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thank you very much for a fantastic opening presentation. So if we could know welcome, Doctor Dan stayed. Oh, who's the cardiologists at King's? Who's also going to be talking about the M I R MRI and red flags in this long coat Welcome. Thank you very much. And I think firstly, think charity s I've sort of been watching a charity and sending patients in your direction. It's probably about 20 to think 2013. Fantastic on very grateful. It's very nice to me to be able to do something. Say, I'm going to open up. This is the fourth time I've showed this slide. Every time I get the same feeling, sit in that chair. Think I'm gonna show boys Johnson, What if you said to me get here ago, You're gonna make a slide with him on that level. Wouldn't believe that. So why am I why I put him on the slides here? Because actually, much as I'm not a massive, I have some sympathy thing from March 2020 2020. The good news, Prime Minister, Everything's wonderful. We got the already everything's wonderful. Had to sit down and say, you know, I told you all that don't need your house, right? I must have been quite hard for him, as goes against everything that he was. In my view, everything stands for if you watch me talk about MRI in pretty much any fourth one, you're here. A Boris s debate. Here's why were wonderful. Everything we do is amazing. Send this lows of work except this talk. And every time I do this talk, I kind of think of Boris. And then must be hard then because I find Mr Difficult today and you'll see why so gonna go through mindset changes. Okay. For 19, talk about my cards and pericarditis. Refer back to the patient. Look at mom's and arms. This side says apologies to regulate. The first time I did this talk was for a cardiac MRI conference where we have mixture Provigil, this radiologist, maybe for cardiologists. But for any general physician, you have a patient. A night to you who gets a proponent Measure. That's the the A septic shock And it comes back very mild. Normal. The next day I to call the cardiology registrar for advice. That's that's a pain in interest. You in terms of clinical What would you get it? That's and rather ask you, all of you could tell you what 2.5 1000 people thought of this on Twitter. 83% know interested. That's I got lots of things on Twitter. Say, can I apologize on behalf of the eye to community that we would bother you with? This thing was made up, case. This is not really, you know. So they it was to make a point after this talk of the talk was it was going to be When I first did it. About six months ago. Most cardiologists went interested, but that that question is is much about philosophy. Is it is about science. Somethings happens when a training goes up. You have a leak of it from somewhere. Why didn't we can? And of course, what is different is that in April 2020 when that phone calls made to the cardiology registrar, they couldn't get try to you quicker. Cov changed our way of thinking. We started looking well. Interesting. My first had a paper published in your heart journal. Pericardial effusion on the MRI. That is not interesting. On the MRI. I'm gonna go back to London Bridge in a minute and stand something. He's got the peri cardio infusion. Thousands of units around the world will be doing that every day. I've got high impact publication because it was the first kind of thick packet cards infusion. It's completely changed the way of thinking physicians. And the reason I bring it up when I say this to see MRI reports, cardiac MRI reports is changed the way that we bought a swell or drying calls. It might be interesting that more notes this. Maybe then you might have done in 2019 with a similar sort of referral for a similar sorts of being the summer. No, she had a mindset change. So okay, we'll do that. Why, you wise MRI of interest in my colitis. We can help you function open, do that to what we could do. The echo cancers of get information and echo really struggles with scarring. So we come into our own for myocarditis. This is being, um I mean, it's my car. That's long before is a patient who actually had a hospital say he was a hospital. The coping 19 here you're seeing left ventricle the muscles on the outside here. This cavity eso the gray and lighter great stuff here is but traction hearts are are it's a little bit down here we can do inflammatory. Imagine she brighter here in the lateral wall. We can get contrast. That takes you can basically that that contrast that I went well on this, but that basically showed she micronize us in a patient who was actually quite sick. We can bury the pericardium very well as well. Sickness effusions of constrictive physiology and pericardial way are good tool for these problems. People thought we were going to talk for this. Let's start looking at what you find in covert 19. And here's weather fun begins. The first study in 2020 took predominantly people who never made it asked a week over. This is in Germany 67% and we're in the community. 78% of people having that more memory. Now most of this audience now will have had it just by statistics. I lost my copay virginity a month ago, so I mean, right this study is saying is a 78% chance of never have normal cardiac tomorrow press everybody in this room. If they come from combat minutes on average in a minute. What is this stuff is gonna have normal. That cause big news. This study was widely quoted. It's it's how I think Last I looked, it had over half a million people. Look at it when we published up the number. I must have you on interested. So you get that when you saw No, you got college athletics. One was quite a lot in there. And another one here. These are all in 2020. This something here? That's the patients who are actually sick in the hospital. Who troponin Positive. Much with the higher potential yield. Only 27% had my car. So you're really sick. You already suddenly starting to see a much lower number here and down the Boston here. This lecture from UCL from brutal Toby works with you actually saw no difference between controls and patients out. So patients is actually healthcare professionals. You have. So you've gone from basically everybody in this room is gonna have a problem. It's noted, Mr how much to your problem? Number two here is you have not grossly confected literature in this pill makes extremely difficult. So I have a paper you choose to read two very different stories. What? The problem is happy actually, diagnose my arthritis is not good. Is this guy is how you do it on MRI, but no outside of that. So your typical patient's of nicotine acid describe what my fighters means to you. Neck would think the patient who comes into hospital with chest pain component positive, has a normal angiogram, then comes to me for the MRI scanner, which that's my that tissue. That's what typically, cardiology would have called particular viral myocarditis in the past. That's what you would have expected. But that's there's no actual guidelines that that's how you did so the thing. In fact, in Germany, if you're going to have to write that majority, get cardiac biopsy, which we don't do you care of most of the country with biopsies your gold standard, but it often misses it. So if you see it, great specificity. Very good sensitivity minutes. So that happens to people with myocarditis. If you look at all groups, I work. We have a marker rises clinic. This is pre cope it. If you look at 100 patients who came to us with definite myocarditis. Probably viral. So sometimes we So today you come to us. But you got to swap everybody else. You can think off before 2020. You never got swab. If you did get swelled up, it was often a bit late and it was a number. It's a completely different world. So minorities people probably had a virus, but we don't know the story sounds like a viral infection. 100 patients. The majority came in. Um, well, chest pain. By the time you follow them up, the chest pain, everything's going away. Generally see with viral markers Precose that you've got some ongoing grumbling chest pain in patients who definitely hard myocarditis. In fact, in my line of work with a lot of work in autoimmune disease of the brutal patients were pulling my sight is in the matter myositis. My research is looking at my notes. Didn't screw. We go looking for it. Which opponents? An MRI. When we find staff need always, the patient has no symptoms. We tell them they got it. They don't come to us and say, I got chest pain. I might have it sort of them. So this is a low 11 myocarditis in this sort of patients doesn't cause symptoms. I would say this this the group a stop on on immune suppression not necessarily directly compare. It will be just to give you some what Harry got Lots of disease because there's European guidelines to tell you how to diagnose. So there's a whole load of diagnostic criteria, and this is important because if you look at what's some of the patients that have had done this kind of a one c 34 been forgotten. Everything been comes out to this bit here, which is the additional support of finding that MRI suggesting something. And over this, So that's where the rest of it just gonna call it back. I take Toby's comment about with the monster. The patient's telling you a story that sounds nothing like pericarditis Gonna end up with a big jump, saying That's what it is if everything's normal, apart from some mind, big jump. So issue number three and I haven't been injured this in detail just because there was a time MRI is not easy to do in the cohort. Patients were talking about post copays syndrome. Doing inflammatory imaging on patients who have eczema is more difficult. The reason for that is because my cartoons spinner and therefore you need better resolution images. Chicken youngest, email, older and hypertensive. So much younger females hard with swimming fast heart rates adds complexity to that because many post go bit syndrome patients have got faster. Heart rate makes it more difficult because the standards trying to get information, information with the heart being more dynamic. A lot of the techniques we use with validated. Looking at just imaging the septum here, we're trying to think of other bits of the heart and some of the older imaging we do something called Stairs more difficult. I'm sticking again in the spring, so you have some challenges with it, so I want to keep back to the patient. Seven year old female heavy chest pain I do. I run some of the cardiology side of on Kobe. It or POSTOP. It's syndrome in southeast terms. How often this sort of referral to maybe I would change it slightly. What I would have from the R. C. Is this patient's been told they got pericarditis. My crisis they've been given. Culture seen often hasn't worked. They may or may not tolerated prednisolone. Can we offer something else? And the reason for those come to me is because people know that I work with a rheumatologist who has an interest in this with all sorts of funny antibody type treatments. What's what I do with that? Actually, my approach to this often is difficult, because what the patient doesn't states is we start again. We go through everything from first principles and you find all sorts of stuck with this. You make a big agree with what somebody else thought, or you may find that the patients have a history taken and know examination, blood test in every subject, and someone's just put him through a number. I scan. It said you got pericarditis. You think on this Avalide I must have criteria you look for here. You know, the story might sound good month so bad. So I will start again with this and go through it again and make um, to my own decision. What? I think this is not the problem. Actually, what totally was saying about the general this he can't do this, pet this is the generalist is fine, but you need a mixture and it's the same. I mean, I look at pictures from the end. I think, actually beautifully sums up for me while I think about scoping syndrome, lots of people. It's been voting sort of pick. Lots of sames are supposed to open. Lots of people with some of this is just really technical. And you just need someone who's the or insulated to say to You actually have that MRI scan and I think it's no, I think it's great. Yeah, because there's a real problem here and we see this in our my colitis clinic, what we call office and walks of moms where we come once. Fine that we think these things have been over called labels have been given that we don't necessarily agree with this big decision making, you know. But something else like sports. My, that's not mine. For example, she has a big call to get the diagnosis. Run it in the first place. We may agree we may not necessarily start again best. So what about the red flag side of it? Which was the end of the talk? This is hard on my part. Right? Ear's arrhythmia, Definitely a red fly. Someone with make most of it, I think, generally thinking about why that happened. It may be that they don't have myocarditis, ones that I've seen in the more chronic setting quite often stupid. But it starts. In fact, what place is postcode with my colitis I'm seeing next week, So I know very well she had just by. She presents it without thinking night percent, then presentations, quite distressed by it. And she's been running a marked, elevated troponin but has no trust night. It's never had just pericarditis. The red flags knee for me is this. You know, people have forgotten that, you know, this is what pericarditis scenes. And if it sounds nothing like any of this that's on the screen, it's a big jump to then say, Let's have some cyclophosphamide, the big jump. So from my perspective, you know, I think this is a useful the see guidelines here. You really help. So what am I? A difficult talk to God said, Just send everybody with chest pains. I'll start out with a problem. It'll this is some of the hard stuff I did It is much, much easier dealing with a gross pathology than some of the more subtle stuff off when you're talking about here much, much easier, because there's a whole load of textbooks that say to you. But it looks like this is what it is up to 100 Cardiologist in a river, Never great. You can see from the stuff on the market, I said. The reason why you were seeing the growth change in micro I situ is not different in patients. My view is just to do with people are calling abnormality and scans. Some groups say this is just in the normal spectrum, so that is the real challenge, because a lot of what we're seeing is quite subtle. So for me, a lot of it is about first principles of this. Some of it's difficult because it's totally starting to suggest, you know, this is a new disease. The first principles were with best, but for me pericarditis, for example, is what it is. But I think over pericarditis per say, well, why wouldn't know if you pericardium and framed Why would the nature of the chest pain you get? The different, but that's what it used to be with know influenza pericarditis, sort of thinking symptoms the patients get with it likely to be the same because that always trust is that there's a potential to over call in a desire to once a day and then they are not labeled drug. Give you coach. I can give you cycle thing. I could do stuff. You've got to make sure we diagnosed rights and effects. Is that doing MRI To me? It's what about, like, most lot of what I'm doing and why it's about trying to get the time. That's That's right. Thank you very much. This presentation and we know that you need Teo to take the injections and three perhaps start in the hole If anyone's got any. Any questions? Can I take 50 lbs of this? Point is a bet you to say that I won't get 60 questions. That party specialist between the studies is that any difference between depo bit strange study? I don't just one strength. Yeah, so I don't think there's any question that if you look at what you're seeing in the coverage strain, the only quantity obviously great difference. What region if you go back to If you go back to this. This is obviously looking at the original strain. This is going to be looking at the outfit straight, but it could it be a difference between the two? Yeah, possibly. I think that's what it is because both place Strange. We're clearly extremely aggressive. Uh, somebody who that neck ended up in a hospital. That's so awful lot of problems both straight cause the same sorts of things I do think you got a big change between on the front and the rest. But what you're seeing there is going to say because they say that's published. I think in some 21 the bottom study said is going to have in stuff that happened with the the January 21 way. Yeah. I mean, it may be that I don't think that's what it is. I mean, I let me put it another way. If you look at what if the original study is true, I should be seeing an avalanche of disasters now, which I know if you're really saying 78 7 people in the original way, that it's problems which you would be seeing a shed later things that we are not seeing. It's possible that maybe not so people get lots of mild things that don't matter. But we are not seeing these answers. No, thank you very much on the others. Other questions in the room. Anyone want to make a loss? Yes, We ask about tachycardia. Cribbage? Whether you will say, See people with those ready? Um, much more common. See, tachycardia relate to this year's mean. It will be more expert on this labor. If you look at certain what I've seen your of it is much more related to a party related issue. Bradley card related issues. I'm trying to think about seeing anyone. Well, then we thought, Gosh, it's a bit slow. For some reason, I don't understand this needle, always the other way wise, this conference running spots. You okay? Because, yeah, it is much more likely to be tachycardia related issues, not sitting next to the shaking doing well. So No, I don't. Maybe that might be a loaded question for someone who is that way. So they have all the well kids. We might leave a one c your acid email discussion about it, but I can't think of anyone. Think