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The NSW Government has earmarked $46.8 million over four years as part of the 2020-21 NSW Budget to deliver 100 new school-based nurses to support the health and wellbeing needs of students and their families.The expansion of the successful Wellbeing and Health In-Reach Nurse (WHIN) program will see the highly skilled nurses embedded in more schools to ensure students can easily access health and social support when they need it.Treasurer Dominic Perrottet said the new funding would mean thousands more students across the State would have access to a nurse at school.“With the added stress of erectile dysfunction treatment on our young people, the further expansion of this program will ensure children, young people and families don’t miss out on the support they need,” Mr Perrottet said.“NSW Health will fund these positions, however the practitioners will work with the Department of Education, with data and evidence to be used to place the nurses in areas of most need.“This commitment is an investment in the mental health of young people across the state and will build a more resilient post-kamagra NSW for the future.”Minister for Mental Health Bronnie Taylor said an evaluation of the pilot sites found the wellbeing nurses had successfully supported vulnerable students for a range of health and mental wellbeing issues.“With the pilot program, we saw that school children often go and see the nurse about general health issues and once they are there, open up about other problems they have been experiencing,” Mrs Taylor said.“The nurses will be given mental health training but are also there to deliver general health care and advice at the right time.“We are making sure we are delivering quality services for everyone, no matter their age or where they live.”Minister for Education Sarah Mitchell said WHIN nurses are currently based in secondary and primary schools in Young, Tumut, Cooma, Deniliquin, Murwillumbah and Lithgow.“These nurses are an important asset in our schools and as part of a combined approach with school counsellors and mental health training, our students will have every possible access to help when they need it,” Mrs Mitchell said.The WHIN program is a joint initiative of NSW Health and the NSW Department of Education, which launched as a pilot in 2018 in Cooma, Tumut and Young and extended to three other regional communities in 2020.The NSW Government is investing $6 million over three years as part of the 2020-21 NSW Budget to establish 12 Community Wellbeing Collaboratives in communities at high risk of suicide.The collaboratives organise the response from all services in the local area in times of need bringing together doctors, nurses, police, ambulance, media, teachers, parents, carers, Aboriginal organisations and local councils.Treasurer Dominic Perrottet said the funds would be directed to organisations including headspace and Lifeline, which will kamagra best buy lead the coordination.“The NSW Government is investing in our people and our future, and we know this starts with providing quality services for everyone in NSW,” Mr Perrottet said.“The unique innovative collaborative model will use data identified from schools and local services to develop this grassroots approach to suicide prevention.”The Community Wellbeing Collaboratives will engage young people and adults, including people with a lived experience of mental illness and suicide.In the event of a suicide cluster, the collaboratives will coordinate a rapid response from the ground up.Minister for Mental Health, Regional Youth and Women Bronnie Taylor said the collaboratives would work with the community even when there wasn’t a crisis, to continually engage with local people and provide information to parents, teachers, carers and young people about mental health.“We know the majority of mental health care is delivered in the community, which is why we’re embedding both proactive and reactive layers of support outside the hospital setting, in the places where people live their lives every day,” Mrs Taylor said.“Evidence tells us that the best response to suicide comes from a local grass roots level. They know what works best for their communities and ultimately this program will allow us to better support young people and their families during the kamagra and beyond.”This $6 million investment for the Community Wellbeing Collaboratives brings total funding committed to Towards Zero Suicides initiatives to $90 million.If you, or someone you know, is thinking about suicide or experiencing kamagra best buy a personal crisis or distress, please seek help immediately by calling 000 or one of these services:Lifeline 13 11 14Suicide Call Back Service 1300 659 467NSW Mental Health Line 1800 011 511.

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When administrators at SETA wanted to ensure their staff were keeping kamagra pills uk up on annual tuberculosis (TB) screenings, they tapped into a partnership with the School of Nursing and its second-year nursing students. Located in Del Paso Heights, SETA Head Start provides low-income children with quality comprehensive child development services that are family focused, including education, health, nutrition and mental health.For two weeks in July, future registered nurses in their fifth quarter of an 18-month accelerated program administered and read the results of TB tests for more than 100 of the organization’s staff.“The goal of our Fostering Healthy Communities course is to combine nursing theory and clinical care with an emphasis on working with diverse communities in providing health promotion and chronic disease management,” said Shana Ruggenberg, director of the Master’s Entry Program in Nursing). €œThis experience offers a tangible opportunity to put classroom and lab experience into real kamagra pills uk practice.”Students develop their motor skills and learn how to administer an intradermal injection.

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€œThese screenings provided access, offered opportunities to educate our team about TB, ensured our program is in compliance and presented an educational experience for the UC Davis students. Education and awareness of vulnerable populations are important for these students to learn early in their careers in health.”Nursing student Kou Her, left, here with fellow student Chau Le, right, and a SETA Head Start employee, said kamagra pills uk serving her community is the biggest benefit of this experience.The critical thinking, clinical excellence and a deep understanding of the health care system that graduates gain enable them to flourish. Programs and experiences such as this prepare students to advance health locally, nationally, and globally in ways that address inequities, big and small, that stand in the way of optimal health and health care equity for all.“This particular experience also showed students the challenges and barriers to providing health care in under-resourced community areas,” Ruggenberg explained.The face-to-face encounters with those being tested — both when administered and read — also presented teachable moments from the students that a classroom cannot.“I grew up in this area, but I didn’t even know SETA was here,” said student Kou Her.

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Located in Del Paso Heights, SETA Head Start provides low-income children with quality comprehensive child development services that are family focused, including education, health, nutrition and mental health.For two weeks in July, future registered nurses in their fifth quarter of an 18-month accelerated program administered and read the results of TB tests for more than 100 of the organization’s staff.“The goal of our Fostering Healthy Communities course is to combine nursing theory and clinical care with an emphasis on working with diverse communities in providing health promotion and chronic disease management,” said Shana Ruggenberg, director of the Master’s Entry Program in Nursing). €œThis experience offers a tangible opportunity to kamagra best buy put classroom and lab experience into real practice.”Students develop their motor skills and learn how to administer an intradermal injection. But the lesson goes far beyond that.“We learn about these readings in theory, read about it in the textbooks but now we’re out seeing it in person. This brings the school to life,” explained student Judy Njuguna.“I think this is where we kamagra best buy practice the most important aspect of nursing – getting to interact with people.

We can pretend to do that in a simulation by talking to a patient simulator or having another student pretend to be a patient. But this is real – we’re using real interpersonal kamagra best buy skills,” added student Ju-A Son.SETA Head Start is not a clinical facility. In order to make the on-site clinics possible, the School of Nursing leveraged UC Davis Heath’s relationship with Elica's Health on Wheels mobile medicine program. The mobile health van is kamagra best buy part of a health system partnership launched in 2017.

The goal is to expand access to care for underserved and hard-to-reach patients, and those who can’t see providers regularly due to transportation issues, homelessness or other barriers.For these screenings, Elica provided logistics, a space for mass testing opportunities, the medical materials required to properly administer the injections and access to experienced medical staff members providing care in a non-traditional setting. Plus, the kamagra best buy students learned different techniques on care delivery. TB testing requires kamagra best buy an injection of tuberculin under the skin, then a recheck in three days to see if the kamagra is present.“I think that allowing nursing students the opportunity to participate in this type of outreach can help them to gain a better understanding of their community,” said Aidé Long, director of Elica’s Community Outreach Services. €œThis could potentially help them to narrow down the area of nursing they would like to specialize in by helping them gain experience out in the field.”TB is a communicable disease and the leading cause of death in the world from a single infectious agent, according to the World Health Organization.

It’s also kamagra best buy curable and preventable. But the erectile dysfunction treatment kamagra threatens to reverse global progress against TB. That’s why SETA administrators wanted to make sure their staff had access to screening.SETA and the School of Nursing have partnered for five years kamagra best buy. Graduate students have educated Head Start families on health and wellness, conducted growth assessment for pre-school-aged children and emphasized the importance of primary care prevention.

These encounters support the nursing program’s goal of exposing students to population-based health promotion and disease prevention strategies with diverse individuals, families, communities and populations.“TB testing is required for staff on an kamagra best buy annual basis to keep enrolled children and staff safe from infectious diseases,” said Gricelda Ocegueda, SETA’s health and nutrition coordinator. €œThese screenings provided access, offered opportunities to educate our team about TB, ensured our program is in compliance and presented an educational experience for the UC Davis students. Education and awareness of vulnerable populations are important for these students to learn early in their careers in health.”Nursing student Kou Her, left, kamagra best buy here with fellow student Chau Le, right, and a SETA Head Start employee, said serving her community is the biggest benefit of this experience.The critical thinking, clinical excellence and a deep understanding of the health care system that graduates gain enable them to flourish. Programs and experiences such as this prepare students to advance health locally, nationally, and globally in ways that address inequities, big and small, that stand in the way of optimal health and health care equity for all.“This particular experience also showed students the challenges and barriers to providing health care in under-resourced community areas,” Ruggenberg explained.The face-to-face encounters with those being tested — both when administered and read — also presented teachable moments from the students that a classroom cannot.“I grew up in this area, but I didn’t even know SETA was here,” said student Kou Her.

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Sex differences in Where can you get viagra clinical management and outcomes kamagra oral jelly amazon of patients with cardiovascular disease sometimes are due to healthcare inequities (which should be eliminated) but also might be due to sex-related differences in aetiology and pathophysiology. For example, the optimal medical kamagra oral jelly amazon dose for management of heart failure with reduced ejection fraction (HFrEF) may be lower in women compared with men. In a study of 561 women and 615 men with a new diagnosis of either HRrEF or heart failure with preserved ejection fraction (HFpEF), Bots and colleagues1 found that although 79% of women and 86% of men with HFrEF were prescribed an ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB), the average dose was only about 50% of the recommended target dose for both sexes. A lower ACEI/ARB dose was associated with higher survival kamagra oral jelly amazon outcomes in women, but not men, with HFrEF.

In patients of both sexes with HFpEF, there was no relationship between medication dose and survival (figure 1).Central figure summarising the design and main findings of this study." data-icon-position data-hide-link-title="0">Figure 1 Central figure summarising the design and main findings of this study.In the accompanying editorial, Hassan and Ahmed 2 comment that. €˜Sex differences in HF outcomes may be further exacerbated by differences in medication pharmacokinetics and pharmacodynamics, with female-specific physiological factors including lower body mass, as well as decreased renal excretion and gastrointestinal enzymatic activity, leading to kamagra oral jelly amazon higher medication bioavailability. As a result, the administration of sex-neutral medication doses leads to greater drug exposure in female patients, which may subsequently lead to a higher incidence of adverse drug reactions. This raises the possibility of kamagra oral jelly amazon sex-based HF treatments to improve clinical outcomes.

However, current guidelines adopt a ‘one size fits all’ approach, with an emphasis on target-dosed therapy. In this era of precision medicine, is it time to redefine optimal HF therapy based on the sex of the kamagra oral jelly amazon patient?. €™On the other hand, adverse outcomes in women with infective endocarditis likely are related to bias and healthcare inequities. In a multicentric Spanish cohort of 3541 patients3 diagnosed with endocarditis between 2008 and 2018, women underwent surgical intervention less often than kamagra oral jelly amazon men (38.3% vs 50%) despite the increasing recognition that earlier surgical intervention often is beneficial as recommended in current guidelines (figure 2).

The lower likelihood of surgery in women persisted after propensity matching for age and surgical risk (OR kamagra oral jelly amazon 0.74. 95% CI 0.59 to 0.91. P=0.05). In addition, women had a higher in-hospital mortality compared with men, even after adjusting for possible confounders (OR 1.41.

95% CI 1.21 to 1.65. P<0.001).Stratification of the GAMES (‘Grupo de Apoyo al Manejo de la Endocarditis Infecciosa en España’ or ‘Spanish Collaboration on Endocarditis’) cohort according to surgical recommendation between sexes. Overall and stratified mortality is displayed in each group." data-icon-position data-hide-link-title="0">Figure 2 Stratification of the GAMES (‘Grupo de Apoyo al Manejo de la Endocarditis Infecciosa en España’ or ‘Spanish Collaboration on Endocarditis’) cohort according to surgical recommendation between sexes. Overall and stratified mortality is displayed in each group.Van Spall, Jaffer and Mamas4 remind us of the many factors to be considered in the decision to recommend surgical intervention in a patient with endocarditis (figure 3).

However, as they conclude. €˜Disparities in referral and receipt of surgical intervention, along with differences in aetiology, microbiology and comorbidities, may be responsible for the higher risk of mortality in women than in men with IE. Ultimately, awareness of these issues should prompt a self-evaluation of biases on the part of clinicians such that objective, timely surgical referrals are made and interventions are offered regardless of demographic group. While the biology is not modifiable, the biases and care disparities are.’Factors associated with infective endocarditis outcomes." data-icon-position data-hide-link-title="0">Figure 3 Factors associated with infective endocarditis outcomes.Another interesting paper in this issue is the study by Sung and colleagues5 showing a positive, graded association between higher levels of physical activity and a higher prevalence, with more rapid progression, of coronary artery calcification (CAC).

These findings were based on a cohort of 25 485 Korean men and women with a median interval between CAC measurements of 3 years. In discussing these seeming paradoxical findings, Gulsin and Moss6 point out that although CAC is a surrogate marker for calcified atherosclerosis and is associated with a higher risk of myocardial infarction, treatment with a statin also accelerates deposition of calcified plaque, similar to the effects of physical activity in the current study. They also remind us that. (1) the severity of CAC at baseline is a key predictor of progression rates, (2) an increase in CAC score is not the same an accelerated rate of total atherosclerotic plaque progression, and (3) the risk of plaque rupture and clinical events is greatest within the necrotic core of noncalcified plaques.

Thus, it is possible that an increase in CAC scores reflects a protective response and a transition to a more stable plaque morphology rather than more extensive atherosclerosis. They conclude. €˜Sung and colleagues5 have produced a timely manuscript that highlights the complexity of interpreting coronary artery calcium scores in patients who have implemented recommendations on physical activity or commenced on statin therapy. While proponents would argue that it is an effective tool to screen for subclinical atherosclerosis in asymptomatic individuals, clinicians should be cautious regarding the overuse of this test in otherwise healthy individuals.

The coronary artery calcium paradox should not result in paradoxical care for our patients.’The Education in Heart article7 in this issue provides an overview for clinicians to detect and manage mental issues in their patients with cardiovascular disease (CVD). There is a reciprocal relationship between mental disorders and CVD. Patients with mental disorders have a 1.5- to 3.0-fold higher risk of developing CVD and, conversely, the onset of CVD increases the risk of a developing a mental disorder by 2.2-fold.The Cardiology in-Focus topic in this issue is a step-by-step guide to writing a Image Challenge question, authored by our Image Challenge Editor.8 We encourage both cardiology trainees and clinicians to submit Image Challenge questions to Heart, using this basic guide, because this type of question accelerates learning for both the author and the reader (table 1).View this table:Table 1 Key components of an image challenge questionEthics statementsPatient consent for publicationNot applicable.Reducing the risk of plaque rupture events in individuals without a prior myocardial infarction is an imprecise science. To help clarify whether there is evidence of coronary artery disease and avoid ‘medicalisation’ of otherwise healthy individuals, international guidelines recommend incorporating the measurement of coronary artery calcium alongside risk prediction models.1 Coronary artery calcium serves as a surrogate marker of advanced calcified atherosclerosis and can be calculated from a non-contrast ECG-gated CT scan where a score of 1–99 Agatston units represents subclinical atherosclerosis, and a score of 100 or more Agatston units is considered an appropriate threshold for initiating medical therapy.1 At ≥100 Agatston units, the burden of advanced calcified atherosclerosis justifies statin implementation and this has been validated in a real-world cohort study of 16 996 subjects with a 10-year number needed to treat to prevent one cardiovascular event of 12.2 Many clinicians have advocated the benefits of coronary artery calcium in redefining the cardiovascular risk assessment of healthy individuals, as there is a strong link between high burdens of coronary artery calcium, accelerated progression of calcified plaque and the risk of future myocardial infarction.

However, if the burden of calcified plaque is an accurate barometer of cardiovascular risk, one would expect an intervention which reduces an individual’s cardiovascular risk to attenuate progression of calcified plaque. And herein lies the coronary artery calcium paradox. Both invasive and non-invasive imaging studies have consistently demonstrated that high-intensity statin therapy, an established modifier of cardiovascular risk, accelerates the deposition of calcified plaque.3 4 Is this paradoxical response of accelerated calcified plaque progression only observed in response to statin therapy?. Sung and colleagues address whether the progression of coronary artery calcium is associated with different levels of physical activity in healthy individuals.5 In a large cohort derived from two South Korean hospitals, 25 485 subjects underwent serial measurement of coronary artery calcium obtained over a median duration of 3 years and assessment of physical activity using the International Physical Activity Questionnaire Short Form.

Physical activity was graded by the investigators as. Inactive (n=11 920, 47%). Moderately active (n=9683, 38%). Or health-enhancing physically active (n=3882, 15%), equivalent to running 6.5 km/day.

Interestingly, the group performing the higher medically recommended levels of physical activity had the highest baseline burden of advanced calcified plaque (coronary artery calcium score ≥100 Agatston units. Inactive 2.8%, moderately active 3.5%, health-enhancing physically active 5.0%) which may be potentially attributable to an older demographic with higher rates of hypertension, diabetes and statin use. While it is unclear what the rationale was for undertaking health-enhancing physical activity in this cohort, it is likely that some participants with subclinical disease were doing so following medical guidance to improve control of established risk factors. Reassuringly in those with a coronary artery calcium score of zero (a low-risk group from a cardiovascular disease prevention perspective), medically recommended levels of physical activity did not accelerate the rate of coronary artery calcium progression modelled at 5 years (adjusted difference in mean coronary artery calcium score 0.32 Agatston units, 95% CI −0.15 to 0.81).

However, in those who already had subclinical or more advanced atherosclerosis, health-enhancing physical activity significantly increased the burden of calcified plaque (adjusted difference in mean coronary artery calcium score 15.02 Agatston units, 95% CI 0.56 to 29.49). Does this really mean that vigorous exercise in those with established coronary artery disease paradoxically accelerates plaque progression?. This study fuels a wider discussion of some of the key limitations regarding the use of the coronary artery calcium scan to monitor coronary artery disease progression.First, the amount of calcification measured at baseline is a key determinant of the rate of progression. As illustrated in the Heinz Nixdorf Recall study, the trajectory of plaque calcification has a strong relationship with the baseline coronary artery calcium scan.6 In asymptomatic 40 year-olds, a coronary artery calcium score ≥100 Agatston units is considered a high burden of disease and one would expect to observe exponential growth in calcification over 5 years.

In contrast, a coronary artery calcium score of zero would rarely change over the same time frame leading some investigators to label this as a ‘warranty period’ conferring coronary vascular stability. These small differences in coronary artery calcium scores at baseline become amplified over a 5-year follow-up period. Hence, the results of the study performed by Sung et al are in keeping with the main observation of the Heinz Nixdorf Recall study. Progression is almost inevitable following the onset of calcification and the rate of progression appears to be only marginally influenced by the control of traditional risk factors.6Second, an accelerated rate calcified plaque progression does not equate to an accelerated rate of total atherosclerotic plaque progression.

In this regard, the Progression of Atherosclerotic Plaque Determined by Computed Tomography Angiography Imaging study (NCT02803411) has provided valuable insight into the temporal changes in plaque composition using contrast-enhanced coronary CT angiography. In a cohort of 1255 patients recruited from seven countries, including South Korea, interval scans performed over a median of 3.4 years demonstrated a small increase in calcified plaque volume per annum in statin-taking compared with statin-naïve patients (progression of calcified plaque volume per annum 1.27±1.54 mm3 vs 0.98±1.27 mm3).4 However, the overall trend was towards slower rates of total plaque progression in those taking statins and this was driven by lower rates of non-calcified plaque accumulation (progression of non-calcified plaque volume per annum 0.49±2.39 mm3 vs 1.06±2.42 mm3).4 These changes are small in line with the chronic nature of atherosclerotic coronary artery disease. More advanced molecular imaging techniques have shown that metabolically active plaques undergo phenotypic transformation from a non-calcified phenotype towards a more calcified plaque.7 It is within necrotic cores of non-calcified plaques, identified on coronary CT angiography as low-attenuation regions, where the propensity of plaques to rupture is greatest.8 As such, the calcification pathways upregulated in non-calcified plaques are thought to be a protective mechanism in response to chronic inflammation. By ‘walling off’ necrotic cores, calcification may indicate a transition towards a more stable metabolic phenotype.Do these findings mean that we should stop using coronary artery calcium scores to assess coronary artery disease?.

Sung and colleagues have produced a timely manuscript that highlights the complexity of interpreting coronary artery calcium scores in patients who have implemented recommendations on physical activity or commenced on statin therapy. While proponents would argue that it is an effective tool to screen for subclinical atherosclerosis in asymptomatic individuals, clinicians should be cautious regarding the overuse of this test in otherwise healthy individuals. The coronary artery calcium paradox should not result in paradoxical care for our patients.Ethics statementsPatient consent for publicationNot required..

Sex differences in clinical management and outcomes of patients with kamagra best buy cardiovascular disease sometimes are due to healthcare inequities (which should be http://2017.berlin-conferences.com/where-can-you-get-viagra/ eliminated) but also might be due to sex-related differences in aetiology and pathophysiology. For example, the optimal medical dose kamagra best buy for management of heart failure with reduced ejection fraction (HFrEF) may be lower in women compared with men. In a study of 561 women and 615 men with a new diagnosis of either HRrEF or heart failure with preserved ejection fraction (HFpEF), Bots and colleagues1 found that although 79% of women and 86% of men with HFrEF were prescribed an ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB), the average dose was only about 50% of the recommended target dose for both sexes. A lower ACEI/ARB dose was associated kamagra best buy with higher survival outcomes in women, but not men, with HFrEF.

In patients of both sexes with HFpEF, there was no relationship between medication dose and survival (figure 1).Central figure summarising the design and main findings of this study." data-icon-position data-hide-link-title="0">Figure 1 Central figure summarising the design and main findings of this study.In the accompanying editorial, Hassan and Ahmed 2 comment that. €˜Sex differences in HF outcomes may be further exacerbated by differences in medication pharmacokinetics and pharmacodynamics, with female-specific physiological factors kamagra best buy including lower body mass, as well as decreased renal excretion and gastrointestinal enzymatic activity, leading to higher medication bioavailability. As a result, the administration of sex-neutral medication doses leads to greater drug exposure in female patients, which may subsequently lead to a higher incidence of adverse drug reactions. This raises the possibility of sex-based HF treatments kamagra best buy to improve clinical outcomes.

However, current guidelines adopt a ‘one size fits all’ approach, with an emphasis on target-dosed therapy. In this era of precision medicine, kamagra best buy is it time to redefine optimal HF therapy based on the sex of the patient?. €™On the other hand, adverse outcomes in women with infective endocarditis likely are related to bias and healthcare inequities. In a multicentric Spanish cohort of 3541 patients3 diagnosed with endocarditis between 2008 and 2018, women underwent surgical intervention less often than men kamagra best buy (38.3% vs 50%) despite the increasing recognition that earlier surgical intervention often is beneficial as recommended in current guidelines (figure 2).

The lower likelihood of surgery in women persisted after propensity matching for kamagra best buy age and surgical risk (OR 0.74. 95% CI 0.59 to 0.91. P=0.05). In addition, women had a higher in-hospital mortality compared with men, even after adjusting for possible confounders (OR 1.41.

95% CI 1.21 to 1.65. P<0.001).Stratification of the GAMES (‘Grupo de Apoyo al Manejo de la Endocarditis Infecciosa en España’ or ‘Spanish Collaboration on Endocarditis’) cohort according to surgical recommendation between sexes. Overall and stratified mortality is displayed in each group." data-icon-position data-hide-link-title="0">Figure 2 Stratification of the GAMES (‘Grupo de Apoyo al Manejo de la Endocarditis Infecciosa en España’ or ‘Spanish Collaboration on Endocarditis’) cohort according to surgical recommendation between sexes. Overall and stratified mortality is displayed in each group.Van Spall, Jaffer and Mamas4 remind us of the many factors to be considered in the decision to recommend surgical intervention in a patient with endocarditis (figure 3).

However, as they conclude. €˜Disparities in referral and receipt of surgical intervention, along with differences in aetiology, microbiology and comorbidities, may be responsible for the higher risk of mortality in women than in men with IE. Ultimately, awareness of these issues should prompt a self-evaluation of biases on the part of clinicians such that objective, timely surgical referrals are made and interventions are offered regardless of demographic group. While the biology is not modifiable, the biases and care disparities are.’Factors associated with infective endocarditis outcomes." data-icon-position data-hide-link-title="0">Figure 3 Factors associated with infective endocarditis outcomes.Another interesting paper in this issue is the study by Sung and colleagues5 showing a positive, graded association between higher levels of physical activity and a higher prevalence, with more rapid progression, of coronary artery calcification (CAC).

These findings were based on a cohort of 25 485 Korean men and women with a median interval between CAC measurements of 3 years. In discussing these seeming paradoxical findings, Gulsin and Moss6 point out that although CAC is a surrogate marker for calcified atherosclerosis and is associated with a higher risk of myocardial infarction, treatment with a statin also accelerates deposition of calcified plaque, similar to the effects of physical activity in the current study. They also remind us that. (1) the severity of CAC at baseline is a key predictor of progression rates, (2) an increase in CAC score is not the same an accelerated rate of total atherosclerotic plaque progression, and (3) the risk of plaque rupture and clinical events is greatest within the necrotic core of noncalcified plaques.

Thus, it is possible that an increase in CAC scores reflects a protective response and a transition to a more stable plaque morphology rather than more extensive atherosclerosis. They conclude. €˜Sung and colleagues5 have produced a timely manuscript that highlights the complexity of interpreting coronary artery calcium scores in patients who have implemented recommendations on physical activity or commenced on statin therapy. While proponents would argue that it is an effective tool to screen for subclinical atherosclerosis in asymptomatic individuals, clinicians should be cautious regarding the overuse of this test in otherwise healthy individuals.

The coronary artery calcium paradox should not result in paradoxical care for our patients.’The Education in Heart article7 in this issue provides an overview for clinicians to detect and manage mental issues in their patients with cardiovascular disease (CVD). There is a reciprocal relationship between mental disorders and CVD. Patients with mental disorders have a 1.5- to 3.0-fold higher risk of developing CVD and, conversely, the onset of CVD increases the risk of a developing a mental disorder by 2.2-fold.The Cardiology in-Focus topic in this issue is a step-by-step guide to writing a Image Challenge question, authored by our Image Challenge Editor.8 We encourage both cardiology trainees and clinicians to submit Image Challenge questions to Heart, using this basic guide, because this type of question accelerates learning for both the author and the reader (table 1).View this table:Table 1 Key components of an image challenge questionEthics statementsPatient consent for publicationNot applicable.Reducing the risk of plaque rupture events in individuals without a prior myocardial infarction is an imprecise science. To help clarify whether there is evidence of coronary artery disease and avoid ‘medicalisation’ of otherwise healthy individuals, international guidelines recommend incorporating the measurement of coronary artery calcium alongside risk prediction models.1 Coronary artery calcium serves as a surrogate marker of advanced calcified atherosclerosis and can be calculated from a non-contrast ECG-gated CT scan where a score of 1–99 Agatston units represents subclinical atherosclerosis, and a score of 100 or more Agatston units is considered an appropriate threshold for initiating medical therapy.1 At ≥100 Agatston units, the burden of advanced calcified atherosclerosis justifies statin implementation and this has been validated in a real-world cohort study of 16 996 subjects with a 10-year number needed to treat to prevent one cardiovascular event of 12.2 Many clinicians have advocated the benefits of coronary artery calcium in redefining the cardiovascular risk assessment of healthy individuals, as there is a strong link between high burdens of coronary artery calcium, accelerated progression of calcified plaque and the risk of future myocardial infarction.

However, if the burden of calcified plaque is an accurate barometer of cardiovascular risk, one would expect an intervention which reduces an individual’s cardiovascular risk to attenuate progression of calcified plaque. And herein lies the coronary artery calcium paradox. Both invasive and non-invasive imaging studies have consistently demonstrated that high-intensity statin therapy, an established modifier of cardiovascular risk, accelerates the deposition of calcified plaque.3 4 Is this paradoxical response of accelerated calcified plaque progression only observed in response to statin therapy?. Sung and colleagues address whether the progression of coronary artery calcium is associated with different levels of physical activity in healthy individuals.5 In a large cohort derived from two South Korean hospitals, 25 485 subjects underwent serial measurement of coronary artery calcium obtained over a median duration of 3 years and assessment of physical activity using the International Physical Activity Questionnaire Short Form.

Physical activity was graded by the investigators as. Inactive (n=11 920, 47%). Moderately active (n=9683, 38%). Or health-enhancing physically active (n=3882, 15%), equivalent to running 6.5 km/day.

Interestingly, the group performing the higher medically recommended levels of physical activity had the highest baseline burden of advanced calcified plaque (coronary artery calcium score ≥100 Agatston units. Inactive 2.8%, moderately active 3.5%, health-enhancing physically active 5.0%) which may be potentially attributable to an older demographic with higher rates of hypertension, diabetes and statin use. While it is unclear what the rationale was for undertaking health-enhancing physical activity in this cohort, it is likely that some participants with subclinical disease were doing so following medical guidance to improve control of established risk factors. Reassuringly in those with a coronary artery calcium score of zero (a low-risk group from a cardiovascular disease prevention perspective), medically recommended levels of physical activity did not accelerate the rate of coronary artery calcium progression modelled at 5 years (adjusted difference in mean coronary artery calcium score 0.32 Agatston units, 95% CI −0.15 to 0.81).

However, in those who already had subclinical or more advanced atherosclerosis, health-enhancing physical activity significantly increased the burden of calcified plaque (adjusted difference in mean coronary artery calcium score 15.02 Agatston units, 95% CI 0.56 to 29.49). Does this really mean that vigorous exercise in those with established coronary artery disease paradoxically accelerates plaque progression?. This study fuels a wider discussion of some of the key limitations regarding the use of the coronary artery calcium scan to monitor coronary artery disease progression.First, the amount of calcification measured at baseline is a key determinant of the rate of progression. As illustrated in the Heinz Nixdorf Recall study, the trajectory of plaque calcification has a strong relationship with the baseline coronary artery calcium scan.6 In asymptomatic 40 year-olds, a coronary artery calcium score ≥100 Agatston units is considered a high burden of disease and one would expect to observe exponential growth in calcification over 5 years.

In contrast, a coronary artery calcium score of zero would rarely change over the same time frame leading some investigators to label this as a ‘warranty period’ conferring coronary vascular stability. These small differences in coronary artery calcium scores at baseline become amplified over a 5-year follow-up period. Hence, the results of the study performed by Sung et al are in keeping with the main observation of the Heinz Nixdorf Recall study. Progression is almost inevitable following the onset of calcification and the rate of progression appears to be only marginally influenced by the control of traditional risk factors.6Second, an accelerated rate calcified plaque progression does not equate to an accelerated rate of total atherosclerotic plaque progression.

In this regard, the Progression of Atherosclerotic Plaque Determined by Computed Tomography Angiography Imaging study (NCT02803411) has provided valuable insight into the temporal changes in plaque composition using contrast-enhanced coronary CT angiography. In a cohort of 1255 patients recruited from seven countries, including South Korea, interval scans performed over a median of 3.4 years demonstrated a small increase in calcified plaque volume per annum in statin-taking compared with statin-naïve patients (progression of calcified plaque volume per annum 1.27±1.54 mm3 vs 0.98±1.27 mm3).4 However, the overall trend was towards slower rates of total plaque progression in those taking statins and this was driven by lower rates of non-calcified plaque accumulation (progression of non-calcified plaque volume per annum 0.49±2.39 mm3 vs 1.06±2.42 mm3).4 These changes are small in line with the chronic nature of atherosclerotic coronary artery disease. More advanced molecular imaging techniques have shown that metabolically active plaques undergo phenotypic transformation from a non-calcified phenotype towards a more calcified plaque.7 It is within necrotic cores of non-calcified plaques, identified on coronary CT angiography as low-attenuation regions, where the propensity of plaques to rupture is greatest.8 As such, the calcification pathways upregulated in non-calcified plaques are thought to be a protective mechanism in response to chronic inflammation. By ‘walling off’ necrotic cores, calcification may indicate a transition towards a more stable metabolic phenotype.Do these findings mean that we should stop using coronary artery calcium scores to assess coronary artery disease?.

Sung and colleagues have produced a timely manuscript that highlights the complexity of interpreting coronary artery calcium scores in patients who have implemented recommendations on physical activity or commenced on statin therapy. While proponents would argue that it is an effective tool to screen for subclinical atherosclerosis in asymptomatic individuals, clinicians should be cautious regarding the overuse of this test in otherwise healthy individuals. The coronary artery calcium paradox should not result in paradoxical care for our patients.Ethics statementsPatient consent for publicationNot required..