Device-measured physical activity and cardiometabolic health: the Prospective Physical Activity, Sitting, and Sleep (ProPASS) consortium.

BACKGROUND AND AIMS: Physical inactivity, sedentary behaviour (SB), and inadequate sleep are key behavioural risk factors of cardiometabolic diseases. Each behaviour is mainly considered in isolation, despite clear behavioural and biological interdependencies. The aim of this study was to investigate associations of five-part movement compositions with adiposity and cardiometabolic biomarkers. METHODS: Cross-sectional data from six studies (n = 15 253 participants; five countries) from the Prospective Physical Activity, Sitting and Sleep consortium were analysed. Device-measured time spent in sleep, SB, standing, light-intensity physical activity (LIPA), and moderate-vigorous physical activity (MVPA) made up the composition. Outcomes included body mass index (BMI), waist circumference, HDL cholesterol, total:HDL cholesterol ratio, triglycerides, and glycated haemoglobin (HbA1c). Compositional linear regression examined associations between compositions and outcomes, including modelling time reallocation between behaviours. RESULTS: The average daily composition of the sample (age: 53.7 ± 9.7 years; 54.7% female) was 7.7 h sleeping, 10.4 h sedentary, 3.1 h standing, 1.5 h LIPA, and 1.3 h MVPA. A greater MVPA proportion and smaller SB proportion were associated with better outcomes. Reallocating time from SB, standing, LIPA, or sleep into MVPA resulted in better scores across all outcomes. For example, replacing 30 min of SB, sleep, standing, or LIPA with MVPA was associated with -0.63 (95% confidence interval -0.48, -0.79), -0.43 (-0.25, -0.59), -0.40 (-0.25, -0.56), and -0.15 (0.05, -0.34) kg/m2 lower BMI, respectively. Greater relative standing time was beneficial, whereas sleep had a detrimental association when replacing LIPA/MVPA and positive association when replacing SB. The minimal displacement of any behaviour into MVPA for improved cardiometabolic health ranged from 3.8 (HbA1c) to 12.7 (triglycerides) min/day. CONCLUSIONS: Compositional data analyses revealed a distinct hierarchy of behaviours. Moderate-vigorous physical activity demonstrated the strongest, most time-efficient protective associations with cardiometabolic outcomes. Theoretical benefits from reallocating SB into sleep, standing, or LIPA required substantial changes in daily activity.

Relationship of device measured physical activity type and posture with cardiometabolic health markers: pooled dose-response associations from the Prospective Physical Activity, Sitting and Sleep Consortium.

AIMS/HYPOTHESIS: The aim of this study was to examine the dose-response associations of device-measured physical activity types and postures (sitting and standing time) with cardiometabolic health. METHODS: We conducted an individual participant harmonised meta-analysis of 12,095 adults (mean ± SD age 54.5±9.6 years; female participants 54.8%) from six cohorts with thigh-worn accelerometry data from the Prospective Physical Activity, Sitting and Sleep (ProPASS) Consortium. Associations of daily walking, stair climbing, running, standing and sitting time with a composite cardiometabolic health score (based on standardised z scores) and individual cardiometabolic markers (BMI, waist circumference, triglycerides, HDL-cholesterol, HbA1c and total cholesterol) were examined cross-sectionally using generalised linear modelling and cubic splines. RESULTS: We observed more favourable composite cardiometabolic health (i.e. z score <0) with approximately 64 min/day walking (z score [95% CI] -0.14 [-0.25, -0.02]) and 5 min/day stair climbing (-0.14 [-0.24, -0.03]). We observed an equivalent magnitude of association at 2.6 h/day standing. Any amount of running was associated with better composite cardiometabolic health. We did not observe an upper limit to the magnitude of the dose-response associations for any activity type or standing. There was an inverse dose-response association between sitting time and composite cardiometabolic health that became markedly less favourable when daily durations exceeded 12.1 h/day. Associations for sitting time were no longer significant after excluding participants with prevalent CVD or medication use. The dose-response pattern was generally consistent between activity and posture types and individual cardiometabolic health markers. CONCLUSIONS/INTERPRETATION: In this first activity type-specific analysis of device-based physical activity, ~64 min/day of walking and ~5.0 min/day of stair climbing were associated with a favourable cardiometabolic risk profile. The deleterious associations of sitting time were fully attenuated after exclusion of participants with prevalent CVD and medication use. Our findings on cardiometabolic health and durations of different activities of daily living and posture may guide future interventions involving lifestyle modification.

Prospective Association of Daily Steps With Cardiovascular Disease: A Harmonized Meta-Analysis.

BACKGROUND: Taking fewer than the widely promoted "10 000 steps per day" has recently been associated with lower risk of all-cause mortality. The relationship of steps and cardiovascular disease (CVD) risk remains poorly described. A meta-analysis examining the dose-response relationship between steps per day and CVD can help inform clinical and public health guidelines. METHODS: Eight prospective studies (20 152 adults [ie, ≥18 years of age]) were included with device-measured steps and participants followed for CVD events. Studies quantified steps per day and CVD events were defined as fatal and nonfatal coronary heart disease, stroke, and heart failure. Cox proportional hazards regression analyses were completed using study-specific quartiles and hazard ratios (HR) and 95% CI were meta-analyzed with inverse-variance-weighted random effects models. RESULTS: The mean age of participants was 63.2±12.4 years and 52% were women. The mean follow-up was 6.2 years (123 209 person-years), with a total of 1523 CVD events (12.4 per 1000 participant-years) reported. There was a significant difference in the association of steps per day and CVD between older (ie, ≥60 years of age) and younger adults (ie, <60 years of age). For older adults, the HR for quartile 2 was 0.80 (95% CI, 0.69 to 0.93), 0.62 for quartile 3 (95% CI, 0.52 to 0.74), and 0.51 for quartile 4 (95% CI, 0.41 to 0.63) compared with the lowest quartile. For younger adults, the HR for quartile 2 was 0.79 (95% CI, 0.46 to 1.35), 0.90 for quartile 3 (95% CI, 0.64 to 1.25), and 0.95 for quartile 4 (95% CI, 0.61 to 1.48) compared with the lowest quartile. Restricted cubic splines demonstrated a nonlinear association whereby more steps were associated with decreased risk of CVD among older adults. CONCLUSIONS: For older adults, taking more daily steps was associated with a progressively decreased risk of CVD. Monitoring and promoting steps per day is a simple metric for clinician-patient communication and population health to reduce the risk of CVD.

Prevalence and prognostic value of electrocardiographic abnormalities in hypokalemia: A multicenter cohort study.

BACKGROUND: Hypokalemia is common in hospitalized patients and associated with ECG abnormalities. The prevalence and prognostic value of ECG abnormalities in hypokalemic patients are, however, not well established. METHODS: The study was a multicentered cohort study, including all ault patients with an ECG and potassium level <4.4 mmol/L recorded at arrival to four emergency departments in Denmark and Sweden. Using computerized measurements from ECGs, we investigated the relationship between potassium levels and heart rate, QRS duration, corrected QT (QTc) interval, ST-segment depressions, T-wave flattening, and T-wave inversion using cubic splines. Within strata of potassium levels, we further estimated the hazard ratio (HR) for 7-day mortality, admission to the intensive care unit (ICU), and diagnosis of ventricular arrhythmia or cardiac arrest, comparing patients with and without specific ECG abnormalities matched 1:2 on propensity scores. RESULTS: Among 79,599 included patients, decreasing potassium levels were associated with a concentration-dependent increase in all investigated ECG variables. ECG abnormalities were present in 40% of hypokalemic patients ([K+ ] <3.5 mmol/L), with T-wave flattening, ST-segment depression, and QTc prolongation occurring in 27%, 16%, and 14%. In patients with mild hypokalemia ([K+ ] 3.0-3.4 mmol/L), a heart rate >100 bpm, ST-depressions, and T-wave inversion were associated with increased HRs for 7-day mortality and ICU admission, whereas only a heart rate >100 bpm predicted both mortality and ICU admission among patients with [K+ ] <3.0 mmol/L. HR estimates were, however, similar to those in eukalemic patients. The low number of events with ventricular arrhythmia limited evaluation for this outcome. CONCLUSIONS: ECG abnormalities were common in hypokalemic patients, but they are poor prognostic markers for short-term adverse events under the current standard of care.

Device-measured sedentary time and intensity-specific physical activity in relation to all-cause and cardiovascular disease mortality: the UK Biobank cohort study.

BACKGROUND AND AIMS: Understanding the amounts of intensity-specific movement needed to attenuate the association between sedentary time and mortality may help to inform personalized prescription and behavioral counselling. Herein, we examined the joint associations of sedentary time and intensity-specific physical activity with all-cause and cardiovascular disease (CVD) mortality. METHODS: Prospective cohort study including 73,729 adults from the UK Biobank who wore an Axivity AX3 accelerometer on their dominant wrist for at least 3 days, being one a weekend day, between June 2013 and December 2015. We considered the median tertile values of sedentary time and physical activity in each intensity band to determine the amount of physical activity needed to attenuate the association between sedentary time and mortality. RESULTS: During a median of 6.9 years of follow-up (628,807 person-years), we documented 1521 deaths, including 388 from CVD. Physical activity of any intensity attenuated the detrimental association of sedentary time with mortality. Overall, at least a median of 6 min/day of vigorous physical activity, 30 min/day of MVPA, 64 min/day of moderate physical activity, or 163 min/day of light physical activity (mutually-adjusted for other intensities) attenuated the association between sedentary time and mortality. High sedentary time was associated with higher risk of CVD mortality only among participants with low MVPA (HR 1.96; 95% CI 1.23 to 3.14). CONCLUSIONS: Different amounts of each physical activity intensity may attenuate the association between high sedentary time and mortality.

Complications in Emergency Department Patients with Acute Coronary Syndrome with Contemporary Care.

INTRODUCTION: With the implementation of early reperfusion therapy, the number of complications in patients with acute coronary syndrome (ACS) has diminished significantly. However, ACS patients are still routinely admitted to units with high-level monitoring such as the coronary or intensive care unit (CCU/ICU). The cost of these admissions is high and there is often a shortage of beds. The aim of this study was to analyze the complications in contemporary emergency department (ED) patients with ACS and to map patient management. METHODS: This observational study was a secondary analysis of data collected in the ESC-TROP trial (NCT03421873) that included 26,545 consecutive chest pain patients ≥18 years at five Swedish EDs. Complications were defined as the following within 30 days: death, cardiac arrest, cardiogenic shock, pulmonary edema, severe ventricular arrhythmia, high-degree atrioventricular (AV) block that required a pacemaker, and mechanical complications such as papillary muscle rupture, cardiac tamponade, or ventricular septum defects (VSDs). Complications were identified via diagnosis and/or intervention codes in the database, and manual chart review was performed in cases with complications. RESULTS: Of all 26,545 patients, 2,463 (9.3%) were diagnosed with ACS, and 151 of these (6.1%) suffered any complication within 30 days. Mean age was higher in patients with (79.2 years) than without (69.4 years) complications, and more were female (39.7% vs. 33.0%). Eighty-four (3.4% of all ACS patients) patients died, 33 (1.3%) had cardiac arrest, 22 (0.9%) respiratory failure, 13 (0.5%) high-degree AV block, 10 (0.4%) cardiogenic shock, 12 (0.5%) severe ventricular arrhythmia, and 2 each (<0.1%) had VSD or cardiac tamponade. Almost 30% of the complications were present already at the ED, and 40% of patients with complications were not admitted to the CCU/ICU. Only 80 (53%) of the patients with complications underwent coronary angiography and 62 (41%) were revascularized with percutaneous coronary intervention or coronary artery bypass grafting. CONCLUSION: With current care, serious complications occurred in only 6 out of 100 ACS patients, and 2 of these complications were present already at the ED. Four out of 10 ACS patients with complications were not admitted to the CCU/ICU and about half did not undergo coronary angiography. Further research is needed to improve risk assessment in ED ACS patients, which may allow more effective use of cardiac monitoring and hospital resources.

Joint associations of device-measured physical activity and abdominal obesity with incident cardiovascular disease: a prospective cohort study.

OBJECTIVE: To examine the joint associations between physical activity and abdominal obesity with the risk of cardiovascular disease (CVD) events. METHODS: We included 70 830 UK Biobank participants (mean age±SD=61.6 ± 7.9 years; 56.4% women) with physical activity measured by wrist-worn accelerometers and without major chronic diseases. Participants were jointly categorised into six groups based on their physical activity level (tertiles of total volume and specific intensity levels) and presence or absence of abdominal obesity based on measured waist circumference. Associations with incident CVD (fatal and non-fatal events) were determined using proportional subdistribution hazard models with multivariable adjustment. RESULTS: After excluding events during the first 2 years of follow-up, participants were followed for a median of 6.8 years, during which 2795 CVD events were recorded. Compared with the low abdominal adiposity and highest tertile of physical activity, abdominal obesity was associated with higher risk of incident CVD, especially in those with low levels of vigorous-intensity physical activity (HR 1.42, 95% CI 1.22 to 1.64). Approximately 500 min per week of moderate-to-vigorous intensity and approximately 30-35 min of vigorous-intensity physical activity offset the association of abdominal obesity and the risk of having a CVD event. CONCLUSION: Physical activity equivalent to approximately 30-35 min of vigorous intensity per week appears to offset the association between abdominal obesity and incident CVD. About 15 times more physical activity of at least moderate intensity is needed to achieve similar results.

Occupational physical activity and risk of mortality in women and men: the Tromsø Study 1986-2021.

OBJECTIVE: Associations between occupational physical activity (OPA) and mortality risks are inconclusive. We aimed to examine associations between (1) OPA separately and (2) jointly with leisure time physical activity (LTPA), and risk of all-cause, cardiovascular disease (CVD) and cancer mortality, over four decades with updated exposure and covariates every 6-8 years. METHODS: Adults aged 20-65 years from the Tromsø Study surveys Tromsø3-Tromsø7 (1986-2016) were included. We categorised OPA as low (sedentary), moderate (walking work), high (walking+lifting work) or very high (heavy manual labour) and LTPA as inactive, moderate and vigorous. We used Cox/Fine and Gray regressions to examine associations, adjusted for age, body mass index, smoking, education, diet, alcohol and LTPA (aim 1 only). RESULTS: Of 29 605 participants with 44 140 total observations, 4131 (14.0%) died, 1057 (25.6%) from CVD and 1660 (40.4%) from cancer, during follow-up (median: 29.1 years, 25th-75th: 16.5.1-35.3). In men, compared with low OPA, high OPA was associated with lower all-cause (HR 0.83, 95% CI 0.74 to 0.92) and CVD (subdistributed HR (SHR) 0.68, 95% CI 0.54 to 0.84) but not cancer mortality (SHR 0.99, 95% CI 0.84 to 1.19), while no association was observed for moderate or very high OPA. In joint analyses using inactive LTPA and low OPA as reference, vigorous LTPA was associated with lower all-cause mortality combined with low (HR 0.75, 95% CI 0.64 to 0.89), high (HR 0.67, 95% CI 0.54 to 0.82) and very high OPA (HR 0.74, 95% CI 0.58 to 0.94), but not with moderate OPA. In women, there were no associations between OPA, or combined OPA and LTPA, with mortality. CONCLUSION: High OPA, but not moderate and very high OPA, was associated with lower all-cause and CVD mortality risk in men but not in women. Vigorous LTPA was associated with lower mortality risk in men with low, high and very high OPA, but not moderate OPA.

Prior electrocardiograms not useful for machine learning predictions of major adverse cardiac events in emergency department chest pain patients.

At the emergency department (ED), it is important to quickly and accurately determine which patients are likely to have a major adverse cardiac event (MACE). Machine learning (ML) models can be used to aid physicians in detecting MACE, and improving the performance of such models is an active area of research. In this study, we sought to determine if ML models can be improved by including a prior electrocardiogram (ECG) from each patient. To that end, we trained several models to predict MACE within 30 days, both with and without prior ECGs, using data collected from 19,499 consecutive patients with chest pain, from five EDs in southern Sweden, between the years 2017 and 2018. Our results indicate no improvement in AUC from prior ECGs. This was consistent across models, both with and without additional clinical input variables, for different patient subgroups, and for different subsets of the outcome. While contradicting current best practices for manual ECG analysis, the results are positive in the sense that ML models with fewer inputs are more easily and widely applicable in practice.

Direct Comparison of the European Society of Cardiology 0/1-Hour Vs. 0/2-Hour Algorithms in Patients with Acute Chest Pain.

BACKGROUND: The recent guidelines from the European Society of Cardiology recommends using high-sensitivity cardiac troponin (hs-cTn) in either 0/1-h or 0/2-h algorithms to identify or rule out acute myocardial infarction (AMI). Several studies have reported good diagnostic accuracy with both algorithms, but few have compared the algorithms directly. OBJECTIVE: We aimed to compare the diagnostic accuracy of the algorithms head-to-head, in the same patients. METHODS: This was a secondary analysis of data from a prospective observational study; 1167 consecutive patients presenting with chest pain to the emergency department at Skåne University Hospital (Lund, Sweden) were enrolled. Only patients with a hs-cTnT sample at presentation AND after 1 AND 2 h were included in the analysis. We compared sensitivity, specificity, and negative (NPV) and positive predictive value (PPV). The primary outcome was index visit AMI. RESULTS: A total of 710 patients were included, of whom 56 (7.9%) had AMI. Both algorithms had a sensitivity of 98.2% and an NPV of 99.8% for ruling out AMI, but the 0/2-h algorithm ruled out significantly more patients (69.3% vs. 66.2%, p < 0.001). For rule-in, the 0/2-h algorithm had higher PPV (73.4% vs. 65.2%) and slightly better specificity (97.4% vs. 96.3%, p = 0.016) than the 0/1-h algorithm. CONCLUSION: Both algorithms had good diagnostic accuracy, with a slight advantage for the 0/2-h algorithm. Which algorithm to implement may thus depend on practical issues such as the ability to exploit the theoretical time saved with the 0/1-h algorithm. Further studies comparing the algorithms in combination with electrocardiography, history, or risk scores are needed.

Body composition and mortality from middle to old age: a prospective cohort study from the UK Biobank.

BACKGROUND: How the association between adiposity and the risk of death changes with age, and which is the optimal level of adiposity to reduce mortality in older ages, is still not completely understood. We aimed to ascertain the age-specific risks of mortality associated with different measures of adiposity. METHODS: This was a prospective UK Biobank cohort study. Participants were categorized based on five different adiposity and body composition metrics. We explored the age-varying associations between body composition indices and all-cause mortality from 45 to 85 years of age at follow-up using hazard ratios (HR) from flexible parametric survival models with multivariable adjustment and age as timescale. Participants were followed from baseline (2006-2010) through 31 March 2020. RESULTS: We included 369,752 participants (mean baseline age = 56.3 ± 8.1 years; range 38.9-73.7 years; 54.1% women) and 10,660 deaths during a median follow-up of 11.4 years. Associations between body mass index and mortality were similar when using the fat mass index in magnitude and shape. Compared to participants with normal weight, overweight was not associated with the risk of death regardless of age and the adiposity measure used. Participants with obesity class I showed an HR of 1.20 (95% confidence interval [CI]: 1.08, 1.33) and 1.14 (95%CI: 0.98, 1.30) at ages 60 and 80, respectively, and participants with obesity class II an HR about 1.55 across all age. More attenuated associations with higher age were found in individuals with the highest obesity using the fat mass index. Very high lean mass was associated with an increased risk of mortality in those aged 55-75 years (HR about 1.20 across all ages). CONCLUSION: Obesity should be prevented at any age. Attenuated associations with older age were observed only among the individuals with the highest obesity, but the risk remained higher compared to normal-weight participants. Lean mass did not reduce mortality risk at any age.

Greater male variability in daily energy expenditure develops through puberty.

There is considerably greater variation in metabolic rates between men than between women, in terms of basal, activity and total (daily) energy expenditure (EE). One possible explanation is that EE is associated with male sexual characteristics (which are known to vary more than other traits) such as musculature and athletic capacity. Such traits might be predicted to be most prominent during periods of adolescence and young adulthood, when sexual behaviour develops and peaks. We tested this hypothesis on a large dataset by comparing the amount of male variation and female variation in total EE, activity EE and basal EE, at different life stages, along with several morphological traits: height, fat free mass and fat mass. Total EE, and to some degree also activity EE, exhibit considerable greater male variation (GMV) in young adults, and then a decreasing GMV in progressively older individuals. Arguably, basal EE, and also morphometrics, do not exhibit this pattern. These findings suggest that single male sexual characteristics may not exhibit peak GMV in young adulthood, however total and perhaps also activity EE, associated with many morphological and physiological traits combined, do exhibit GMV most prominently during the reproductive life stages.

Joint associations of physical activity and sedentary time with body mass index: A prospective study of mortality risk.

Device-measured physical activity and sedentary time are suggested to be more important determinants of all-cause mortality compared to body mass index (BMI) in mainly older adults. However, the joint associations of physical activity and sedentary time with BMI in relation to mortality risk in relatively healthy middle-aged individuals are unclear. We followed 770 adults (56% women, mean age 55.6 years) from a population-based cohort study for up to 15.3 years. BMI categories were combined with tertiles of total, light, and moderate-to-vigorous physical activity and sedentary time. Cox proportional hazards models estimated hazard ratios (HR) of all-cause mortality with 95% confidence intervals (CI). High total and light intensity physical activity and low sedentary time were associated with a lower risk of mortality in normal weight individuals compared with low active overweight/obese; HR: 0.35 (CI: 0.14, 0.86), HR: 0.33 (CI: 0.12, 0.89), and HR: 0.34 (CI: 0.13, 0.92). Among overweight/obese individuals, those who were medium active in light physical activity had a lower mortality risk, HR: 0.36 (CI: 0.15, 0.83), compared with low active. Medium sedentary individuals had a lower risk, HR: 0.43 (CI: 0.20, 0.94) compared with those who were most sedentary. Associations among the most active or least sedentary tertiles were similar irrespective of BMI category. In conclusion, higher physical activity and lower sedentary time were associated with lower mortality risk irrespective of BMI. Physical activity should be promoted and prescribed to individuals with low physical activity levels irrespective of weight status.

Absolute intensity thresholds for tri-axial wrist and waist accelerometer-measured movement behaviors in adults.

AIM: This study was aimed to: (1) compare raw triaxial acceleration data from GENEActiv (GA) and ActiGraph GT3X+ (AG) placed on the non-dominant wrist; (2) compare AG placed on the non-dominant and dominant wrist, and waist; (3) derive brand- and placement-specific absolute intensity thresholds for inactive and sedentary time, and physical activity intensity in adults. METHODS: Eighty-six adults (44 men; 34.6 ± 10.8 years) performed nine activities while simultaneously wearing GA and AG on wrist and waist. Acceleration (in gravitational equivalent units; mg) was compared with oxygen uptake (measured with indirect calorimetry). RESULTS: Increases in acceleration mirrored increases in intensity of activities, regardless of device brand and placement. Differences in acceleration between GA and AG worn at the non-dominant wrist were small but tended to be high at lower intensity activities. Thresholds for differentiating inactivity (<1.5 MET) from activity (≥1.5 MET) ranged from 25 mg (AG non-dominant wrist; sensitivity 93%, specificity 95%) to 40 mg (AG waist; sensitivity 78%, specificity 100%). For moderate intensity (≥3 METs), thresholds ranged from 65 mg (AG waist; sensitivity 96%, specificity 94%) to 92 mg (GA non-dominant; sensitivity 93%, specificity 98%); vigorous intensity (≥6 METs) thresholds ranged from 190 mg (AG waist; sensitivity 82%, specificity 92%) to 283 mg (GA non-dominant; sensitivity 93%, specificity 98%). CONCLUSION: Raw triaxial acceleration outputs from two widely used accelerometer brands may have limited comparability in low intensity activities. Thresholds derived in this study can be utilized in adults to reasonably classify movement behaviors into categories of intensity.

Effects of 2-year dietary and physical activity intervention on cognition in children-a nonrandomized controlled trial.

BACKGROUND AND OBJECTIVE: We investigated the effects of a combined dietary and PA intervention on cognition in children and whether changes in diet quality, PA, sedentary behavior (SB), and sedentary time (ST) are associated with changes in cognition. METHODS: We conducted a 2-year nonrandomized controlled trial in 504 children aged 6-9 years at baseline. The children were allocated to a combined dietary and PA intervention group (n = 237) or a control group (n = 160) without blinding. INTERVENTIONS: The children and their parents allocated to the intervention group had six dietary counseling sessions of 30-45 min and six PA counseling sessions of 30-45 min during the 2-year intervention period. The children were also encouraged to participate in after-school exercise clubs. Cognition was assessed by the Raven's Colored Progressive Matrices. We assessed dietary factors by 4 days food records and computed the Baltic Sea Diet Score (BSDS) as a measure of diet quality. PA and ST were assessed by a combined heart rate and body movement monitor, types of PA and SB by a questionnaire. RESULTS: The intervention had no effect on cognition. Increased BSDS and consumption of low-fat milk and decreased consumption of red meat and sausages were associated with improved cognition over 2 years. Increased organized sports, ST, and reading were positively, while unsupervised PA, computer use, and writing were negatively associated with cognition. CONCLUSION: Combined dietary and PA intervention had no effect on cognition. Improved diet quality and increased organized sports and reading were associated with improved cognition.

Performance of the European Society of Cardiology 0/1-Hour, 0/2-Hour, and 0/3-Hour Algorithms for Rapid Triage of Acute Myocardial Infarction : An International Collaborative Meta-analysis.

BACKGROUND: The 2020 European Society of Cardiology (ESC) guidelines recommend using the 0/1-hour and 0/2-hour algorithms over the 0/3-hour algorithm as the first and second choices of high-sensitivity cardiac troponin (hs-cTn)-based strategies for triage of patients with suspected acute myocardial infarction (AMI). PURPOSE: To evaluate the diagnostic accuracies of the ESC 0/1-hour, 0/2-hour, and 0/3-hour algorithms. DATA SOURCES: PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus from 1 January 2011 to 31 December 2020. (PROSPERO: CRD42020216479). STUDY SELECTION: Prospective studies that evaluated the ESC 0/1-hour, 0/2-hour, or 0/3-hour algorithms in adult patients presenting with suspected AMI. DATA EXTRACTION: The primary outcome was index AMI. Twenty unique cohorts were identified. Primary data were obtained from investigators of 16 cohorts and aggregate data were extracted from 4 cohorts. Two independent authors assessed each study for methodological quality. DATA SYNTHESIS: A total of 32 studies (20 cohorts) with 30 066 patients were analyzed. The 0/1-hour algorithm had a pooled sensitivity of 99.1% (95% CI, 98.5% to 99.5%) and negative predictive value (NPV) of 99.8% (CI, 99.6% to 99.9%) for ruling out AMI. The 0/2-hour algorithm had a pooled sensitivity of 98.6% (CI, 97.2% to 99.3%) and NPV of 99.6% (CI, 99.4% to 99.8%). The 0/3-hour algorithm had a pooled sensitivity of 93.7% (CI, 87.4% to 97.0%) and NPV of 98.7% (CI, 97.7% to 99.3%). Sensitivity of the 0/3-hour algorithm was attenuated in studies that did not use clinical criteria (GRACE score <140 and pain-free) compared with studies that used clinical criteria (90.2% [CI, 82.9 to 94.6] vs. 98.4% [CI, 88.6 to 99.8]). All 3 algorithms had similar specificities and positive predictive values for ruling in AMI, but heterogeneity across studies was substantial. Diagnostic performance was similar across the hs-cTnT (Elecsys; Roche), hs-cTnI (Architect; Abbott), and hs-cTnI (Centaur/Atellica; Siemens) assays. LIMITATION: Diagnostic accuracy, inclusion and exclusion criteria, and cardiac troponin sampling time varied among studies. CONCLUSION: The ESC 0/1-hour and 0/2-hour algorithms have higher sensitivities and NPVs than the 0/3-hour algorithm for index AMI. PRIMARY FUNDING SOURCE: National Taiwan University Hospital.

Device-measured physical activity, sedentary time, and risk of all-cause mortality: an individual participant data analysis of four prospective cohort studies.

OBJECTIVES: To examine whether moderate-to-vigorous physical activity (MVPA) modifies the association between sedentary time and mortality and vice versa, and estimate the joint associations of MVPA and sedentary time on mortality risk. METHODS: This study involved individual participant data analysis of four prospective cohort studies (Norway, Sweden, USA, baseline: 2003-2016, 11 989 participants ≥50 years, 50.5% women) with hip-accelerometry-measured physical activity and sedentary time. Associations were examined using restricted cubic splines and fractional polynomials in Cox regressions adjusted for sex, education, body mass index, smoking, alcohol, study cohort, cardiovascular disease, cancer, and/or diabetes, accelerometry wear time and age. RESULTS: 6.7% (n=805) died during follow-up (median 5.2 years, IQR 4.2 years). More than 12 daily sedentary hours (reference 8 hours) was associated with mortality risk only among those accumulating <22 min of MVPA per day (HR 1.38, 95% CI 1.10 to 1.74). Higher MVPA levels were associated with lower mortality risk irrespective of sedentary time, for example, HR for 10 versus 0 daily min of MVPA was 0.85 (95% CI 0.74 to 0.96) in those accumulating <10.5 daily sedentary hours and 0.65 (95% CI 0.53 to 0.79) in those accumulating ≥10.5 daily sedentary hours. Joint association analyses confirmed that higher MVPA was superior to lower sedentary time in lowering mortality risk, for example, 10 versus 0 daily min of MVPA was associated with 28-55% lower mortality risk across the sedentary time spectrum (lowest risk, 10 daily sedentary hours: HR 0.45, 95% CI 0.31 to 0.65). CONCLUSIONS: Sedentary time was associated with higher mortality risk but only in individuals accumulating less than 22 min of MVPA per day. Higher MVPA levels were associated with lower mortality risk irrespective of the amount of sedentary time.

Study of ECG-derived atrial fibrillatory rate for prediction of the outcome of cardioversion of short duration atrial fibrillation (CASAF).

AIMS: The present study aimed at testing the hypothesis that atrial fibrillatory rate (AFR) is predictive of sinus rhythm maintenance after electrical cardioversion. METHODS AND RESULTS: The study comprised 32 patients admitted for cardioversion of atrial fibrillation of short duration (mean duration 3.8 ± 7.7 days). AFR was estimated using frequency power spectrum analysis of QRST-cancelled ECG. At six-weeks follow-up 22% of the patients had relapsed to AF. The pre-cardioversion mean AFR of those was 332 ± 64 fpm compared to 378 ± 59 fpm among patients maintaining sinus rhythm (p = 0.12). CONCLUSION: AFR was not predictive of sinus rhythm maintenance in patients of short duration AF undergoing cardioversion. This is in stark contrast with the earlier reported findings. CLINICAL TRIAL REGISTRATION: NCT02112318 (http://www. CLINICALTRIALS: gov).

Machine learning for early prediction of acute myocardial infarction or death in acute chest pain patients using electrocardiogram and blood tests at presentation.

AIMS: In the present study, we aimed to evaluate the performance of machine learning (ML) models for identification of acute myocardial infarction (AMI) or death within 30 days among emergency department (ED) chest pain patients. METHODS AND RESULTS: Using data from 9519 consecutive ED chest pain patients, we created ML models based on logistic regression or artificial neural networks. Model inputs included sex, age, ECG and the first blood tests at patient presentation: High sensitivity TnT (hs-cTnT), glucose, creatinine, and hemoglobin. For a safe rule-out, the models were adapted to achieve a sensitivity > 99% and a negative predictive value (NPV) > 99.5% for 30-day AMI/death. For rule-in, we set the models to achieve a specificity > 90% and a positive predictive value (PPV) of > 70%. The models were also compared with the 0 h arm of the European Society of Cardiology algorithm (ESC 0 h); An initial hs-cTnT < 5 ng/L for rule-out and ≥ 52 ng/L for rule-in. A convolutional neural network was the best model and identified 55% of the patients for rule-out and 5.3% for rule-in, while maintaining the required sensitivity, specificity, NPV and PPV levels. ESC 0 h failed to reach these performance levels. DISCUSSION: An ML model based on age, sex, ECG and blood tests at ED arrival can identify six out of ten chest pain patients for safe early rule-out or rule-in with no need for serial blood tests. Future studies should attempt to improve these ML models further, e.g. by including additional input data.

Bi-directional associations between physical activity and growth indicators of pre-school aged children.

Physical activity for young children provides a wealth of benefits for health and development. However, little is known about the inter-relationship of physical activity and growth indicators. The aim of this study was to test the bi-directional associations of physical activity and growth indicators in children under five years of age. This prospective study included 1,575 children with data on physical activity and growth indicators at ages 12, 24 and 48 months. Accelerometers were used to measure physical activity. Z-scores for length/height-for-age, weight-for-length/height, weight-for-age and body mass index (BMI)-for-age were calculated. Bi-directional associations between physical activity and growth indicators were evaluated using cross-lagged panels based on Generalized Estimating Equations and cross-lagged structural equation models. Physical activity was consistently associated with lower weight-related growth indicators: BMI-for-age: ß=-0.12; Weight-for-age: ß=-0.11; Weight-for-length/height: ß=-0.12. Higher BMI-for-age indicated lower physical activity (ß=-0.06). When the exposure was lagged, the association of physical activity on weight-related growth indicators remained, but weight-related growth indicators showed a negative association on physical activity. A bi-directional association between physical activity and weight-related growth indicators was observed. The magnitude of associations were stronger when physical activity was modelled as exposure. These results reinforce the importance of physical activity since early years.