaging results that suggest the presence of coronary or carotid artery disease also increased perceived susceptibility to CVD. However, the review also identified some gaps in the literature, such as a lack of guiding theoretical frameworks and assessments of critical determinants of health-related behaviours. By carefully considering the key issues highlighted in this review, we can make significant strides towards reducing CVD risks and improving population health.