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This manuscript focuses on the broad aviation medicine considerations that are required to optimally manage aircrew with established coronary artery disease (CAD) without myocardial infarction (MI) or revascularisation (both pilots and non-pilot aviation professionals). It presents expert consensus opinion and associated recommendations and is part of a series of expert consensus documents covering all aspects of aviation cardiology.Aircrew may present with MI (both ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI)) as the initial presenting symptom of obstructive CAD requiring revascularisation. Management of these individuals should be conducted according to published guidelines, ideally with consultation between the cardiologist, surgeon and aviation medical examiner. Return to restricted flight duties is possible in the majority of aircrew; however, they must have normal cardiac function, acceptable residual disease burden and no residual ischaemia. They must also be treated with aggressive cardiac risk factor modification. Aircrew should be restricted to dual pilot operations in non-high-performance aircraft, with return to flying no sooner than 6 months after the event. At minimum, annual follow-up with routine non-invasive cardiac evaluation is recommended.

This manuscript focuses on the broad aviation medicine considerations that are required to optimally manage aircrew with suspected or confirmed heart muscle disease (both pilots and non-pilot aviation professionals). ECG abnormalities on aircrew periodic medical examination or presentation of a family member with a confirmed cardiomyopathy are the most common reason for investigation of heart muscle disease in aircrew. Holter monitoring and imaging, including cardiac MRI is recommended to confirm or exclude the presence of heart muscle disease and, if confirmed, management should be led by a subspecialist. Confirmed heart muscle disease often requires restriction toflying duties due to concerns regarding arrhythmia. Pericarditis and myocarditis usually require temporary restriction and return to flying duties is usually dependent on a lack of recurrent symptoms and acceptable imaging and electrophysiological investigations.

Valvular heart disease (VHD) is highly relevant in the aircrew population as it may limit appropriate augmentation of cardiac output in high-performance flying and predispose to arrhythmia. Aircrew with VHD require careful long-term follow-up to ensure that they can fly if it is safe and appropriate for them to do so. Anything greater than mild stenotic valve disease and/or moderate or greater regurgitation is usually associated with flight restrictions. Associated features of arrhythmia, systolic dysfunction, thromboembolism and chamber dilatation indicate additional risk and will usually require more stringent restrictions. The use of appropriate cardiac imaging, along with routine ambulatory cardiac monitoring, is mandatory in aircrew with VHD.Aortopathy in aircrew may be found in isolation or, more commonly, associated with bicuspid aortic valve disease. Progression rates are unpredictable, but as the diameter of the vessel increases, the associated risk of dissection also increases. Restrictions on aircrew duties, particularly in the context of high-performance or solo flying, are usually required in those with progressive dilation of the aorta.

This article focuses i on the broad aviation medicine considerations that are required to optimally manage aircrew ii with suspected or confirmed congenital heart disease (both pilots and non-pilot aviation professionals). It presents expert consensus opinion and associated recommendations and is part of a series of expert consensus documents covering all aspects of aviation cardiology. This expert opinion was born out of a 3 year collaborative working group between international military aviation cardiologists and aviation medicine specialists, as part of a North Atlantic Treaty Organization (NATO) led initiative to address the occupational ramifications of cardiovascular disease in aircrew (HFM-251) many of whom also work with and advise civil aviation authorities.

This manuscript focuses on the broad aviation medicine considerations that are required to optimally manage aircrew following non-coronary surgery or percutaneous cardiology interventions (both pilots and non-pilot aviation professionals). Aircrew may have pathology identified earlier than non-aircrew due to occupational cardiovascular screening and while aircrew should be treated using international guidelines, if several interventional approaches exist, surgeons/interventional cardiologists should consider which alternative is most appropriate for the aircrew role being undertaken; liaison with the aircrew medical examiner is strongly recommended prior to intervention to fully understand this. This is especially important in aircrew of high-performance aircraft or in aircrew who undertake aerobatics. Many postoperative aircrew can return to restricted flying duties, although aircrew should normally not return to flying for a minimum period of 6 months to allow for appropriate postoperative recuperation and assessment of cardiac function and electrophysiology.

Cardiovascular diseasesiare the most common cause of loss of flying licence globally, and cardiac arrhythmia is the main disqualifier in a substantial proportion of aircrew. Aircrewiioften operate within a demanding physiological environment, that potentially includes exposure to sustained acceleration (usually resulting in a positive gravitational force, from head to feet (+Gz)) in high performance aircraft. Aeromedical assessment is complicated further when trying to discriminate between benign and potentially significant rhythm abnormalities in aircrew, many of whom are young and fit, have a resultant high vagal tone, and among whom underlying cardiac disease has a low prevalence. In cases where a significant underlying aetiology is plausible, extensive investigation is often required and where appropriate should include review by an electrophysiologist. The decision regarding restriction of flying activity will be dependent on several factors including the underlying arrhythmia, associated pathology, risk of incapacitation and/or distraction, the type of aircraft operated, and the specific flight or mission criticality of the role performed by the individual aircrew.

ObjectiveCardiac auscultation is a key clinical skill, particularly for the diagnosis of valvular heart disease (VHD). However, its utility has declined due to the widespread availability of echocardiography and diminishing emphasis on the importance of clinical examination. We aim to determine the contemporary accuracy of auscultation for diagnosing VHD in primary care.MethodsCardiac auscultation was undertaken by one of two experienced general practitioners (primary care/family doctors) in a subset of 251 asymptomatic participants aged >65 years undergoing echocardiography within a large community-based screening study of subjects with no known VHD. Investigators were blinded to the echocardiographic findings. Newly detected VHD was classified as mild (mild regurgitation of any valve or aortic sclerosis) or significant (at least moderate regurgitation or mild stenosis of any valve).ResultsNewly identified VHD was common, with mild disease in 170/251 participants (68%) and significant disease in 36/251 (14%). The sensitivity of auscultation was low for the diagnosis of mild VHD (32%) but slightly higher for significant VHD (44%), with specificities of 67% and 69%, respectively. Likelihood ratios were not statistically significant for the diagnosis of either mild or significant VHD in the overall cohort, but showed possible value for auscultation in non-overweight subjects (body mass index 2).ConclusionCardiac auscultation has limited accuracy for the detection of VHD in asymptomatic patients and is a poor diagnostic screening tool in primary care, particularly for overweight subjects. Ensuring easy access to echocardiography in patients with symptoms suggesting VHD is likely to represent a better diagnostic strategy.

Introduction The Armed Forces places considerable occupational demands on its workforce. Cardiovascular disease (CVD) remains a common cause of death and premature discharge. Simple CVD screening is performed periodically throughout the careers of service personnel, particularly in those in high risk roles such as aircrew. Abnormalities commonly require investigation with advanced cardiovascular imaging. Methods A retrospective cohort analysis of all military CMR requests to two military cardiologists was undertaken to determine demographics, reason for referral, results of investigation and occupational outcome. Results Between 2011 and 2015, fifty-six patients (95% male, median age 44 years) were referred for CMR. The commonest indications were abnormal echocardiography (21%), ventricular ectopy (16%), suspicion of cardiomyopathy (13%) and other asymptomatic ECG abnormalities (T wave inversion (11%) and bundle branch block (7%)). Of the CMR scans performed, 25% demonstrated features confirming cardiomyopathy (25% dilated and 12.5% hypertrophic phenotype). CMR features of athletic heart were seen in 11% of scans, and considered potentially suggestive of early cardiomyopathy. A quarter of patients had significant late gadolinium enhancement, in a variety of pathological patterns. Adenosine stress imaging was performed in 21% of patients, a quarter of which demonstrated perfusion abnormalities. Whilst 30% of patients were able to return to unrestricted duties following CMR, 70% required occupational restriction, mostly in aircrew. Of these 18% were unable to fly pending further review, 36% were deemed unfit to fly solo, and 7% had restrictions placed on their ability to deploy on overseas operations. Conclusion CMR is a valuable tool in the investigation of military personnel, and a useful adjunct to determine occupational, as well as clinical, risk. With the recent introduction of more rigorous CVD screening to join the Army, and the importance of comprehensive risk assessment in aircrew, the use of CMR in this population is likely to increase.

Background The timing of valve surgery in asymptomatic patients with significant aortic regurgitation can be challenging. Current indications focus on symptoms and left ventricular (LV) dilation/dysfunction, but prognosis is already reduced by this time. Quantification of the regurgitation has not previously been used to guide management, likely due to the difficulty of achieving this with echocardiography. Cardiovascular magnetic resonance (CMR) can accurately quantify aortic regurgitation and LV volumes, and we examined whether either could predict symptom development and the need for aortic valve surgery. Methods 94 asymptomatic patients with moderate or severe aortic regurgitation on echocardiography were identified from four high volume CMR centres. CMR scans were performed to quantify aortic regurgitation and LV volume indices, and subsequent clinical follow-up occurred for up to 7 years (mean 2.6±2.1 years). The best predictors of progression to symptoms and other conventional indications for surgery were determined. Results Aortic regurgitant fraction was the best predictor of clinical outcome; area under the curve (AUC) on receiver operating characteristics analysis 0.93 (p 38 mls and regurgitant volume index >25 ml/m 2 were also good predictors (AUC 0.91 and 0.90 respectively), though regurgitant fraction had significantly greater predictive power (OR 1.26 compared to 1.09 for regurgitant volume). LV volumetric indices also predicted outcome, but less strongly than measures of regurgitation: LV end-diastolic volume >267 mls (AUC 0.85), LV end-systolic volume >88 mls (AUC 0.78). Regurgitant fraction and volume were the only independent outcome predictors on multiple logistic regression analysis. The predictive ability of CMR applied to patients with both moderate and severe aortic regurgitation on echocardiography. Supporting data also comes from a comparison with patients already planning to undergo surgery at the time of CMR scanning, which showed similar regurgitant fractions in the surgical group (mean ±SD: 45.4%±12.1%) compared to the initially asymptomatic patients who developed symptoms or other indications for surgery (42.8%±10.4%); p=0.32. Subjects who remained asymptomatic had a significantly lower regurgitant fraction: 25.3±8.6% (p Conclusions CMR quantification of aortic regurgitation and LV volumes accurately predicts the progression to symptoms/surgery. Its use in patients with aortic regurgitation should be encouraged.

Background Bicuspid aortic valves (BAV) are a common inherited abnormality with a very high rate of adverse cardiac events at an earlier age than tricuspid aortic valves (TAV). Risk stratification for moderate to severe aortic stenosis, in both bicuspid and tricuspid disease, remains a significant clinical challenge. It is unknown whether pathological left ventricular (LV) remodelling, a strong predictor of adverse cardiac events, differs between patients with bicuspid and tricuspid valvular disease with comparable transvalvular gradients. Cardiovascular magnetic resonance (CMR) tagging provides detailed characterisation of global and regional contractility, and is a powerful investigative tool in the assessment of myocardial disease. We therefore assessed left ventricular strain (using CMR tagging), valve morphology and LV hypertrophy in patients with bicuspid and tricuspid aortic valve disease matched for transvalvular gradient. Methods 42 subjects were recruited in total: 24 patients with moderate to severe BAV (age 55 ±15 yrs, female 21%, peak trans-aortic velocity 3.1±0.6/ms, LV mass 172±48 g; SBP 127 ±14 mm Hg DBP 76 ±10 mm Hg) and 18 patients with velocity-matched TAV (age 74 ±6 years, female 28%, velocity 3.1±0.6/ ms, LV mass 147±27 g; SBP 136±17 mm Hg; DBP 79±7 mm Hg; Abstract 166 table 1). Patients were scanned using a 1.5 T Avanto scanner (Siemens Healthcare, Erlangen, Germany) and basal, mid-ventricular and apical short axis tagging images were acquired. Peak systolic global circumferential strain was calculated at each ventricular level using CimTag2D software v.7 (Auckland MRI Research Group, New Zealand). Results Patients with BAV had significantly greater left ventricular hypertrophy (BAV 172 ±48 g vs TAV 147±27 g; p=0.04) despite similar degrees of valve stenosis. Peak systolic circumferential strain was lower (ie, reduced contractility) in patients with BAV than TAV (Basal BAV 20±3% vs TAV 22±3% P=0.04; Mid BAV 19 ± 2% vs TAV 21 ± 2% p=0.07; apical BAV 17±4% vs TAV 19±3%; p Conclusion Ventricular remodelling differs between BAV and TAV patients with equivalent transvalvular gradients. BAV patients, despite being younger and having lower systolic blood pressure, have more severe hypertrophy and lower myocardial contractility. This finding may have implications for monitoring disease progression or more timely medical or surgical intervention in patients with BAV.

Introduction Valvular heart disease (VHD) is poorly researched in comparison with other areas of cardiovascular disease. Principle limitations are the diverse nature of patients with VHD, inability to identify individuals at the earliest stages of disease and lack of an appropriate investigational infrastructure. Studies addressing the contemporary epidemiology and natural history of VHD are scarce but demonstrate an increasing prevalence in the elderly, associated with significant morbidity and mortality. Cohort studies in the USA are ongoing but there are no European or UK studies to date. We have developed a large scale, prospective community echocardiographic screening study within the adult Oxfordshire population, to determine the epidemiological characteristics of VHD in the UK for the first time, to assess the acceptability of echocardiographic screening for VHD, and establish cohorts with well-characterised genetic and echocardiographic phenotypes for future study. Herein, we present preliminary data for the first 1050 patients, with enrolment ongoing. Methods Patients >65 years, registered with participating general practices (GP) and with no known VHD, were invited to attend their GP surgery where routine demographic and cardiac data were collected and a focused examination undertaken. Participants underwent a standard transthoracic echocardiogram (TTE) according to British Society of Echocardiography guidelines. The threshold for inclusion in the screen positive group was deliberately low to capture all manifestations of VHD. Participants were given preliminary results, before completing a shortened Spielberger STAI questionnaire. Results Uptake was 46% (age range 65–96 years; male to female ratio 1:1.1). VHD was detected in 33% of participants and prevalence increased with increasing age (see Abstract 165 figure 1). Mitral regurgitation and aortic regurgitation were the most common lesions detected (present in 17% and 14% respectively). The majority of VHD was graded as mild (84%); only 1% of VHD detected was severe. The majority of participants (99%) described themselves as calm or relaxed at the time of screening; none expressed significant levels of worry or tension. 98% would be prepared to undergo repeat echocardiography as screening for VHD. Conclusions The prevalence of VHD in adults aged over 65 in the Oxfordshire population, using a low threshold for detection, is approximately 33% and increases with age. Mitral regurgitation is the most common lesion, and the majority of detected VHD is mild. Echocardiographic screening for VHD is feasible in the primary care setting and acceptable in this group of patients.