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Funding Acknowledgements Type of funding sources: None. Introduction Stress only (SO) instead of stress/rest single photon emission computed tomography myocardial perfusion imaging (MPI) is encouraged if perfusion and left ventricular ejection fraction (LVEF) are normal on SO images.  Concurrent coronary artery calcium (CAC) scoring has also been recommended to assess atherosclerotic burden in ‘normal’ MPIs.  However, the safety of SO MPI in high CAC cases is unclear as additional rest imaging may show transient ischaemic dilation (TID) and/or impaired LVEF reserve (iLVEFr) which are markers of severe coronary artery disease (CAD) and indicate ‘balanced ischaemia’. Purpose We aim to assess the incidence and outcomes of TID and iLVEFr in stress/rest MPIs with normal SO images and elevated CAC.   Methods Retrospective analysis of all normal stress/rest MPIs performed between 1 March 2016 to 31 January 2017 with concurrently measured CAC >300.  A SO protocol was not in place then.  Prone post stress images were routinely done.  Known CAD cases were excluded.  A reader reviewed only the post stress supine/prone images and excluded cases ineligible for SO MPI (non-homogenous perfusion, LVEF ≤50%, abnormal wall motion). The remaining cases were assessed for TID (software derived TID ratio >1.20) and iLVEFr (stress LVEF – rest LVEF ≤-5%).  Coronary angiography (CAG) and major adverse cardiac events (MACE, defined as cardiac death, non fatal myocardial infarction, revascularisation) within 24 months post MPI were traced using electronic medical records. Results There were 230 cases included (mean age 71, 56.5% male) of which 43 (18.7%) had TID and/or iLVEFr (9 TID, 22 iLVEFr, 12 both).  There were no significant differences in baseline characteristics, CAC and aspirin/statin use between cases with or without TID and/or iLVEFr (Table 1).  More patients in the TID and/or iLVEFr group underwent elective CAG [10 (23.3%) vs 10 (5.3%), p = 0.001] although CAG diagnosis of severe CAD (left main, 3-vessel or 2-vessel disease with proximal left anterior descending involvement) was not different [4/6 (40.0%) vs 5/10 (50.0%), p = 1.000).  MACE was significantly higher in the TID and/or iLVEFr group [10 (23.3%) vs 16 (8.6%), p = 0.013], driven by higher elective revascularisation [8 (18.6%) vs 8 (4.3%), p = 0.003] with no significant differences in cardiac death or non fatal myocardial infarction (Table 2). Conclusion TID and/or iLVEFr is seen in <20% of cases eligible for SO MPI with high CAC, suggesting that routine rest scan in these cases exposes the majority to unnecessary radiation.  Identification of TID and/or iLVEFr is associated with higher 24 month MACE, driven by higher elective revascularisation from more CAG referral.  Approximately half of cases in each group had revascularisation for non severe CAD not typically associated with TID and/or impaired LVEFr.  Overall cardiac death and non fatal myocardial infarction rates were low and not significantly different between groups with or without TID and/or iLVEFr.

IntroductionJunior students making the transition from pre-clinical to clinical years often struggle to integrate into ward teams during ward-round activities. The SimRound is a novel approach to facilitate embedding of junior medical students into incumbent ward teams through simulation rounds specially designed to replicate actual ward-round proceedings. Using the situated learning and cognitive load theories, this study aims to describe the rationale, processes and lessons learnt from our experience in developing the SimRound. MethodsThird-year students undergo two SimRound sessions at weeks two and six during the eight-week General Medicine clerkship. There are four phases in each SimRound: Prioritisation and triage; pre-round; consultant round; and evaluation and feedback. Using framework analysis, we compared open-ended survey data from pre-SimRound and SimRound cohorts to develop descriptive and explanatory accounts of identified themes. ResultsDespite the benefits to learning from being embedded in the ward team, students reported challenges to learning arising from engagement and team identity; increased intrinsic load; and increased extraneous load. SimRound addresses this by enabling deliberate learning in a controlled and authentic setting with inter-professional participation. The reduction of cognitive load enabled students to assimilate the necessary knowledge and skills.In conclusion, SimRound complements embedding and facilitates the integration of junior students into the community of practice of incumbent ward teams.