Abstract Background/Introduction Recent guidelines and randomised controlled trials have proposed less frequent use of invasive strategies for patients with stable chest pain, and demonstrated the non-inferiority of an initial medical management strategy. However, the impact of these updates on clinical practice in the United Kingdom has not been previously reported. Purpose We aimed to identify if recent guidelines and literature have changed the management of patients being referred for stress echocardiography to assess inducible ischaemia in a real-world, multi-centre national healthcare system, and determine if this has significantly impacted patient outcomes. Methods Patients were recruited to the EVAREST/BSE-NSTEP prospective cohort study between 2015 and 2023 across the UK as part of two phases (phase 1: Mar 2015-Sep 2020; phase 2: Oct 2020-Sep 2023). Patient demographics, and stress echocardiogram procedural details were collected by study team members at each participating hospital, and 1 year medical outcome data was collected via the Data Access Request Service from NHS England. Patient management decisions and outcomes including referral for invasive coronary angiography, mortality, and cardiovascular events were compared between recruitment phases using Kaplan-Meier analysis and Cox proportional hazard ratios. Results 5,082 participants were included in this analysis of patient management and outcomes (2,613 in phase 1, and 2,469 in phase 2), with a consistent age, sex, and BMI between recruitment cohorts. There was a higher rate of smoking and hypercholesterolaemia in phase 2 participants, but a decrease in hypertension and peripheral vascular disease (Table 1). There was a decrease in referral rate for invasive angiography for participants with a positive stress echocardiogram in phase 2 (p<0.05; Fig. 1B). Overall, participants in phase 2 had a higher rate of mortality (p<0.01) than those in phase 1, but there was no difference in cardiac event rate between phases (Fig. 1C-F). These results remained consistent after adjusting for covariates, with a reduced hazard ratio for invasive angiography in phase 2 participants who had a positive stress echocardiogram (HR 0.78, 95% CI 0.66-0.92, p<0.01). Additionally, phase 2 participants had an increased hazard ratio for mortality (HR 1.93, 95% CI 1.05-3.55, p<0.05), but no significant increase in risk of cardiac event (HR 0.69, 95% CI 0.43-1.12, p=0.13). Conclusions Since 2020, participants are being less frequently referred for invasive coronary angiography after stress echocardiography possibly in favour of an initial medical management strategy. However, this reduction in referral to coronary angiography does not appear to have a negative impact on patient health as measured by cardiac event rate.

Abstract Background/Introduction EVAREST is a large-scale prospective, multicenter, observational study evaluating the use and accuracy of stress echocardiography (SE) in patients recruited from 31 NHS hospitals. Purpose Sub-study analysis to assess whether SE practice and outcome varies with age of patients. Methods Patients were recruited sequentially on attendance at the SE clinic between March 2015 and March 2020. Differences in SE characteristics and outcomes were compared between two age groups separated by the median age of the study population into Younger and Older patients. Results We studied 7846 pts with a median age for all pts of 66 yrs. The mean age in the Younger Group was 55 (range 20-65) years and in the Older Group was 74 (range 66-94) years. An abnormal SE response occurred more commonly in the Older Group (19% vs 13%, p<0.001). Key demographic and risk factors that differed between groups were a higher proportion of females in the Older Group (2185 male, 1769 female) compared to the Younger group (2255 male, 1626 female), p=0.011, higher mean BMI in the Younger Group (29.61±5.8 vs 28.1±5.2 kg/m², p<0.001) and lower resting pulse pressure in the Older Group at 56.3±15.9 (95%CI 55.8-56.8) compared to 65.9±16.6 (95%CI 65.3-66.4), p<0.001. Exercise test was performed more commonly in the Younger Group compared to the Older Group (39% vs 23%, p<0.001). For those undergoing dobutamine stress, atropine was used more commonly in the Younger Group (36% vs 34%, p<0.001). However, dobutamine dosing was similar between groups, with the highest dose (40 µg/kg/min) achieved in 13% of the Younger Group and 14% of the Older Group, p=0.05. Ultrasound contrast was used less frequently in the Older Group (73% vs 70%, p=0.03) compared to the Younger group, (p<0.001). Complication rates were similar between groups with the Older Group having a lower peak SBP (150.7±29.3 (95%CI 149.7-151.7) vs 154.9±30.3 mm Hg (95%CI 153.8-155.9), p<0.001) and similar rates of an exaggerated BP response (defined as a peak SBP ≥220 mm Hg) evident in both groups (20% of the Younger Group compared to 21% of the Older Group, p=0.55). A low BP response (defined as peak systolic blood pressure <120 mm Hg) occurred in 8% of the Younger Group and 11% of the Older Group (p=0.001), while a severe hypotensive response (peak SBP<82 mm Hg) was very rare and occurred 0.31% of the Younger Group and 0.56% of the Older Group (p=0.09). Conclusions Stress echocardiography is being performed in patients with a wide age range from 20 to 94 years of age within the UK. Older patients undergoing stress echocardiography are more likely to be female and have a relatively lower cardiovascular risk profile. Delivery of stress echocardiography differs significantly with age, with lower contrast use and more frequent use of dobutamine. However, there is no evidence of higher rates of complications in older patients that might limit use of stress echocardiography in older populations.

Stress echocardiography is a key imaging modality for assessing coronary artery disease in the UK. Traditionally, stress echo services were led by consultant cardiologists, but evolving workforce models have increased the involvement of cardiac physiologists and scientists. This study, as part of the National Review of Stress Echocardiography Practice (BSE N-STEP), aimed to evaluate current stress echo workforce structures and test outcomes across a group of UK hospitals to inform future workforce planning. Data were analysed from 8506 stress echocardiograms, conducted between September 2020 and June 2023 across 34 UK hospitals. Based on the supervising workforce, stress echocardiograms were allocated into either a doctor-led (DL) or cardiac physiologist/scientist and nurse-led (CNL) model. 56.9

Abstract Introduction The British Society of Echocardiography National Review of Stress Echo Practice (BSE N-STEP) is a large, prospective, multicentre study investigating stress echocardiography (SE) practice within the UK National Health Service. We used this dataset to identify, categorise and compare the characteristics of the workforce groups delivering SE within this real-world study cohort. Method Recruitment occurred between September 2020 and June 2023 across 34 NHS trusts. All patients provided informed consent and underwent SE following the local policy of each trust. Baseline characteristics of participants and details of SE procedure were recorded including stress modality and test outcome data. In addition, workforce involved in delivery of each test was self-reported including a description of staff responsible for test delivery, reporting and overall test supervision. Based on this, studies were categorised as either doctor-led (DL) which included both consultants and doctors in training, or cardiac physiologist/nurse-led (CNL). Frequency data was reported for each workforce group with Chi-square analysis used to identify differences between categorical variables. Results Data from 8506 patients were included in this analysis. SE supervision was identified as DL in 4839 (56.9%) and CNL in 3636 (42.7%) of which 79% was supervised by a cardiac physiologist. 28 hospitals reported both DL and CNL services. CNL services tended to be within higher volume centres, so that 4 trusts (two regional hospitals and two tertiary) contributed 71% of the total SE activity. Patients in CNL services were of similar age compared to DL service but were more likely to be male (p=0.008) and had a higher risk factor profile including hypertension (54.9% vs 50.1%), hypercholesterolaemia (50.3% vs 39.6%), and diabetes (24.9% vs 18.8%) (p=<0.001). The proportion of patients seen for ischaemic heart disease tests was similar between DL and CNL clinics (89.1% vs 89.7%, p=ns) but CNL services performed more viability (0.8% vs 1.2%, p= 0.04) and pre-op studies (2.6% vs 3.4%, p= 0.03). DL services more commonly performed dobutamine stress studies (63.0% vs 56.3%, p=<0.001) whilst the CNL group performed more exercise SE (42.8% vs 36.4%, p=<0.001). Positivity rates for SE were similar across DL and CNL groups (17.1% vs 17.7%) as were inconclusive/ abandoned tests (3.8% vs 3.6%, p=ns). However, there was a lower rate of reported complications in the CNL services (2.2% vs 5.3% (p= <0.001). Discussion: Supervision of SE testing has traditionally been led by cardiologists with nursing and physiologist staff acting in supporting roles. This study demonstrates that the UK SE workforce is evolving, with non-medical-led services contributing significantly to the volume of SE activity although clear differences in the test modality remain between DL and CNL services at present.

AIMS:To assess the real-world impact of updated clinical guidelines and literature on the management of patients undergoing stress echocardiography for the assessment of inducible ischaemia across a national health service. METHODS AND RESULTS:A total of 13 819 patients from 32 UK hospitals, referred for stress echocardiography between 2015 and 2023, were analysed across two phases: phase 1 (2015-2020) and phase 2 (2020-2023). Follow-up data for 1 year was available for 4920 participants through NHS Digital. Patients in phase 2 were younger and presented with a higher cardiovascular risk profile, although sex distribution remained similar across phases. There was an observed reduction in invasive angiography referrals within 1 year following a positive stress echocardiogram (P < 0.01), which appeared to be attributed to changes in the management of patients with moderate ischaemia (3-4 segments; P < 0.01). For those who did receive invasive assessment, there were no changes in intervention rate (P = 0.27), regardless of ischaemic burden. This trend was most evident in centres performing a higher volume of stress echocardiograms. CONCLUSION:Coronary disease management pathways have changed within the UK and fewer patients with moderate ischaemia are undergoing invasive coronary angiography. However, coronary intervention rates are unchanged, suggesting that stress echocardiography is being used to improve patient selection for invasive procedures while minimizing unnecessary referrals. Future work will assess if this reduction in angiography referrals is maintained long term, and if there are any effects on patient outcomes.

Impairment of left ventricular (LV) diastolic function is common amongst those with left heart disease and is associated with significant morbidity. Given that, in simple terms, the ventricle can only eject the volume with which it fills and that approximately one half of hospitalisations for heart failure (HF) are in those with normal/’preserved’ left ventricular ejection fraction (HFpEF) (Bianco et al. in JACC Cardiovasc Imaging. 13:258–271, 2020. 10.1016/j.jcmg.2018.12.035), where abnormalities of ventricular filling are the cause of symptoms, it is clear that the assessment of left ventricular diastolic function (LVDF) is crucial for understanding global cardiac function and for identifying the wider effects of disease processes. Invasive methods of measuring LV relaxation and filling pressures are considered the gold-standard for investigating diastolic function. However, the high temporal resolution of trans-thoracic echocardiography (TTE) with widely validated and reproducible measures available at the patient’s bedside and without the need for invasive procedures involving ionising radiation have established echocardiography as the primary imaging modality. The comprehensive assessment of LVDF is therefore a fundamental element of the standard TTE (Robinson et al. in Echo Res Pract7:G59–G93, 2020. 10.1530/ERP-20-0026). However, the echocardiographic assessment of diastolic function is complex. In the broadest and most basic terms, ventricular diastole comprises an early filling phase when blood is drawn, by suction, into the ventricle as it rapidly recoils and lengthens following the preceding systolic contraction and shortening. This is followed in late diastole by distension of the compliant LV when atrial contraction actively contributes to ventricular filling. When LVDF is normal, ventricular filling is achieved at low pressure both at rest and during exertion. However, this basic description merely summarises the complex physiology that enables the diastolic process and defines it according to the mechanical method by which the ventricles fill, overlooking the myocardial function, properties of chamber compliance and pressure differentials that determine the capacity for LV filling. Unlike ventricular systolic function where single parameters are utilised to define myocardial performance (LV ejection fraction (LVEF) and Global Longitudinal Strain (GLS)), the assessment of diastolic function relies on the interpretation of multiple myocardial and blood-flow velocity parameters, along with left atrial (LA) size and function, in order to diagnose the presence and degree of impairment. The echocardiographic assessment of diastolic function is therefore multifaceted and complex, requiring an algorithmic approach that incorporates parameters of myocardial relaxation/recoil, chamber compliance and function under variable loading conditions and the intra-cavity pressures under which these processes occur. This guideline outlines a structured approach to the assessment of diastolic function and includes recommendations for the assessment of LV relaxation and filling pressures. Non-routine echocardiographic measures are described alongside guidance for application in specific circumstances. Provocative methods for revealing increased filling pressure on exertion are described and novel and emerging modalities considered. For rapid access to the core recommendations of the diastolic guideline, a quick-reference guide (additional file 1) accompanies the main guideline document. This describes in very brief detail the diastolic investigation in each patient group and includes all algorithms and core reference tables.

Stress echocardiography is widely used to detect coronary artery disease, but little evidence on downstream hospital costs in real-world practice is available. We examined how stress echocardiography accuracy and downstream hospital costs vary across NHS hospitals and identified key factors that affect costs to help inform future clinical planning and guidelines. Data on 7636 patients recruited from 31 NHS hospitals within the UK between 2014 and 2020 as part of EVAREST/BSE-NSTEP clinical study, were used. Data included all diagnostic tests, procedures, and hospital admissions for 12 months after a stress echocardiogram and were costed using the NHS national unit costs. A decision tree was built to illustrate the clinical pathway and estimate average downstream hospital costs. Multi-level regression analysis was performed to identify variation in accuracy and costs at both patient, procedural, and hospital level. Linear regression and extrapolation were used to estimate annual hospital cost-savings associated with increasing predictive accuracy at hospital and national level. Stress echocardiography accuracy varied with patient, hospital and operator characteristics. Hypertension, presence of wall motion abnormalities and higher number of hospital cardiology outpatient attendances annually reduced accuracy, adjusted odds ratio of 0.78 (95

Ultrasound contrast agents (UCAs) have a well-established role in clinical cardiology. Contrast echocardiography has evolved into a routine technique through the establishment of contrast protocols, an excellent safety profile, and clinical guidelines which highlight the incremental prognostic utility of contrast enhanced echocardiography. This document aims to provide practical guidance on the safe and effective use of contrast; reviews the role of individual staff groups; and training requirements to facilitate its routine use in the echocardiography laboratory.

Immersion pulmonary oedema (IPE) is an under-reported and poorly understood phenomenon thought to be related to exercise-induced haemodynamic changes while submersed in water. Previous work has demonstrated reversible myocardial dysfunction during acute episodes. We present a case of IPE with concomitant, transient, left ventricular myocardial oedema characterised via MRI. This is a novel finding and may be evidence of left ventricular strain due to pressure overload or secondary to a subclinical myocarditis.

Abstract Introduction Transthoracic echocardiography (TTE) is an established screening tool used in the assessment of suspected Pulmonary Hypertension (PH). ESC guidelines released in 2015 recommend the use of specific echocardiographic parameters for the assessment of PH. Here, the tricuspid regurgitation velocity (TRV) together with echocardiographic markers of PH from three categories (the ventricles, the pulmonary artery, and the IVC/RA) are used to define the echocardiographic probability of PH being present (as either, low, intermediate or high). In 2022, the ESC updated this algorithm to include a revised haemodynamic definition of PH and also additional parameters for estimating the echocardiographic probability of PH(1). New parameters include the TAPSE/sPAP ratio as well as the combined assessment of the pulmonary artery (PA) and aortic root diameter. This retrospective audit evaluates the impact of the most recent 2022 ESC TTE PH algorithm in detecting PH in a real world cohort referred to a shared care PH centre. Method Between 2010 and 2020, a total of 306 patients referred for initial assessment of PH underwent TTE followed by RHC (mean interval 31±29 days). PH TTE probabilities were calculated using both 2015 and 2022 ESC guidance. The 2022 haemodynamic definition of PH was applied to both cohorts. The sensitivity and specificity of both 2015 and 2022 were calculated. Results The mean sample age is 67±14years (62% female). A summary of the TTE PH probability parameters is shown in Table 1. Using the 2015 ESC algorithm, the cohort comprised 24% (n=75), 23% (n=70) and 53% (161) for low, intermediate, and high TTE PH probability respectively. Within the low TTE probability group, 33% (n=25) had PH confirmed at RHC (see Figure 1). Sensitivity and specificity for the cohort is 88% and 65% respectively. The same dataset analysed using the 2022 algorithm demonstrates that 23% (n=71) has a low TTE PH probability, 19% (n=58) intermediate and 58% (n=177) a high TTE PH probability. Within the low TTE group the percentage of patients with PH at RHC was 35% (n=25) (Figure 1). Sensitivity and specificity for the 2022 TTE PH probability algorithm was 89% and 62% respectively. The introduction of the TAPSE/sPAP ratio (<0.55 mm/mmHg) contributed to 16 patients changing from intermediate to high TTE PH probability. Two patients with a low TTE probability demonstrated a ratio <0.55 mm/mmHg, of which one moved from low to intermediate probability. The PA/AR diameter led to 3 patients changing from low to intermediate TTE PH probability. Conclusion The sensitivity and specificity for the 2015 and new 2022 PH TTE probability algorithm are similar. Further developments in TTE algorithms are needed to improve the detection of PH in those thought to have a low TTE probability of PH.Table 1.0Figure 1.0

Abstract Background The world symposium on pulmonary hypertension (PH) has proposed that PH be defined as a mean pulmonary artery pressure (mPAP) > 20 mmHg as assessed by right heart catheterisation (RHC). Transthoracic echocardiography (TTE) is an established screening tool used for suspected PH. International guidelines recommend a multi-parameter assessment of the TTE PH probability although effectiveness has not been established using real world data. Study aims To determine accuracy of the European Society of Cardiology (ESC) and British Society of Echocardiography (BSE) TTE probability algorithm in detecting PH in patients attending a UK PH centre. To identify echocardiographic markers and revised algorithms to improve the detection of PH in those with low/intermediate BSE/ESC TTE PH probability. Methods TTE followed by RHC (within 4 months after) was undertaken in patients for suspected but previously unconfirmed PH. BSE/ESC PH TTE probabilities were calculated alongside additional markers of right ventricular (RV) longitudinal and radial function, and RV diastolic function. A refined IMPULSE algorithm was devised and evaluated in patients with low and/or intermediate ESC/BSE TTE PH probability. Results Of 310 patients assessed, 236 (76%) had RHC-confirmed PH (average mPAP 42.8 ± 11.7). Sensitivity and specificity for detecting PH using the BSE/ESC recommendations was 89% and 68%, respectively. 36% of those with low BSE/ESC TTE probability had RHC-confirmed PH and BSE/ESC PH probability parameters did not differ amongst those with and without PH in the low probability group. Conversely, RV free wall longitudinal strain (RVFWLS) was lower in patients with vs. without PH in low BSE/ESC probability group (− 20.6 ± 4.1% vs − 23.8 ± 3.9%) (P < 0.02). Incorporating RVFWLS and TTE features of RV radial and diastolic function (RVFAC and IVRT) within the IMPULSE algorithm reduced false negatives in patients with low BSE/ESC PH probability by 29%. The IMPULSE algorithm had excellent specificity and positive predictive value in those with low (93%/80%, respectively) or intermediate (82%/86%, respectively) PH probability. Conclusion Existing TTE PH probability guidelines lack sensitivity to detect patients with milder haemodynamic forms of PH. Combining additional TTE makers assessing RV radial, longitudinal and diastolic function enhance identification of milder forms of PH, particularly in those who have a low BSE/ESC TTE PH probability.

Introduction Transthoracic echocardiography (TTE) is an established screening tool used in the assessment of suspected Pulmonary Hypertension (PH). There is evidence to suggest Doppler estimates of Pulmonary Artery Systolic Pressure (PASP) are inaccurate compared to Right Heart Catheter (RHC) measures. Therefore, the ESC and BSE recommend a multi parameter assessment of TTE probability of PH. This retrospective audit sought to evaluate the effectiveness of the BSE/ESC TTE probability algorithm in detecting PH in a real world cohort referred to a shared care PH centre. Method Between 2010 and 2019, a total of 310 patients referred for initial assessment of PH underwent TTE followed by RHC (median interval 31±30 days). PH TTE probabilities were calculated following BSE/ESC guidance. Bland-Altman analysis was used to investigate the accuracy of Doppler estimates of PASP compared to RHC. Results The mean sample age was 67±14years (62% female). Seventy-six percent (n=235) had PH (mPAP ≥25mmHg) (average mPAP 42.8±11.7mmHg), 26% (n=80) having CTEPH. Doppler estimates of PASP tended to underestimate true PASP (bias -3.7±15.2mmHg) with wide limits of agreement (95% limits of agreement -33.5-26.1mmHg) (figure 1); highlighting the imprecision of Doppler estimates alone. Only 44% of Doppler TTE PASP estimates were within 10mmHg of RHC PASP readings. Underestimation occurred more frequently accounting for 66% of inaccurate TTE PASP estimates. Ninety-six percent of those with a high TTE probability (average RHC mPAP 45.3±12.1mmHg) and 78% with an intermediate probability of PH (average RHC mPAP 32.8±11.2mmHg) had PH confirmed at RHC (figure 2). The sensitivity and specificity for detecting PH for the whole cohort was 89% and 68%, respectively. However, 35% (n=27) of low TTE probability had PH (average RHC mPAP 31.9±6.6mmHg) with PH secondary to LHD (n=17), CTEPH (n=5), PAH (n=4) and multifactorial/unclear PH (n=1) observed in this group. The 4 PAH patients all had PH secondary to connective tissue disease (systemic sclerosis). NT-proBNP values were significantly higher in those with LHD compared to those with pre-capillary PH (462.6±428.1ng/L vs 148.4±107.7ng/L, p<0.01). There were 38 documented all-cause mortalities (median FU 2 years, IQR 2), 37 in those with PH. Eighty-four percent (n=31) of these had a high TTE probability of PH. Those that died were significantly older, had lower cardiac index, PA sats, 6MWT distance, higher NT-proBNP, mPAP, PVR, TRV and more frequently had TTE evidence of raised RAP and pericardial effusion (p<0.05) (table 1). Conclusion The PH TTE probability algorithm provides high sensitivity and moderate specificity for screening individuals at risk of PH. However, 35% of patients with low TTE probability had PH confirmed by RHC. Alternative strategies are needed to improve the sensitivity to detect PH in those with a low TTE probability of PH. Conflict of Interest None

Abstract Introduction Right heart catheterisation (RHC) is the gold standard investigation for the diagnosis of pulmonary hypertension (PH). Transthoracic echocardiography (TTE) allows non-invasive screening for PH. This retrospective audit sought to compare the accuracy of non-invasive Doppler estimates of pulmonary artery pressure and pulmonary vascular resistance (PVR) compared to RHC in a real world cohort referred to a shared care PH centre. Method Between 2010 and 2019, a total of 310 patients referred for initial assessment of PH underwent TTE followed by RHC (mean interval 31±30 days). Bland-Altman analysis was used to retrospectively investigate the accuracy of Doppler estimates of Pulmonary Artery Systolic Pressure (PASP), mean Pulmonary Artery Pressure (mPAP), Right Atrial Pressure (RAP) and PVR compared to RHC. TTE mPAP estimates were made using the pulmonary regurgitation velocity at the beginning of diastole (mPAP = 4(PRVBD)2 + RAP). TTE PVR estimates were calculated using the equation 10(TRV / RVOTVTI) + 0.16. Results Seventy-six percent of the cohort (n=235) had RHC diagnosed PH (average mPAP 42.8±11.7mmHg). The peak tricuspid regurgitation velocity (TRV) was measurable in 87% (n=269) and was unmeasurable in 8% (n=19) of those with confirmed RHC PH. Ten percent (n=30) had inadequate IVC imaging. TTE estimates of PASP (n=239) had a good correlation to RHC PASP (rs=0.82, 95% CI 0.75–0.84). TTE PASP estimates tended to underestimate RHC PASP (bias −3.7±15.2mmHg) with wide limits of agreement (95% limits of agreement −33.5–26.1mmHg) (figure 1); highlighting the imprecision of Doppler estimates alone. Only 44% of TTE PASP estimates were within 10mmHg of RHC PASP readings. Underestimation occurred more frequently accounting for 66% of inaccurate TTE PASP estimates. TTE RAP estimates (n=292) were weakly correlated to RHC RAP (rs=0.38, 95% CI 0.27–0.48). TTE estimates of mPAP were only measurable in 81 patients and demonstrated moderate correlation to RHC mPAP (rs=0.58, 95% CI 0.4–0.71). TTE estimates tended to underestimate RHC mPAP (bias of −10±10.9mmHg) with wide limits of agreement (95% limits of agreement −31.3–11.3mmHg) (figure 1) suggesting poor accuracy and precision. Only 51% of TTE estimates were within 10mmHg of RHC mPAP with 93% of inaccuracies due to an underestimation of RHC mPAP. TTE PVR estimates (n=238) correlated well with RHC PVR measures (rs=0.68, 95% CI 0.6–0.74). However, Bland-Altman analysis (figure 2) demonstrated bias of −2.2±3.1WU with wide limits of agreement (95% limits of agreement −8.2–3.8WU), highlighting significant inaccuracy. Conclusion Doppler TTE measures to assess PH lack accuracy when compared with the gold standard RHC. Furthermore, the peak TRV was unmeasurable in 8% of those with confirmed RHC diagnosed PH. These findings further support the use of a multi parameter TTE approach for screening of PH. Funding Acknowledgement Type of funding sources: None.

Introduction: Athletic training often results in changes that may mimic features of pathological cardiomyopathies. These changes are influenced by age, ethnicity and sporting discipline. Studies detailing the physiological adaptation to exercise on the right ventricle (RV) of adolescent athletes are fewer compared to the left ventricle, with even fewer describing the impact of ethnicity on the RV. One such potential physiological overlap with pathological change is arrhythmogenic right ventricular dysplasia (ARVD). An erroneous interpretation may have profound consequences ranging from false reassurance in a vulnerable athlete to unfair disqualification in a healthy individual. Therefore, it is important for the clinician to distinguish physiology from pathology. Results: ECG and echocardiographic data of 3000 academy male footballers were analysed, aged between 13 and 18 years old (mean age 16.4 ± 0.5 years), who underwent mandatory cardiac screening. Ethnicity was categorised as white (n=1000), black (n=1000) and mixed-race (n=1000). Overlap between ECG changes expected in ARVD and the adolescent athlete was observed. ARVD major criteria for TWI was seen in (n=63) 6.3% of the cohort. This was more prevalent in black footballers (n= 37; 3.7%) when compared to mixed race footballers (n=20; 2%) or white footballers (n=6; 0.6%), p<0.05. In up to 67% of the overall cohort, RV values exceeded those for normal adult reference ranges. Overall, 0.2% of the cohort would fulfil diagnosis for ‘definite’ ARVD and 2.2% would fulfil diagnosis for ‘borderline’ ARVD. This was seen more frequently in black footballers (n=99, 9.9%) than mixed race footballers (n=39, 3.9%) or white footballer (n=6; 0.6%), P = 0.0005. Among athletes meeting definite or borderline ARVD criteria, no cardiomyopathy was identified. Conclusion: This is the largest study to our knowledge that reports RV dimension data among adolescent footballers of different ethnicities. Right heart sizes in excess of standard adult ranges occurred in as many as one in 5 athletes. It is not unusual to observe values that would overlap with criteria for ARVD. As with LV parameters, variations in terms of ethnicity should be accounted for when performing routine cardiac assessments of adolescent athletes.

Background: Marathon running in novices represents a natural experiment of short-term cardiovascular remodeling in response to running training. We examine whether this stimulus can produce exercise-induced left ventricular (LV) trabeculation. Methods: Sixty-eight novice marathon runners aged 29.5 +/- 3.2 years had indices of LV trabeculation measured by echocardiography and cardiac magnetic resonance imaging 6 months before and 2 weeks after the 2016 London Marathon race, in a prospective longitudinal study. Results: After 17 weeks unsupervised marathon training, indices of LV trabeculation were essentially unchanged. Despite satisfactory inter-observer agreement in most methods of trabeculation measurement, criteria defining abnormally hypertrabeculated cases were discordant with each other. LV hypertrabeculation was a frequent finding in young, healthy individuals with no subject demonstrating clear evidence of a cardiomyopathy. Conclusion: Training for a first marathon does not induce LV trabeculation. It remains unclear whether prolonged, high-dose exercise can create de novo trabeculation or expose concealed trabeculation. Applying cut off values from published LV noncompaction cardiomyopathy criteria to young, healthy individuals risks over-diagnosis. (C) 2020 The Authors. Published by Elsevier B.V.

The structure and function of the right side of the heart is influenced by a wide range of physiological and pathological conditions. Quantification of right heart parameters is important in a variety of clinical scenarios including diagnosis, prognostication, and monitoring response to therapy. Although echocardiography remains the first-line imaging investigation for right heart assessment, published guidance is relatively sparse in comparison to that for the left ventricle. This guideline document from the British Society of Echocardiography describes the principles and practical aspects of right heart assessment by echocardiography, including quantification of chamber dimensions and function, as well as assessment of valvular function. While cut-off values for normality are included, a disease-oriented approach is advocated due to the considerable heterogeneity of structural and functional changes seen across the spectrum of diseases affecting the right heart. The complex anatomy of the right ventricle requires special considerations and echocardiographic techniques, which are set out in this document. The clinical relevance of right ventricular diastolic function is introduced, with practical guidance for its assessment. Finally, the relatively novel techniques of three-dimensional right ventricular echocardiography and right ventricular speckle tracking imaging are described. Despite these techniques holding considerable promise, issues relating to reproducibility and inter-vendor variation have limited their clinical utility to date.

J A Willis PhD1, A Kendler-Rhodes MB ChB1, O Slegg BSC1, K Carson MD FRCP1, J Easaw MD FCP FESC1, S R Kandan MBChB MRCP1, J C L Rodrigues BSc MBChB MRCP FRCR FSCMR PhD1, R MacKenzie-Ross MB BChir1, T Hall MBBS MRCP FRCR1, G Robinson FRCR1, D Little MBChB FRCR1, B Hudson MBBS FRCR1, J Pauling1, S Redman1, R Graham1, G Coghlan2, J Suntharalingam BSc FRCP MD1,3 and D X Augustine BSc MBBS MSc MD FHEA FRCP1

Background: Three-dimensional speckle-tracking echocardiography (3D-STE) is believed to be influenced by image quality, although quantitative evidence on this is limited. A previous evaluation indicated that sub-optimal image quality introduces a systematic bias in 3D-STE derived left ventricular (LV) deformation indices1, 2. Therefore, we aimed to quantify the extent of bias in proportion to impairment in image quality. Methods: This was a prospective experimental study. 18 healthy participants (age 31 ± 6 years, 83.3 % men) with good echocardiographic windows underwent 3D echocardiography (3DE). To impair the quality of the 3DE images of the LV in a reproducible and graded manner, a sheet of ultrasound-attenuating material, neoprene rubber, of three different thicknesses (2, 3 and 4 mm) was used to mimic mild, moderate and severe impairment in image quality respectively. 4 gated LV 3DE full-volume data-sets (including the optimal quality reference) were acquired per participant. All acquisitions were free of stitching artefacts and similar frame rates were maintained throughout. LV volumetric, and global and segmental LV deformation indices were measured. Mixed linear modelling was used to estimate the extent of bias. Results: There was a systematic bias in all global and segmental LV strains, and LV rotational indices. quality Conclusions: Abstract 2: First-phase ejection fraction is a powerful predictor of adverse events in asymptomatic patients with aortic stenosis preserved total ejection fraction Objectives First-phase ejection fraction (EF1), the ejection fraction up to the time of maximal ventricular contraction may be more sensitive than existing markers in detecting early systolic dysfunction. We examined the prognostic value of EF1 in patients with aortic stenosis (AS), a condition in which left ventricular dysfunction as measured by conventional indices is an indication for valve replacement. Methods Abstract 3: Improved Aortic Dimension Assessment With Specialist Echocardiography Clinics: A Quality Improvement Study. Background: Aortopathy is a common clinical problem. Guidelines recommend the use of double-oblique short axis imaging (CT/MRI) for significant aortic dilatation. Echocardiography is more readily available and cost effective. However accuracy and reproducibility is affected by operator variability. Good correlation between imaging techniques is vital for patient management, and may reduce health care expense and ionizing radiation. Objectives: We investigated the effect of dedicated specialist valve/aortopathy echocardiography clinics on accuracy of measurements and correlation with CT/MRI, compared to routine echocardiography performed outside these clinics. We hypothesized that a dedicated specialist based clinics would yield a better correlation with CT/MRI. Methods: 30 patients undergoing echocardiography in a specialist clinic for aortopathy, who also had correlative imaging with CT/MRI were retrospectively analysed. Aortic measurements were obtained using the inner edge to inner edge in end diastole method. Correlative imaging was compared for the aortic root (aortic annulus, sinus of valsalva, sinotubular junction) and ascending aortic measurements. A similar cohort of 25 patients outside specialist echocardiography clinic was used for comparison. Results: Patient Abstract 5: Introduction: BSE guidelines to assess the probability of pulmonary hypertension (PH) have been recently published. We present a contemporary dataset of patients attending a regional service for evaluation of PH. We audit BSE guidelines and highlight areas for potential development. Methods: 174 patients attending from August 2017 for PH assessment had echo and right heart catheter (RHC) data analysed from the RUH PH registry. Results: Of the 174 patients, 142 (82%) were diagnosed as having PH at RHC (mean RHC mPAP 44.4mmHg). Of those with RHC PH (n=142), 92 (65%) had high probability of PH based on echo assessment, 33 (23%) had intermediate echo probability of PH whilst 17 (12%) had low echo probability of PH (Figures 5 & 6). Only 2 patients with a high echo probability of PH (2%) had no RHC PH.

There is increasing demand on cardiac physiology services, particularly echocardiography, in centres throughout the UK. Valvular heart disease (VHD) and its management is a significant contributor to this burden and as such it is crucial that the appropriate follow-up echocardiogram frequency is selected for these patients. This study sought to investigate the impact of the 2017 ESC/EACTS Guidelines for the management of valvular heart disease and the 2017 Appropriateness criteria for the use of cardiovascular imaging in heart valve disease in adults, adapted for local use within the department. An example is shown in Fig. 8.