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Aims Stress echocardiography is widely used to identify obstructive coronary artery disease (CAD). High accuracy is reported in expert hands but is dependent on operator training and image quality. The EVAREST study provides UK-wide data to evaluate real-world performance and accuracy of stress echocardiography. Methods and results Participants undergoing stress echocardiography for CAD were recruited from 31 hospitals. Participants were followed up through health records which underwent expert adjudication. Cardiac outcome was defined as anatomically or functionally significant stenosis on angiography, revascularization, medical management of ischaemia, acute coronary syndrome, or cardiac-related death within 6 months. A total of 5131 patients (55% male) participated with a median age of 65 years (interquartile range 57–74). 72.9% of studies used dobutamine and 68.5% were contrast studies. Inducible ischaemia was present in 19.3% of scans. Sensitivity and specificity for prediction of a cardiac outcome were 95.4% and 96.0%, respectively, with an accuracy of 95.9%. Sub-group analysis revealed high levels of predictive accuracy across a wide range of patient and protocol sub-groups, with the presence of a resting regional wall motion abnormalitiy significantly reducing the performance of both dobutamine (P Conclusion Stress echocardiography has high accuracy across UK-based hospitals and thus indicates stress echocardiography is being delivered effectively in real-world practice, reinforcing its role as a first-line investigation in the assessment of patients with stable chest pain.

BACKGROUND: Obesity causes significant cardiac remodelling even in health, and yet the contribution of this maladaptation in the setting of an additional cardiomyopathic process is poorly understood. Cardiovascular magnetic resonance is the gold-standard tool for assessing cardiac geometry, especially in an obese population, and hence perfectly suited to investigate this important question. METHODS: Using data from our extensive imaging registry (n=1,554), we documented the relationship between increasing BMI and left ventricular (LV) remodelling in patients with dilated (DCM; n=529) and hypertrophic cardiomyopathy (HCM; n=297), compared to the normal heart (n=728). RESULTS: Regardless of cardiac status, increasing BMI resulted in similar increases in LV stroke volume (P>0.18). However, there was a difference in the degree of LV cavity dilatation associated with this change in stroke volume; when compared to normal hearts [increase in end-diastolic volume of 0.7 mL per unit of rising BMI (mL/kg/m(2))], there was a threefold greater LV cavity dilatation in DCM (+2.2 mL/kg/m(2)) and twofold greater in HCM (+1.9 mL/kg/m(2), all P

Background Phase contrast velocity mapping sequences utilising ultrashort echo time (UTE) radial k-space sequences have been used to reduce intravoxel dephasing at high velocities. We evaluated the accuracy of the UTE flow sequence for mitral regurgitation (MR) quantification, including patients with atrial fibrillation. Methods Forty patients underwent cardiac MRI for indirect MR quantification by assessment of aortic flow using a UTE phase contrast sequence (TE 0.65 ms) combined with left ventricular stroke volume. Retrospective ECG-gating was used in sinus rhythm (30 patients), prospective ECG-triggering in atrial fibrillation (10). MR was also quantified by a standard phase contrast sequence (TE 2.85 ms, standard flow method) and by comparing stroke volumes (volumetric method). Results UTE flow-derived MR measurement showed modest agreement in sinus rhythm (95% limits of agreement: ±38.2 ml; ±29.8%) and atrial fibrillation (±33.7 ml; ±30.3%) compared to standard flow assessment. There was little systematic bias in sinus rhythm (mean offset −4.4 ml /−3.5% compared to standard flow assessment), but a slight bias towards greater regurgitation in atrial fibrillation (+15.2 ml /+14.0%). There were wider limits of agreement between the UTE flow method and volumetric method than between the regular flow method and the volumetric method in sinus rhythm (±48.4 ml; ±36.4%; mean offset: −12.2 ml /−9.0%) and similar limits of agreement in atrial fibrillation (±29.6 ml; 25.8%; +12.0 ml /+10.3%). Conclusions UTE flow imaging is inferior to conventional flow techniques for MR assessment in patients with sinus rhythm as well as atrial fibrillation. However, the number of atrial fibrillation patients in this initial study is small.

For >40 years, the British Royal Air Force has maintained an aeromedical evacuation facility, the Deployable Air Isolator Team (DAIT), to transport patients with possible or confirmed highly infectious diseases to the United Kingdom. Since 2012, the DAIT, a joint Department of Health and Ministry of Defence asset, has successfully transferred 1 case-patient with Crimean-Congo hemorrhagic fever, 5 case-patients with Ebola virus disease, and 5 case-patients with high-risk Ebola virus exposure. Currently, no UK-published guidelines exist on how to transfer such patients. Here we describe the DAIT procedures from collection at point of illness or exposure to delivery into a dedicated specialist center. We provide illustrations of the challenges faced and, where appropriate, the enhancements made to the process over time.

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.

Background— Surgery for severe mitral regurgitation is indicated if symptoms or left ventricular dilation or dysfunction occur. However, prognosis is already reduced by this stage, and earlier surgery on asymptomatic patients has been advocated if valve repair is likely, but identifying suitable patients for early surgery is difficult. Quantifying the regurgitation may help, but evidence for its link with outcome is limited. Cardiovascular magnetic resonance (CMR) can accurately quantify mitral regurgitation, and we examined whether this was associated with the future need for surgery. Methods and Results— One hundred nine asymptomatic patients with echocardiographic moderate or severe mitral regurgitation had baseline CMR scans and were followed up for up to 8 years (mean, 2.5±1.9 years). CMR quantification accurately identified patients who progressed to symptoms or other indications for surgery: 91% of subjects with regurgitant volume ≤55 mL survived to 5 years without surgery compared with only 21% with regurgitant volume >55 mL ( P 40%. CMR-derived end-diastolic volume index showed a weaker association with outcome (proportions surviving without surgery at 5 years, 90% for left ventricular end-diastolic volume index 2 versus 48% for ≥100 mL/m 2 ) and added little to the discriminatory power of regurgitant fraction/volume alone. Conclusions— CMR quantification of mitral regurgitation was associated with the development of symptoms or other indications for surgery and showed better discriminatory ability than the reference-standard CMR-derived ventricular volumes. CMR may be able to identify appropriate patients for early surgery, with the potential to change clinical practice, although the clinical benefits of early surgery require confirmation in a clinical trial.

Background The benefit of cardiovascular magnetic resonance Imaging (CMR) in assessing occupational risk is unknown. Pilots undergo frequent medical assessment for occult disease, which threatens incapacitation or distraction during flight. ECG and examination anomalies often lead to lengthy restriction, pending full investigation. CMR provides a sensitive, specific assessment of cardiac anatomy, tissue characterisation, perfusion defects and myocardial viability. We sought to determine if CMR, when added to standard care, would alter occupational outcome. Methods A retrospective review was conducted of all personnel attending the RAF Aviation Medicine Consultation Service (AMCS) for assessment of a cardiac anomaly, over a 2-year period. Those undergoing standard of care (history, examination, exercise ECG, 24 h-Holter and transthoracic echocardiography), and those undergoing a CMR in addition, were identified. The influence of CMR upon the final decision regarding flying restriction was determined by comparing the diagnosis reached with standard of care plus CMR vs. standard of care alone. Results Of the ~ 8000 UK military aircrew, 558 personnel were seen for cardiovascular assessment. Fifty-two underwent CMR. A normal TTE did not reliably exclude abnormalities subsequently detected by CMR. Addition of CMR resulted in an upgraded occupational status in 62% of those investigated, with 37% returning to unrestricted duties. Only 8% of referrals were undiagnosed following CMR. All these were cases of borderline chamber dilatation and reduction in systolic function in whom diagnostic uncertainty remained between physiological exercise adaptation and early cardiomyopathy. Conclusions CMR increases the likelihood of a definitive diagnosis and of return to flying. This study supports early use of CMR in occupational assessment for high-hazard occupations. Electronic supplementary material The online version of this article (10.1186/s12968-019-0544-5) contains supplementary material, which is available to authorized users.

Coronary events remain a major cause of sudden incapacitation, including death, in both the general population and among aviation personnel, and are an ongoing threat to flight safety and operations. The presentation is often unheralded, especially in younger adults, and is often due to rupture of a previously non-obstructive coronary atheromatous plaque. The challenge for aeromedical practitioners is to identify individuals at increased risk for such events. This paper presents the NATO Cardiology Working Group (HFM 251) consensus approach for screening and investigation of aircrew for asymptomatic coronary disease.A three-phased approach to coronary artery disease (CAD) risk assessment is recommended, beginning with initial risk-stratification using a population-appropriate risk calculator and resting ECG. For aircrew identified as being at increased risk, enhanced screening is recommended by means of Coronary Artery Calcium Score alone or combined with a CT coronary angiography investigation. Additional screening may include exercise testing, and vascular ultrasound imaging. Aircrew identified as being at high risk based on enhanced screening require secondary investigations, which may include functional ischaemia, and potentially invasive coronary angiography. Functional stress testing as a stand-alone investigation for significant CAD is not recommended in aircrew. Aircrew identified with coronary disease require further clinical and aeromedical evaluation before being reconsidered for flying status.

Objectives: To assess the clinical, occupational and financial outcomes of a new Clinical Aviation Medicine Service (CAMS) for UK military personnel. Methods: Consecutive patients over a 2 year period were included. Predictors of flying restrictions at referral and final outcome following consultation were modelled using logistic regression. National Health Service (NHS) Payment by Results tariffs and Defence capitation data were used to assess the financial impact of the service. Results: Eight hundred and sixteen new referrals (94.5% male, median age 45 years (range 19–75)) were received and 1025 consultations performed. Cardiovascular disease was the commonest reason for referral. CAMS clinical activity cost at NHS tariff was £453 310 representing a saving of £316 173 (£137 137 delivery cost). In total, 310/816 (38%) patients had employment restrictions on referral and 49.0% of this group returned to full employment following their initial consultation. Compared with cardiology, general medicine and respiratory patients were more likely to have been occupationally restricted prior to referral (50 vs. 35%, OR 1.81; 95% CI 1.18–2.76, P values=0.006 and 53 vs. 35%, OR 2.12; 95% CI 1.15–3.90, P values = 0.016, respectively). Overall 581/816 (71.2%) of patients returned to unrestricted employment while 98/816 (12.0%) were unable to continue in any aircrew role. The service saved 7000 lost working days per year at an estimated occupational saving of ∼£1 million per annum. Conclusions: This bespoke service has allowed rapid, occupationally relevant clinical care to be delivered with both time and financial savings. The model may have significant occupational and financial relevance for other environmental and occupational medical organizations.

Atrial fibrillation (AF) is the most common sustained atrial arrhythmia, and increases an individual's risk of morbidity and mortality from cardiovascular and thromboembolic events. In this article, we review the pathophysiology and clinical presentations of AF and describe appropriate investigations and management likely to be appropriate for a military population, in line with current National Institute for Health and Care Excellence and European Society of Cardiology guidelines. The implications for the individual's Medical Employment Standard in the UK Armed Forces, with specific reference to specific military occupational activities such as aviation, diving and driving occupationally, are also reviewed.

Although rare, sudden cardiac death does occur in British military personnel. In the majority of cases, the cause is considered to be a malignant ventricular tachyarrhythmia, which can be precipitated by a number of underlying pathologies. Conversely, a tachyarrhythmia may have a more benign and treatable cause, yet the initial clinical symptoms may be similar, making differentiation difficult. This is an overview of the mechanisms underlying the initiation and propagation of arrhythmias and the various pathological conditions that predispose to arrhythmia genesis, classified according to which parts of the heart are involved: atrial tachyarrhythmias, atrial and ventricular, as well as those affecting the ventricles alone. It encompasses atrial tachycardia, atrial flutter, supraventricular tachycardias and ventricular tachycardias, including the more commonly encountered inherited primary electrical diseases, also known as the channelopathies. The clinical features, investigation and management strategies are outlined. The occupational impact-in serving military personnel and potential recruits-is described, with explanations relating to the different conditions and their specific implication on continued military service.

Venous thromboembolism (VTE) represents a significant preventable cause of hospital mortality. VTE assessment and prophylaxis rates are key patient safety and quality of care indicators. The aim of this study was to audit low molecular weight heparin (LMWH) and graduated elasticated compression stockings (GECS) prescriptions compared with the current Clinical Guidelines for Operations.Complete audit loop in the Role 3 Hospital, Camp Bastion, Afghanistan. A multifaceted intervention programme incorporating physician and nurse education and pre-printed medication charts was introduced to improve VTE assessment and prophylaxis rates.Only 111/301 (36.9%) of patients in the pre-intervention cohort had a VTE risk assessment performed; this improved to 142/155 (91.6%, p0.0001) post-intervention. A total of 57/88 (64.8%) patients prescribed LMWH pre-intervention had a documented assessment of bleeding risk performed; this rose to 65/66 (98.5%, p=0.0003) post-intervention. In pre-intervention, only 63/213 (29.6%) patients had a documented reassessment of VTE and bleeding risk at 24 h; reassessment rates rose to 68.8% (66/96 patients, p0.0001) post-intervention. Of those patients at risk of VTE without ongoing bleeding risk, 62/96 (64.6%) had LMWH prescribed pre-intervention; this rose to 57/62 (91.9%) post-intervention (p0.0001). Inappropriate LMWH prescription rates fell from 26/190 (13.7%) to 4/85 (4.7%, p=0.035) post-intervention. In those patients in whom GECS were not contraindicated, prescription rates rose from 23/95 (24.2%) to 42/62 (67.7%, p0.0001) post-intervention.Inclusion of pre-printed LMWH/GECS prescriptions and risk assessment stickers in the mediction chart significantly improved rates of VTE risk assessment and prophylaxis. These easily reproducible and low-cost interventions could improve patient safety on deployment.

© 2014, BMJ Publishing Group. All rights reserved. Introduction: Valvular heart disease (VHD) is an increasingly important cardiac condition, driven by an ageing population and lack of progress in the development of medical therapies. There is a dearth of accurate information to guide decision-makers in the development of strategies to combat VHD, and no population-based study has been performed specifically to investigate its contemporary epidemiology. This document describes the design and methodology of the OxVALVE population cohort study (OxVALVE-PCS), which was conceived to address this need. Methods and analysis: Participants aged 65 years and older attending a participating general practice in Oxfordshire, UK, are invited to attend a screening examination. Exclusion criteria include previously diagnosed VHD, inability to provide consent, terminal illness or excessive frailty. Demographics, a focused cardiovascular history and vital signs are recorded at the initial screening examination, accompanied by an echocardiogram. Any finding of significant VHD triggers a separate, more formal echocardiographic assessment (including acquisition of a threedimensional dataset) and collection of blood samples for future genetic and biomarker analysis. Participants provide consent for longitudinal follow-up and enrolment in future cohort substudies. We also assess the acceptability of community-based echocardiographic examination and compare self-assessed quality of life between those with and without VHD. Conclusions: OxVALVE-PCS will provide contemporary epidemiological data concerning the community prevalence of undiagnosed VHD, facilitate accurate deployment of scarce resources to meet the anticipated increase in demand for VHD-associated healthcare and create a series of subcohorts with carefully defined genotypes and echocardiographic phenotypes for long overdue clinical studies. Ethics and dissemination: This study was approved by the local research ethics committee (Southampton, UK; REC Ref: 09/H0502/58). Results: Results will be submitted for publication in peer-reviewed scientific journals.

Key Points Transthoracic echocardiography should be considered in all patients with potential valve disease Cardiac magnetic resonance provides accurate assessment of valvular function, particularly quantification of regurgitation, and accurate left ventricular mass and volumes Management

Background Valvular heart disease (VHD) is expected to become more common as the population ages. However, current estimates of its natural history and prevalence are based on historical studies with potential sources of bias. We conducted a cross-sectional analysis of the clinical and epidemiological characteristics of VHD identified at recruitment of a large cohort of older people. Method and Results We enrolled 2500 individuals aged ≥65 years from a primary care population and screened for undiagnosed VHD using transthoracic echocardiography. Newly identified (predominantly mild) VHD was detected in 51% of participants. The most common abnormalities were aortic sclerosis (34%), mitral regurgitation (22%), and aortic regurgitation (15%). Aortic stenosis was present in 1.3%. The likelihood of undiagnosed VHD was 2-fold higher in the two most deprived socioeconomic quintiles than in the most affluent quintile, and 3-fold higher in individuals with atrial fibrillation. Clinically significant (moderate or severe) undiagnosed VHD was identified in 6.4%. In addition, 4.9% of the cohort had pre-existing VHD (a total prevalence of 11.3%). Projecting these findings using population data, we estimate that the prevalence of clinically significant VHD will double before 2050. Conclusions Previously undetected VHD affects 1 in 2 of the elderly population and is more common in lower socioeconomic classes. These unique data demonstrate the contemporary clinical and epidemiological characteristics of VHD in a large population-based cohort of older people and confirm the scale of the emerging epidemic of VHD, with widespread implications for clinicians and healthcare resources.

Background— Current indications for surgery in patients with significant aortic regurgitation (AR) focus on symptoms and left ventricular dilation/dysfunction. However, prognosis is already reduced by this stage, and earlier identification of patients for surgery could be beneficial. Quantifying the regurgitation may help, but there are limited data on its link with outcome. Cardiovascular magnetic resonance (CMR) can accurately quantify AR, and we examined whether this was associated with the future need for surgery. Methods and Results— One hundred thirteen patients with echocardiographic moderate or severe AR were monitored for up to 9 years (mean 2.6±2.1 years) following a CMR scan, and the progression to symptoms or other indications for surgery was monitored. AR quantification identified outcome with high accuracy: 85% of the 39 subjects with regurgitant fraction >33% progressed to surgery (mostly within 3 years) in comparison with 8% of 74 subjects with regurgitant fraction ≤33% ( P P 246 mL had good, although lower, discriminatory ability (area under the curve 0.88), but the combination of this measure with regurgitant fraction provided the best discriminatory power. Conclusions— High degrees of CMR-quantified AR were associated with the development of symptoms or other indications for surgery. Quantifying AR showed slightly better discriminatory ability than “gold standard” CMR ventricular volume assessment. This could provide a new paradigm for the timing of surgical intervention but requires confirmation in a clinical trial.

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.

Background The morphology of the aortic valve is of increasing importance in the evaluation of patients with calcific aortic stenosis (AS). The finding of a bicuspid valve can influence the suitability for transcutaneous aortic valve implantation, the attention paid to the proximal aorta, and consideration of family screening. More recent work has also suggested that the type of bicuspid valve can provide important information for planning surgery. Methods 65 patients with moderate-severe calcific AS underwent routine clinical trans-thoracic echocardiography (Echo) by an experienced echocardiographer, followed by CMR at 1.5T. Echo was performed using the parasternal short axis view through the aortic valve. CMR was performed in a short axis view through the valve, using SSFP sequences (linear and radial k-space acquisition) and analysis undertaken independently by 2 experienced CMR practitioners. For both imaging modalities, aortic valve morphology was examined over multiple heartbeats, in systole and diastole, and classified according to the Sievers criteria. Results Echo identified 13/65 patients with bicuspid valves. Valve morphology was clearly visualised by CMR in all subjects, and agreed with all 13 identified as bicuspid by Echo. However, CMR also identified an additional 11 subjects with bicuspid aortic valves not identified by Echo (a total of 24/65; p