Background High-sensitivity troponin T (hsTNT) levels are often measured in patients who present with new-onset atrial fibrillation. The significance of an elevated hsTNT level in this clinical context has been examined at length. The implications of a normal hsTNT level in this scenario, meanwhile, are not as clearly understood. Aims We aimed to examine the rate of significant coronary artery disease at angiography, or abnormal non-invasive investigations, in those patients with newly-diagnosed atrial fibrillation who presented with a normal high-sensitivity troponin. From this data we sought to describe the negative predictive value of a normal hsTNI for significant underlying coronary disease in this population. Methods We examined all patients presenting with new-onset atrial fibrillation over a 6-month period in a single centre after the adoption of a high-sensitivity troponin assay. We identified patients who had hsTNT sent on the index presentation and who went on to have a subsequent ischaemic evaluation. We included invasive coronary angiography, CT coronary angiography, perfusion cardiac MRI, and dobutamine stress echocardiogram. We defined significant abnormalities on ischaemic assessment in accordance with accepted definitions in the literature (table 1). We examined 953 consecutive hospitalisations with atrial fibrillation over a 6-month period. Patients were initially excluded from our analysis if they had previously diagnosed atrial fibrillation or coronary artery disease, if they reported angina or if their hsTNT was elevated. We identified 38 patients suitable for assessment. 23 of these patients had not had an ischaemic evaluation at the time of our assessment, resulting in 15 patients for evaluation [figure 1]. Results All 15 patients presented with new-onset atrial fibrillation with rapid ventricular response. All ischaemic evaluations were performed within 9 months of initial presentation. 5/15 (33%) patients presented with other primary illnesses with fast atrial fibrillation as a secondary feature. The mean HR at presentation was 135bpm (SD±20). 10/15 (66%) of patients subsequently had invasive coronary angiography, while 4/15 (27%) had a perfusion cardiac MRI and 1/15 (7%) had a stress echocardiogram. 1 patient (7%) satisfied the definition of significant coronary artery disease at invasive coronary angiography despite a normal hsTNT at presentation. Angiography revealed a chronic total occlusion of the RCA with non-obstructive disease in the LAD. Of note, this patient had presented without angina in atrial fibrillation with rates up to 120bpm for over two hours. The remaining 14/15 patients (93%) had normal non-invasive assessments, normal coronary angiography or mild-moderate irregularities at coronary angiography that did not fit the criteria for significant coronary disease. We found that a normal hsTNT yielded a negative predictive value of 93% for significant coronary artery disease or abnormality at non-invasive assessment in those patients who went on to have such investigation. Conclusion In patients with new-onset fast atrial fibrillation without angina, a normal high-sensitivity troponin is associated with a low incidence of significant coronary artery disease. Further work is required to examine the negative predictive value of a normal hsTNT level for significant coronary artery disease in larger patient populations and across multiple centres.

Abstract Funding Acknowledgements Type of funding sources: None. Background The incidence of cardiomyopathy in Duchenne muscular dystrophy (DMD) increases with age, accounting for up to 20% of mortality in the third decade of life. As patients are frequently asymptomatic until advanced stages of disease, imaging plays an essential role in screening for cardiac involvement and monitoring progression. Guidelines recommend annual transthoracic echocardiography assessment, with periodic use of cardiac magnetic resonance imaging (CMR). However, some studies suggest that CMR should be the gold standard imaging in DMD. This study aimed to review the use echo and CMR in adult patients with DMD, with particular focus on practical utility and real-world limitations. Methods A retrospective chart review of 24 patients attending our DMD cardiomyopathy clinic was undertaken. Demographic data including age, genotyping and medical therapy were noted. Results of cardiac imaging, as well as discussions regarding referral for CMR were recorded. Results All patients had echocardiography performed in our facility (table 1) and all had a documented discussion regarding referral for CMR in their medical notes. 15 patients (60%) were unsuitable for CMR and were not referred. Reasons were inability to lie flat due to breathing/claustrophobia (n = 12) and difficulty with positioning due to contractures (n = 9). 2 patients (8%) attended for CMR but were unable to proceed due to difficulty with positioning in the scanner. 4 patients (16.5%) had CMR performed, 3 additional patients were referred and awaited CMR. Results outlined in table 1 and image 1 show correlation between measurement of left ventricular ejection fraction (LVEF) on echo and CMR. Wall motion abnormalities and fibrosis were better detected with CMR. Conclusion Significant limitations were seen with both imaging techniques. Accessibility of CMR for adults with DMD is poor, related primarily to the severity of underlying musculoskeletal and respiratory disease. Echocardiography is easily accessible, but images are frequently suboptimal. Despite this, strong correlation was seen in assessment of LV function in those who underwent both echocardiography and CMR, with indication that echocardiography can accurately guide intensification of medications and cardiac device therapy. CMR remains the optimal modality for the assessment of myocardial fibrosis. Improving accessibility of CMR for patients with DMD should be prioritised for the future of this modality.

Introduction Implantable Cardiac Defibrillators (ICD) are a potentially lifesaving therapy inserted for multiple indications. The indications for insertion of ICDs are stated in the European Society of Cardiology guidelines, and American Heart Association guidelines. One of the most common indications is for implantation in heart failure with reduced ejection fraction (HFrEF). These include patients with New York Heart Association (NYHA) Class I-III in patients with ischaemic cardiomyopathy (ICM) and NYHA Class II-III in patients with non-ischaemic cardiomyopathy (NICM). Purpose While ICDs are not exclusively implanted by electrophysiologists in the country of study, we hypothesised that a hospital having a dedicated electrophysiology service would lead to greater compliance with current guidelines. Methods We compared two major tertiary referral centres, one of which has the largest Electrophysiology (EP) service in the country, with the other currently having no EP physician. We obtained a list of all patients who attended the respective Heart Failure Clinics for a year from the 1st of January 2018 to the 31st of December 2018. We then excluded patients with ejection fraction (EF) of >35% by examining the relevant patients’ echocardiogram reports. Results In Heart Failure Clinic in Hospital A (with an EP service), 172 patients attending the heart failure clinic had an EF less than or equal to 35%. Of those, 116 had an ICD (67.4%); 88 with an ICD and 28 with a Cardiac Resynchronisation Therapy – Defibrillator (CRT-D). 56 patients did not have ICD/CRT. In Hospital B (without an EP service), 174 patients attending the heart failure clinic had an EF less than or equal to 35%. 83 of these patients had an ICD (47.7%). Of those, 56 had an ICD and 27 had a CRT-D. We report a significant difference of 19.7% (p=0.0002) between two large tertiary referral centres in the rate of guideline-directed ICD implantation (figure 1). Conclusion The availability of an electrophysiology service in a hospital may improve the rates of guideline-directed ICD implantation for heart failure with reduced ejection fraction. This hypothesis warrants further investigation in larger studies.

Introduction The National Clinical Programme for Acute Coronary Syndrome in Ireland has successfully improved outcomes for patients presenting with STEMI since its introduction in 2010.1 Appropriate activation of the PPCI protocol is crucial to ensure timely reperfusion for patient with STEMI, while ensuring resources are not over-utilised for patients not requiring urgent PPCI. The aim of this review therefore was to establish the current rate of appropriate activation and false activation for the PPCI service in Galway. Methods Phone records from the dedicated STEMI PPCI telephone number for the Galway PPCI centre were compared to simultaneously transmitted ECGs over a period from 01/01/2019 to 31/03/2019 inclusive (figure 1, table 1). A phone call record corresponding with a transmitted ECG for a new patient was considered activation of the PPCI protocol. These records were compared to the local STEMI database for patients transferred direct to the cardiology team for PPCI. All activations had the corresponding ECG assessed for STEMI criteria as per the ESC guidelines.Abstract 22 Figure 1 Summary of PPCI protocol activations in galway from 01/01/2019 to 31/03/2019 inclusive. Summary of PPCI protocol activations in galway from 01/01/2019 to 31/03/2019 inclusive.Abstract 22 Table 1 Summary of PPCI protocol activations for Galway 01/01/2019 to 31/03/2019 Summary of PPCI protocol activations for Galway 01/01/2019 to 31/03/2019 GRAND TOTAL NAS TOTAL HOSPITALS TOTAL ACTIVATIONS 171 127 44 STEMI CORRECTLY DIAGNOSED – MET ECG AND CLINICAL SYMPTOMS 58 (34%) 39 (31%) 19 (43%) DIRECT TRANSFER TO CARDIOLOGY 13 (8%) 7 (6%) 6 (14%) MET ESC ECG CRITERIA FOR STEMI BUT NO SYMPTOMS 61 (36%) 52 (41%) 9 (21%)  - ST ELEVATION OTHER 8 7 1  - LBBB 30 28 2  - RBBB 17 13 4  - PACED 6 4 2 DID NOT MEET ECG CRITERIA FOR STEMI AND NO SYMPTOMS 39 (23%) 29 (23%) 10 (23%)  - WELLEN’S 2 1 1  - NON-SPECIFIC 30 24 6  - NORMAL SINUS RHYTHM 7 4 3 NAS = National Ambulance Service Results 171 activations of the STEMI PPCI service were recorded from 01/01/2019 to 31/03/2019 inclusive and 71 (42%) were accepted direct to Cardiology for management: 58 patients (34%) were correctly diagnosed with STEMI, 13 patients (7%) were transferred to the direct care of the cardiology team. Five patients (3%) underwent immediate angiography and had no coronary artery disease. Of the 100 patients not transferred directly to cardiology, 61 (36%) patients had ECGs which met ESC ECG criteria2 for STEMI but did not have clinical symptoms consistent with STEMI: LBBB (n=30, 18%), RBBB (n=17, 10%), ST segment elevation (n=8, 5%), paced rhythms (n=6, 4%). 39 patients (23%) had neither ECGs consistent with STEMI nor symptoms requiring urgent transfer for PPCI: Non-specific changes or T-wave inversions (n=30, 18%), normal sinus rhythm (n=7, 5%) and Wellen’s pattern (n=2, 1%). 67 of 100 false activations occurred during on-call hours. The national ambulance service activated the PPCI protocol for 127 cases, of which 39 (31%) cases were correctly diagnosed as STEMI. 52 (39%) patients had ECGs consistent with ESC ECG criteria[2] for STEMI without symptoms and 29 (23%) had neither ECG criteria nor symptoms. In total 44 activations were received from peripheral hospitals, 19 of which were correctly diagnosed as STEMI (43%). 9 (21%) patients had ECG changes consistent with ESC ECG criteria[2] for STEMI without symptoms, and 10 patients(23%) had neither ECG criteria nor symptoms. Conclusion This review identifies important subgroups of patients who were referred for PPCI, in particular 23% of patients who did not require discussion, and 36% of patients who should have discussion with cardiology services before initiating transfer to the catheterisation laboratory.

Introduction Cardiac implantable electronic devices (CIED) are associated with low rates of procedure-related complications but many of these complications are associated with significant morbidity and prolonged hospitalisations. The aim of this study was to perform a retrospective ‘real world’ review of CIED complication rates in a tertiary centre in the West of Ireland and compare rates to a multi-centre CIED complication registry, the REPLACE registry1. Methods All patients who received a new device implant (ICD, PPM, CRT) or revision of an existing implant from 01/01/2016 to 31/12/2016 at Galway University Hospital were included (table 1). Data on complications associated with the procedure were collected from patient records including electronic discharge summaries, cardiothoracic surgery records, catheterisation laboratory log book records, patient clinical files and the pacing registry G-Pace. Complication rates were compared to the REPLACE registry1 data using the same major and minor complication criteria (table 2). Results 373 patients were included in the analysis (male = 257 (69%), female = 116 (31%)) and were followed up for an average of 28.6±7.9 months. The mean age was 73±13 years at the time of the procedure. 106 (28%) patients were transfers from peripheral hospitals and 76 (20%) of these patients returned to their referring centre on the same day. 156 (42%) patients were electively admissions, the remaining 111 (30%) patients were acutely admitted. 73 patients developed (19.6%) complications in the follow up period. Of these, 30 (8%) were early (i.e. before discharge, range 0–4 days) and the remaining 43 (11.5%,) occurred post-discharge. 12 (3%) occurred at 0–1 months, 9 (2%) at 1–3 months, 13 (3%) at 3- 12 months, and 9 (2%) >12 months. The complications with the highest rates (>1%) included lead revision (n=23, 8.6%), pneumothorax (n=8, 4.8%), device infection (n=9, 2.4%) and haematoma/swelling (all n=9, 2.4%). One patient (0.3%) died from RV perforation. Conclusion Overall the CIED major complication rate at our centre is comparable to that of the REPLACE registry1. Major complications such as lead revisions, pneumothorax, infection and haematoma were numerically higher when compared to the same study. Our findings illustrate the risk and variety of complications that can occur with these procedures and highlights the need ongoing strategies to minimise the risks of these complications.

Aims and objectives Heart Failure (HF) and Atrial Fibrillation (AF) are concomitant in many patients. They share common risk factors and can exacerbate or precipitate each other. The aim of this study was to examine the management of patients presenting to Letterkenny University Hospital who were assessed to have tachycardia-induced cardiomyopathy. Methods Patients known to the heart failure support service that had a diagnosis of tachycardia-induced cardiomyopathy were included in this review. Additionally, a HIPE search was undertaken for primary admissions for AF and secondary diagnosis of HF and the medical clinical file reviewed. Patients with known ischaemic heart disease or preserved ejection fraction HF were excluded. Data was analysed using SPSS. Results 48 patients were identified, with a mean age of 67 yrs. The majority had AF and HF diagnosed on the same admission. Hypertension was the most common comorbidity. 96% of patients had an ejection fraction (EF) of <40% at presentation. The majority of patients were appropriately anti-coagulated and had appropriate levels of HF medications (ACE-I/Beta-blockers/MRA). 44% underwent direct current cardioversion with an additional 6% reverting to sinus rhythm chemically or spontaneously. While the total group showed increased EF at one year, those who remained in SR had markedly better improvements with only 12% remaining at EF < 40% compared to 46% of those who were in AF at follow up. Conclusion Tachycardia induced cardiomyopathy is a potentially reversible cause of heart failure and when sinus rhythm is restored it resulted in substantial increases in EF. This group of patients should be identified for early rhythm control in order to improve outcomes.

The incidence of paediatric inflammatory bowel disease diagnosed before age 10 years is reportedly increasing, but national data are limited.

Aims Literature suggests a changing paediatric presentation of coeliac disease. To evaluate this in an Irish setting, we looked at our coeliac patient cohort who were linked with the dietetics service in our tertiary referral centre over a six year period. Methods Data was obtained from 195 patients, identified through our prospective dietetics database. Patients either had elevated TtG or positive histology. Screening reasons included failure to thrive (n = 17), Low iron (n = 19). Gastrointestinal symptoms were highly reported with Vomiting (n = 31), abdominal pain (n = 135), constipation (n = 60), diarrhoea (n = 76). Results Diagnostic bloods and biopsies in this group were as follows (see Table 1). Of note, the patients with a positive biopsy with TtG < 7 (n = 19) presented with gastrointestinal complaints: diarrhoea (n = 13), constipation (n = 10) abdominal pain (n = 14) and vomiting (n = 1) often a combination. Anthropometry at diagnosis (n = 132,%) revealed BMI average of 17.85. Considering BMI variances this places our children within normal-higher ranges. BMI centiles were obtained in 123 (62%) findings are as follows (see Table 2): Based on this initial data we conducted a chart review on our biopsy positive patients over an 18 month period. Anthropometry again showed healthy weights, with BMI calculated in 45% (n = 25), the average of which was 15.655. Weight centiles showed highest distribution in the 50–75th centile (n = 10) and 90–98th (n = 8). Interestingly pre-diagnosis 32%of this group were documented to have Gastrointestinal symptoms. TTG was elevated in 90%, indicating high level of opportunistic screening. Conclusions The majority of our patients demonstrated a normal-high BMI. Only one patient had negative biopsies with tTg > 70. This patient would have been excluded from biopsy based on current NICE guidelines.

Recent studies have shown a worldwide prevalence of coeliac disease (CD) of around 1% and one of the highest prevalence rates (1 in 300) has been found in the West of Ireland. 1,2 The incidence of coeliac disease appears to be increasing. For example, a greater than 6-fold increase over a 20 year period was evident in a recent retrospective Scottish study. 3 Children with selective IgA deficiency, Down syndrome, Type I diabetes mellitus and autoimmune diseases are at increased risk of CD. Those with a family history are particularly vulnerable with as many as 1 in 10 first-degree, and 1 in 40 second-degree relatives affected. 1 The presenting features of coeliac disease are heterogeneous. The most commonly described symptoms include diarrhoea, excessive flatulence, weight loss, failure to thrive, abdominal distension, pain, bloating, vomiting and anorexia. Irritability is a particularly consistent finding in symptomatic coeliac disease in childhood and CD can also present with many other systemic symptoms such as iron deficiency, anaemia, fatigue, short stature, abnormal liver enzyme tests, osteopenia and dermatitis herpetiformis. However, it must also be remembered that the vast majority of affected individuals manifest few or no symptoms at all. 1 The reference standard for the diagnosis of coeliac disease has been the demonstration of histological changes of villous atrophy, crypt hyperplasia and increased intraepithelial lymphocytes in the small intestinal mucosa, as defined by the Marsh criteria.However, the diagnostic criteria for CD have evolved over the past two decades with the availability of newer and better serological assays. The necessity for a confirmatory biopsy in all situations recently has been challenged. 4,5 The European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines continue to recommend IgA anti-tTG (tissue transglutaminase) antibodies as the first line test in all symptomatic children. However, ESPGHAN now propose that in a genetically (HLA) susceptible symptomatic child with tTG of at least 10 times the upper limit of normal, with a positive anti-endomysial antibody (EmA) result and appropriate response to gluten free diet, a confirmatory small intestinal biopsy is no longer needed. 6 HLA testing (for the HLA DR3-DQ2 and DR4-DQ8 haplotype) of non-symptomatic at-risk patients also is recommended as, in the absence of these haplotypes, coeliac disease is very unlikely. Some national bodies have already introduced these criteria into their CD diagnostic pathway. 7,8 Against this background, the findings of a large multinational prospective study on the risk of coeliac disease for children with risk HLA haplotypes by Liu et al 9 is of some interest. The TEDDY (The Environmental Determinants of Diabetes in the Young) study group was formed in 2007 for follow up of children at high genetic risk of Type 1 diabetes (T1DM) who were prospectively enrolled at birth in Sweden, Finland, Germany and the USA. Development of CD was a secondary outcome in the TEDDY study as the major HLA genotypes that confer risk of T1DM also impart a similar risk for CD. More than 6000 children carried one of the four HLA genotypes and had serological screening with tTG. The estimated cumulative risks for development of CD autoimmunity (ie. positive tTG antibodies) and overt coeliac disease by 5 years in those with two copies of HLA DR3-DQ2 were 26% and 12%, respectively. Similarly, the risks were 11% and 3% respectively for those with a single copy of that HLA DQ2 haplotype. Both these results were highly statistically significant (p=<.001). 9 The findings of this study are not truly novel but rather confirm and extend those of previous studies regarding the effects of HLA on the risk of coeliac disease.The authors propose that their results might help inform future studies on population screening. Given that 25% of the children homozygous for DR3-DQ2 in the study cohort developed CD before 5 years of age, on the face of it this suggestion appears not unreasonable. However, it is important to remember that this study did not address many fundamental factors around the appropriateness and effectiveness of population screening. For example, it did not compare the relative effects of the various risk HLA haplotype combinations on the development of coeliac disease within a normal population and did not address issues such as cost effectiveness, efficacy of HLA-based screening compared with other tests or the acceptability of gluten exclusion for screen-positive asymptomatic patients. HLA-based stratification for screening purposes would pose particular challenges for Irish children because HLA DQ2 and DQ8 are very frequently found in our population. 10 In fact, many practitioners, including our group at the National Referral Centre for Paediatric Gastroenterology, do not use HLA testing in our algorithm for testing in coeliac disease. We continue to rely on targeted testing using tTG antibodies and total IgA (the latter to exclude the false negative results in coeliac patients who have IgA deficiency) where there is clinical suspicion and in at-risk groups. Although CD diagnosis without resorting to biopsy may be considered in very limited clinical circumstances we await the results of prospective studies underway to confirm the reliability of non-biopsy based diagnosis of coeliac disease before embracing this approach more widely. J Kutty, S Hussey, AM Broderick, S Quinn, B Bourke National Referral Centre for Paediatric Gastroenterology, Our Lady’s Children’s Hospital, Crumlin, Dublin 12 Email: billy.bourke@ucd.ie

63% female, 63% Chinese).Median (range) age at diagnosis was 3.5 (1 5) years.UC was more common (63%) in EO-IBD, with 60% having extensive involvement (E3).Pan-colonic involvement and proctitis were seen in 83% (6 11 year-olds) and 57% (12 18 year-olds).CD was more common in lateronset disease: 66.7% (6 11 year-olds) and 53.3% (12 18 yearolds).Upper gastrointestinal tract involvement was seen in 37% of CD. 32% of CD had growth delay at presentation.32.2% of children with CD achieved remission with enteral nutrition alone.All other patients required a combination of steroids and immunomodulators with one child needing Adalimumab & thalidomide.A higher proportion of younger patients experienced relapse requiring repeat steroid therapy. Conclusion:We have seen a four-fold rise in paediatric IBD over the last five years.Early onset IBD appears to exhibit more extensive disease. P-022What is the difference between early-onset pediatric ulcerative colitis and late-onset pediatric ulcerative colitis?A single center experience in Japan

Aims To describe the change in incidence of paediatric inflammatory bowel disease (IBD) observed at the National Centre for Paediatric Gastroenterology, Hepatology and Nutrition, and to determine whether the presenting disease phenotype and disease outcomes have changed during the past decade.Methods The annual incidence of IBD in Irish children aged <16 years was calculated for the years 2000-2010. Two subsets of patients, group A (diagnosed between 1 January 2000 and 31 December 2001), and group B (diagnosed between 1 January and 31 December 2008) were phenotyped according to the Paris Classification. Phenotype at diagnosis and 2-year follow-up were then compared.Results 406 new cases of IBD were identified. The incidence was 2.5/100 000/year in 2001, 7.3 in 2008 and 5.6 in 2010, representing a significant increase in the number of new cases of Crohn's disease (CD) and ulcerative colitis (UC). There were 238 cases of CD; 129 of UC; and 39 of IBD unclassified. Comparing groups A and B, no differences were found in disease location at diagnosis or, for CD, in its behaviour.Conclusions There has been a substantial and sustained increase in the incidence of childhood UC and CD in Ireland over a relatively short period of time. However, disease phenotype at diagnosis has not changed. At 2 years follow-up, CD appears to progress less frequently than in some neighbouring countries. These variations remain unexplained. Prospective longitudinal studies will help to elucidate further the epidemiology of childhood IBD.

Background Cyclical vomiting syndrome (CVS) is a disorder that affects all ages and is characterized by episodes of severe nausea and vomiting with symptom-free intervals between episodes. The incidence in children is 3.15/100 000 children per year. Our objective was to evaluate the natural history of CVS and examine factors that predict symptom resolution. Methods Thirty newly diagnosed children (mean 9.15 years, SD 3.31 range 3.515.7) were enrolled. All children had a follow-up interview at 3 months, 27/30 at 6 months, and 22/30 at 9 months. Key Results Following diagnosis of CVS, only 5/22(22.7%) children had no further episodes of vomiting at 9 months, whereas 17/22 (77.3%) continued to vomit. In the year prior to diagnosis, 15/30 (50%) children were admitted to hospital. Of the 22 children with follow-up for 9 months, only one child required hospital admission. Children who continued to vomit had higher internalizing scores on CBCL compared with those who stopped vomiting (P = NS). The Pediatric Quality-of-Life Score suggested those who continued to vomit had a poorer quality of life at diagnosis compared with those who stopped vomiting (P < 0.05). Conclusions & Inferences Making a positive diagnosis of CVS and providing families with information is very important in the management of CVS. Although 75% of children reported regular episodes of vomiting 9 months after diagnosis, there was a significant reduction in the frequency and severity of symptoms in addition to a marked reduction in the use of medical services.