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Abstract
Sudden cardiac death (SCD) accounts for ∼50% of mortality after myocardial infarction (MI). Most SCDs result from ventricular tachyarrhythmias, and the tachycardias that precipitate cardiac arrest result from multiple mechanisms. As a result, it is highly unlikely that any single test will identify all patients at risk for SCD. Current guidelines for use of implantable cardioverter-defibrillators (ICDs) to prevent SCD are based primarily on measurement of left ventricular ejection fraction (LVEF). Although reduced LVEF is associated with increased total cardiac mortality after MI, the focus of current guidelines on LVEF omits ∼50% of patients who die suddenly. In addition, there is no evidence of a mechanistic link between reduced LVEF and arrhythmias. Thus, LVEF is neither sensitive nor specific as a tool for post-MI risk stratification. Newer tests to screen for predisposition to ventricular arrhythmias and SCD examine abnormalities of ventricular repolarization, autonomic nervous system function, and electrical heterogeneity. These tests, as well as older methods such as programmed stimulation, the signal-averaged electrocardiogram, and spontaneous ventricular ectopy, do not perform well in patients with LVEF ≤30%. Recent observational studies suggest, however, that these tests may have greater utility in patients with LVEF >30%. Because SCD results from multiple mechanisms, it is likely that combinations of risk factors will prove more precise for risk stratification. Prospective trials that evaluate the performance of risk stratification schema to determine ICD use are necessary for cost-effective reduction of the incidence of SCD after MI.
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Affiliation(s)
- Jonathan W Waks
- Department of Medicine, Harvard Medical School, Boston, Massachusetts 02115.,Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215; ;
| | - Alfred E Buxton
- Department of Medicine, Harvard Medical School, Boston, Massachusetts 02115.,Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215; ;
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Temporal Evolution and Implications of Ventricular Arrhythmias Associated With Acute Myocardial Infarction. Cardiol Rev 2013; 21:289-94. [DOI: 10.1097/crd.0b013e3182a46fc6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Piers SR, Wijnmaalen AP, Borleffs CJW, van Huls van Taxis CF, Thijssen J, van Rees JB, Cannegieter SC, Bax JJ, Schalij MJ, Zeppenfeld K. Early Reperfusion Therapy Affects Inducibility, Cycle Length, and Occurrence of Ventricular Tachycardia Late After Myocardial Infarction. Circ Arrhythm Electrophysiol 2011; 4:195-201. [DOI: 10.1161/circep.110.959213] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sebastiaan R.D. Piers
- From the Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Adrianus P. Wijnmaalen
- From the Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - C. Jan Willem Borleffs
- From the Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Joep Thijssen
- From the Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Johannes B. van Rees
- From the Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne C. Cannegieter
- From the Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen J. Bax
- From the Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martin J. Schalij
- From the Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Katja Zeppenfeld
- From the Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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URBONAVICIENE GRAZINA, URBONAVICIUS SIGITAS, VORUM HENRIK, BLUZAITE INA, JARUSEVICIUS GEDIMINAS, HONORÉ BENT, TAMOSIUNAITE MINIJA. Evaluation of Prognostic Clinical and ECG Parameters in Patients after Myocardial Infarction By Applying Logistic Regression Method. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:1391-8. [DOI: 10.1111/j.1540-8159.2008.01201.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Estratificación del riesgo y prevención de la muerte súbita en pacientes con insuficiencia cardíaca. Rev Esp Cardiol 2004. [DOI: 10.1016/s0300-8932(04)77188-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Lin D, Marchlinski FE. Advances in ablation therapy for complex arrhythmias: atrial fibrillation and ventricular tachycardia. Curr Cardiol Rep 2003; 5:407-14. [PMID: 12917057 DOI: 10.1007/s11886-003-0099-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Catheter ablation has evolved over the past two decades to become first-line therapy for many cardiac arrhythmias. Multiple advances in the technology and understanding of radiofrequency ablation have allowed this technique to blossom into one of the most powerful therapeutic tools available to the electrophysiologist, and have opened a new chapter in the diagnosis and management of clinical arrhythmias. Catheter ablation often eliminates the need for chronic drug therapy and can result in significant long-term cost savings. As catheter technology continues to improve, and newer, more effective energy delivery systems are developed, the applicability of catheter-based therapy will continue to expand. This review addresses some of the more commonly encountered clinical arrhythmias and the recent developments in the treatment of these arrhythmias from a catheter-based standpoint.
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Affiliation(s)
- David Lin
- University of Pennsylvania Health Systems, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, PA 19104, USA.
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González Carrillo J, García Alberola A, Saura Espín D, Carrillo Sáez P, López Palop R, Sánchez Muñoz JJ, Martínez Sánchez J, Valdés Chávarri M. Impacto de la angioplastia primaria en la indicación de desfibrilador implantable en pacientes con infarto de miocardio. Rev Esp Cardiol 2003; 56:1182-6. [PMID: 14670270 DOI: 10.1016/s0300-8932(03)77036-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION AND OBJECTIVES Implantable cardiac defibrillators (ICD) have been shown to improve survival in patients with myocardial infarctionand LVEF < 0.30 or LVEF < 0.40 + nonsustained ventricular tachycardia + inducible sustained arrhythmias. However, these risk stratification criteria have not been evaluated in patients who are candidates for primary percutaneous transluminal coronary angioplasty (PTCA). The objective of this study was to assess the impact of both strategies on the indication for ICD in a consecutive series of post-infarction patients treated with primary PTCA. PATIENTS AND METHOD One hundred and two consecutive patients with myocardial infarction (80 men, mean age 63.6 11.5 years) included in a single-center-based regional program of primary PTCA were included in the study. A 24-h continuous ECG recording was obtained 2 to 6 weeks after the acute event, and LVEF was determined by 2D-echocardiography one month after the infarct. Patients with nonsustained ventricular tachycardia and LVEF < 0.40 underwent programmed ventricular stimulation using a standard protocol. RESULTS Twenty-two patients (21.6%; 95% CI, 13.6-29.6) showed at least one episode of nonsustained ventricular tachycardia in the 24 h recording. Six of them had LVEF < or = 0.40, and sustained ventricular arrhythmia was induced in 2 out of 5. LVEF < or = 0.30 was found in 3 patients, none of whom had nonsustained ventricular tachycardia. Thus, 5 patients had an indication for ICD according to either of the two risk stratification criteria. CONCLUSIONS The prevalence of nonsustained ventricular tachycardia in post-infarction patients treated with primary PTCA is high. However, because most of them have preserved ventricular function, primary prevention with an ICD is indicated in approximately 5% of the population.
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de Chillou C, Lacroix D, Klug D, Magnin-Poull I, Marquié C, Messier M, Andronache M, Kouakam C, Sadoul N, Chen J, Aliot E, Kacet S. Isthmus characteristics of reentrant ventricular tachycardia after myocardial infarction. Circulation 2002; 105:726-31. [PMID: 11839629 DOI: 10.1161/hc0602.103675] [Citation(s) in RCA: 148] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The reentrant mechanism of postinfarct ventricular tachycardia (VT) has been documented by surgical mapping analysis, but little is known about postinfarct VT circuits and the characteristics of their related protected isthmus with the use of 3D catheter mapping systems. METHODS AND RESULTS A 3D electroanatomic mapping was performed in 21 patients with well-tolerated, postinfarct, sustained VT. In total, 33 episodes of tachycardia (mean cycle length 432+/-74 ms) were induced and mapped. Complete maps demonstrated macroreentrant circuits with 1 loop (n=8) or 2 loops (n=25) rotating around a protected isthmus bounded by 2 approximately parallel conduction barriers that consisted of a line of double potentials, a scar area, or the mitral annulus. A total of 26 critical isthmi were identified for the 33 VTs mapped, with the same isthmus being shared by 2 to 4 different tachycardic morphologies in 5 patients. On average, isthmi were 31+/-7 mm long (ranging from 18 to 41 mm) and 16+/-8 mm wide (ranging from 6 to 36 mm) and harbored diastolic electrograms. The isthmus axis was oriented parallel to the mitral annulus plane in perimitral circuits and perpendicular to the mitral annulus plane in all other circuits. Linear radiofrequency ablation performed across the most accessible part of the isthmus prevented the recurrence of tachycardia in 19 patients (90%) with a follow-up at 16+/-8 months. CONCLUSIONS Detailed 3D electroanatomic mapping is helpful in reconstructing postinfarct VT circuits and in defining the characteristics of their related protected isthmi. The wide range of isthmus width values supports the need of linear radiofrequency lesions to eliminate the reentrant substrate of postinfarct VTs.
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Bailey JJ, Berson AS, Handelsman H, Hodges M. Utility of current risk stratification tests for predicting major arrhythmic events after myocardial infarction. J Am Coll Cardiol 2001; 38:1902-11. [PMID: 11738292 DOI: 10.1016/s0735-1097(01)01667-9] [Citation(s) in RCA: 143] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES We surveyed the literature to estimate prediction values for five common tests for risk of major arrhythmic events (MAEs) after myocardial infarction. We then determined feasibility of a staged risk stratification using combinations of noninvasive tests, reserving an electrophysiologic study (EPS) as the final test. BACKGROUND Improved approaches are needed for identifying those patients at highest risk for subsequent MAE and candidates for implantable cardioverter-defibrillators. METHODS We located 44 reports for which values of MAE incidence and predictive accuracy could be inferred: signal-averaged electrocardiography; heart rate variability; severe ventricular arrhythmia on ambulatory electrocardiography; left ventricular ejection fraction; and EPS. A meta-analysis of reports used receiver-operating characteristic curves to estimate mean values for sensitivity and specificity for each test and 95% confidence limits. We then simulated a clinical situation in which risk was estimated by combining tests in three stages. RESULTS Test sensitivities ranged from 42.8% to 62.4%; specificities from 77.4% to 85.8%. A three-stage stratification yielded a low-risk group (80.0% with a two-year MAE risk of 2.9%), a high-risk group (11.8% with a 41.4% risk) and an unstratified group (8.2% with an 8.9% risk equivalent to a two-year incidence of 7.9%). CONCLUSIONS Sensitivities and specificities for the five tests were relatively similar. No one test was satisfactory alone for predicting risk. Combinations of tests in stages allowed us to stratify 91.8% of patients as either high-risk or low-risk. These data suggest that a large prospective study to develop a robust prediction model is feasible and desirable.
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MESH Headings
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Electrocardiography, Ambulatory
- Humans
- Myocardial Infarction/complications
- Myocardial Infarction/physiopathology
- Myocardial Infarction/therapy
- Predictive Value of Tests
- ROC Curve
- Risk Assessment
- Signal Processing, Computer-Assisted
- Stroke Volume
- Tachycardia, Ventricular/etiology
- Tachycardia, Ventricular/physiopathology
- Tachycardia, Ventricular/therapy
- Ventricular Dysfunction, Left/etiology
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Function, Left/physiology
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Affiliation(s)
- J J Bailey
- Center for Information Technology, National Institutes of Health, Bethesda, Maryland 20892-5620, USA.
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Carluccio E, Tommasi S, Bentivoglio M, Buccolieri M, Filippucci L, Prosciutti L, Corea L. Prognostic value of left ventricular hypertrophy and geometry in patients with a first, uncomplicated myocardial infarction. Int J Cardiol 2000; 74:177-83. [PMID: 10962119 DOI: 10.1016/s0167-5273(00)00264-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The prognostic impact of left ventricular (LV) geometry on cardiovascular risk for patients with a first, uncomplicated acute myocardial infarction (AMI), and echocardiographic ejection fraction > or =50% has not been well described. METHODS AND RESULTS Accordingly, 111 AMI consecutive patients (mean age 59.3+/-10 years) performed echocardiographic examination at predischarge. LV mass was calculated by means of Devereux's formula and subsequently indexed by body surface area. Fifty-three patients had LV hypertrophy and 58 patients had normal LV mass. The two groups were homogeneous for demographic, clinical and angiographic variables as well as for the incidence of residual ischemia on predischarge stress testing. During follow-up period there were 24 cardiac events (cardiac death, unstable angina and non-fatal reinfarction) in the 53 patients with LV hypertrophy and only four events in the remaining 58 patients without LV hypertrophy (RR=2.45; CI=1.76-3.41; P<0.0001). The patients with concentric LV hypertrophy showed a higher incidence of events (64%) than patients with eccentric LV hypertrophy (32%, P<0. 05) and patients with normal geometry and mass (6%, P<0.0001). Multivariate Cox regression model identified concentric geometry as the most powerful predictor of combined end-points (chi(2)=32.7, P<0. 0001). CONCLUSIONS An increased LV mass and concentric geometry resulted important independent markers of an adverse outcome in patients with a first, uncomplicated myocardial infarction and good LV function.
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Affiliation(s)
- E Carluccio
- Department of Clinical and Experimental Medicine, Division of Cardiology, Policlinico Monteluce, University of Perugia, Via Brunamonti, 1, 06100 Perugia, Italy
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García García J, Serrano Sánchez JA, del Castillo Arrojo S, Cantalapiedra Alsedo JL, Villacastín J, Almendral J, Arenal A, González S, Delcán Domínguez JL. [Predictors of sudden death in coronary artery disease]. Rev Esp Cardiol 2000; 53:440-62. [PMID: 10712973 DOI: 10.1016/s0300-8932(00)75108-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Although advances in the management of acute myocardial infarction have resulted in a decline in long-term risk of sudden death, it continues to be high in certain subsets of patients. Thus, it is important to identify and treat these patients. Left ventricular ejection fraction less than 0.40, frequent premature ventricular ectopy on Holter monitoring, late potentials on signal-averaged electrocardiogram, impaired heart rate variability, abnormal baroreflex sensitivity and inducible sustained monomorphic ventricular tachycardia during electrophysiological study are predictors of sudden death and arrhythmic events. Although the negative predictive value of each factor is high, the positive predictive accuracy is low. Several tests can be combined to obtain higher positive predictive values. In fact, in some studies combined noninvasive tests have been used to select patients for ventricular stimulation study. Some preventive treatment can be applied in these patients. Available data do not justify prophylactic therapy with amiodarone in high-risk survivors of acute myocardial infarction. Sudden death and total mortality have been significantly reduced in postinfarction patients by long-term beta blockade. Hence, beta blockers should be given to all patients with acute myocardial infarction who do not have contraindications to their use. The MADIT study has shown the beneficial effect of implantable cardioverter defibrillator in reducing mortality in patients with prior myocardial infarction, an ejection fraction less than 0.36, asymptomatic nonsustained ventricular tachycardia, and inducible sustained ventricular tachycardia, unsuppressable by procainamide. Besides, several studies are under way to evaluate the prophylactic use of implantable defibrillator for improving survival in high-risk patients.
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Affiliation(s)
- J García García
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid
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Carluccio E, Tommasi S, Bentivoglio M, Buccolieri M, Prosciutti L, Corea L. Usefulness of the severity and extent of wall motion abnormalities as prognostic markers of an adverse outcome after a first myocardial infarction treated with thrombolytic therapy. Am J Cardiol 2000; 85:411-5. [PMID: 10728942 DOI: 10.1016/s0002-9149(99)00764-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The prognostic value of wall motion score index (WMSI), assessed at predischarge after a first acute myocardial infarction (AMI) in the thrombolytic era, is still not well known. One-hundred forty-four consecutive patients with a first AMI treated with thrombolytic therapy underwent exercise testing and echocardiography at rest before discharge and were followed-up for a mean period of 18 months. During follow-up, there were 32 cardiac events (12 patients had cardiac deaths, 8 had unstable angina pectoris, 1 had nonfatal reinfarction, and 11 patients had congestive heart failure). The patients who experienced any cardiac event had a higher WMSI (1.67+/-0.15 vs. 1.30+/-0.16, p<0.0001), a higher end-systolic volume (75.1+/-34 vs. 59.5+/-22 ml, p<0.01), and a lower ejection fraction (47+/-16% vs. 55+/-10%, p<0.001) at predischarge than patients without events. The incidence of a positive predischarge exercise testing did not differ between patients with and without cardiac events (22% vs. 24%, p = NS). Multivariate Cox regression analysis, including clinical, exercise results, and echocardiographic parameters, showed that the most powerful predictor of a subsequent event was a resting WMSI > or =1.50 before discharge (chi-square 17.8, p<0.0001). Thus, in patients with a first AMI who underwent thrombolysis, the severity and extent of echocardiographically detected wall motion abnormalities are important independent predictors of cardiac events.
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Affiliation(s)
- E Carluccio
- Department of Clinical and Experimental Medicine, Policlinico Monteluce, University of Perugia, Italy
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Michaels AD, Goldschlager N. Risk stratification after acute myocardial infarction in the reperfusion era. Prog Cardiovasc Dis 2000; 42:273-309. [PMID: 10661780 DOI: 10.1053/pcad.2000.0420273] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Historically, risk stratification for survivors of acute myocardial infarction (AMI) has centered on 3 principles: assessment of left ventricular function, detection of residual myocardial ischemia, and estimation of the risk for sudden cardiac death. Although these factors still have important prognostic implications for these patients, our ability to predict adverse cardiac events has significantly improved over the last several years. Recent studies have identified powerful predictors of adverse cardiac events available from the patient history, physical examination, initial electrocardiogram, and blood testing early in the evaluation of patients with AMI. Numerous studies performed in patients receiving early reperfusion therapy with either thrombolysis or primary angioplasty have emphasized the importance of a patent infarct related artery for long-term survival. The predictive value of a variety of noninvasive and invasive tests to predict myocardial electrical instability have been under active investigation in patients receiving early reperfusion therapy. The current understanding of the clinically important predictors of clinical outcomes in survivors of AMI is reviewed in this article.
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Affiliation(s)
- A D Michaels
- Department of Medicine, University of California at San Francisco Medical Center, 94143-0124, USA.
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Santoni-Rugiu F, Gomes JA. Methods of identifying patients at high risk of subsequent arrhythmic death after myocardial infarction. Curr Probl Cardiol 1999; 24:117-60. [PMID: 10091027 DOI: 10.1016/s0146-2806(99)90006-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- F Santoni-Rugiu
- Division of Electrophysiology and Electrocardiology, Mount Sinai Medical Center, New York, New York, USA
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