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Carvalho TD, Freitas OGAD, Chalela WA, Hossri CAC, Milani M, Buglia S, Precoma DB, Falcão AMGM, Mastrocola LE, Castro I, Albuquerque PFD, Coutinho RQ, Brito FSD, Alves JDC, Serra SM, Santos MAD, Colombo CSSDS, Stein R, Herdy AH, Silveira ADD, Castro CLBD, Silva MMFD, Meneghello RS, Ritt LEF, Malafaia FL, Marinucci LFB, Pena JLB, Almeida AEMD, Vieira MLC, Stier Júnior AL. Brazilian Guideline for Exercise Test in the Adult Population - 2024. Arq Bras Cardiol 2024; 121:e20240110. [PMID: 38896581 DOI: 10.36660/abc.20240110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Affiliation(s)
- Tales de Carvalho
- Clínica de Prevenção e Reabilitação Cardiosport, Florianópolis, SC - Brasil
- Universidade do Estado de Santa Catarina, Florianópolis, SC - Brasil
| | | | - William Azem Chalela
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
| | | | - Mauricio Milani
- Universidade de Brasília (UnB), Brasília, DF, Brasil
- Hasselt University, Hasselt - Bélgica
- Jessa Ziekenhuis, Hasselt - Bélgica
| | - Susimeire Buglia
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | | | - Andréa Maria Gomes Marinho Falcão
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
| | | | - Iran Castro
- Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brasil
| | | | | | | | | | - Salvador Manoel Serra
- Instituto Estadual de Cardiologia Aloysio de Castro (IECAC), Rio de Janeiro, RJ - Brasil
| | - Mauro Augusto Dos Santos
- Instituto Nacional de Cardiologia do Rio de Janeiro, Rio de Janeiro, RJ - Brasil
- Linkcare Saúde, Rio de Janeiro, RJ - Brasil
| | | | - Ricardo Stein
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | - Artur Haddad Herdy
- Clínica de Prevenção e Reabilitação Cardiosport, Florianópolis, SC - Brasil
| | - Anderson Donelli da Silveira
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
- Hospital de Clínicas de Porto Alegre, Porto Alegre, RS - Brasil
- Hospital Moinhos de Vento, Porto Alegre, RS - Brasil
| | - Claudia Lucia Barros de Castro
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
- CLINIMEX - Clínica de Medicina de Exercício, Rio de Janeiro, RJ - Brasil
| | | | | | - Luiz Eduardo Fonteles Ritt
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brasil
- Instituto D'Or de Pesquisa e Ensino, Salvador, BA - Brasil
- Hospital Cárdio Pulmonar, Salvador, BA - Brasil
| | - Felipe Lopes Malafaia
- Hospital Samaritano Paulista, São Paulo, SP - Brasil
- UnitedHealth Group Brasil, São Paulo, SP - Brasil
| | - Leonardo Filipe Benedeti Marinucci
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
| | - José Luiz Barros Pena
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brasil
- Hospital Felício Rocho, Belo Horizonte, MG - Brasil
| | | | - Marcelo Luiz Campos Vieira
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
- Hospital Israelita Albert Einstein, São Paulo, SP - Brasil
| | - Arnaldo Laffitte Stier Júnior
- Universidade Federal do Paraná (UFPR), Curitiba, PR - Brasil
- Secretaria Municipal de Saúde Curitiba, Curitiba, PR - Brasil
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Zimarino M, Montebello E, Radico F, Gallina S, Perfetti M, Iachini Bellisarii F, Severi S, Limbruno U, Emdin M, De Caterina R. ST segment/heart rate hysteresis improves the diagnostic accuracy of ECG stress test for coronary artery disease in patients with left ventricular hypertrophy. Eur J Prev Cardiol 2016; 23:1632-9. [PMID: 27353130 DOI: 10.1177/2047487316655259] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 05/27/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND The exercise electrocardiographic stress test (ExET) is the most widely used non-invasive diagnostic method to detect coronary artery disease. However, the sole ST depression criteria (ST-max) have poor specificity for coronary artery disease in patients with left ventricular hypertrophy. We hypothesised that ST-segment depression/heart rate hysteresis, depicting the relative behaviour of ST segment depression during the exercise and recovery phase of the test might increase the diagnostic accuracy of ExET for coronary artery disease detection in such patients. METHODS In three cardiology centres, we studied 113 consecutive patients (mean age 66 ± 2 years; 88% men) with hypertension-related left ventricular hypertrophy at echocardiography, referred to coronary angiography after an ExET. The following ExET criteria were analysed: ST-max, chronotropic index, heart rate recovery, Duke treadmill score, ST-segment depression/heart rate hysteresis. RESULTS We detected significant coronary artery disease at coronary angiography in 61 patients (53%). At receiver-operating characteristic analysis, ST-segment depression/heart rate hysteresis had the highest area under the curve value (0.75, P < 0.001 when compared with the 'neutral' receiver-operating characteristic curve value of 0.5). Area under the curve values were 0.68 (P < 0.01) for the chronotropic index, 0.58 (P = NS) for heart rate recovery, 0.57 (P = NS) for ST-max and 0.52 (P = NS) for the Duke treadmill score. CONCLUSIONS Among currently available ExET diagnostic variables, ST-segment depression/heart rate hysteresis offers a substantially better diagnostic accuracy for coronary artery disease than conventional criteria in patients with hypertension-related left ventricular hypertrophy.
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Affiliation(s)
- Marco Zimarino
- University Cardiology Division and Institute of Cardiology, "G. d'Annunzio" University, Italy
| | - Elena Montebello
- University Cardiology Division and Institute of Cardiology, "G. d'Annunzio" University, Italy
| | - Francesco Radico
- University Cardiology Division and Institute of Cardiology, "G. d'Annunzio" University, Italy
| | - Sabina Gallina
- University Cardiology Division and Institute of Cardiology, "G. d'Annunzio" University, Italy
| | - Matteo Perfetti
- University Cardiology Division and Institute of Cardiology, "G. d'Annunzio" University, Italy
| | | | | | | | | | - Raffaele De Caterina
- University Cardiology Division and Institute of Cardiology, "G. d'Annunzio" University, Italy
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Zimarino M, Barnabei L, Madonna R, Palmieri G, Radico F, Tatasciore A, Bellisarii FI, Perrucci GM, Corazzini A, De Caterina R. A comparison of the diagnostic performance of the ST/HR hysteresis with cardiopulmonary stress testing parameters in detecting exercise-induced myocardial ischemia. Int J Cardiol 2013; 168:1274-9. [DOI: 10.1016/j.ijcard.2012.12.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 11/15/2012] [Accepted: 12/01/2012] [Indexed: 11/25/2022]
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Svart K, Lehtinen R, Nieminen T, Nikus K, Lehtimäki T, Kööbi T, Niemelä K, Niemi M, Turjanmaa V, Kähönen M, Viik J. Exercise electrocardiography detection of coronary artery disease by ST-segment depression/heart rate hysteresis in women: The Finnish Cardiovascular Study. Int J Cardiol 2010; 140:182-8. [DOI: 10.1016/j.ijcard.2008.11.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Revised: 08/08/2008] [Accepted: 11/08/2008] [Indexed: 11/15/2022]
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Ellestad MH. Unconventional Electrocardiographic Signs of Ischemia During Exercise Testing. Am J Cardiol 2008; 102:949-53. [DOI: 10.1016/j.amjcard.2008.05.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Revised: 05/10/2008] [Accepted: 05/10/2008] [Indexed: 11/16/2022]
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Häggmark S, Haney MF, Johansson G, Reiz S, Näslund U. Contributions of myocardial ischemia and heart rate to ST segment changes in patients with or without coronary artery disease. Acta Anaesthesiol Scand 2008; 52:219-28. [PMID: 17999710 DOI: 10.1111/j.1399-6576.2007.01507.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND ST changes related to ischemia at different heart rates (HRs) have not been well described. We aimed to analyze ST dynamic changes by vectorcardiography (VCG) during pacing-induced HR changes for subjects with proven coronary artery disease (CAD) and without (non-CAD). METHODS Symptomatic CAD patients scheduled for elective surgery were enrolled along with a non-CAD group. During anesthesia, both groups were placed at multiple ascending levels. VCG ST data, and in particular in ST change vector magnitude (STC-VM) from baseline, along with arterial and great coronary artery vein (GCV) blood samples were collected to determine regional myocardial lactate production. RESULTS A total of 35 CAD and 10 non-CAD patients were studied over six incremental 10 beat/min HR increases. STC-VM mean levels increased in the CAD group from 9+/-5 to 131+/-37 microV (standard deviation) compared with non-CAD subjects with 8+/-3-76+/-34 microV. Myocardial ischemia (lactate production) was noted at higher HRs and the positive predictive value for STC-VM to detect ischemia was 58% with the negative predictive value being 88%. STC-VM at 54 microV showed a sensitivity of 88% and a specificity of 75% for identification of ischemia. CONCLUSIONS Both HR and ischemia at higher HRs contribute to VCG ST elevation. Established ST ischemia detection concerning HR levels is suboptimal, and further attention to the effects of HR on ST segments is needed to improve electrocardiographic ischemia criteria.
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Affiliation(s)
- S Häggmark
- Heart Centre, University Hospital, Umeå, Sweden.
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Green M, Ohlsson M, Forberg JL, Björk J, Edenbrandt L, Ekelund U. Best leads in the standard electrocardiogram for the emergency detection of acute coronary syndrome. J Electrocardiol 2007; 40:251-6. [PMID: 17292385 DOI: 10.1016/j.jelectrocard.2006.12.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2006] [Accepted: 12/15/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to determine which leads in the standard 12-lead electrocardiogram (ECG) are the best for detecting acute coronary syndrome (ACS) among chest pain patients in the emergency department. METHODS Neural network classifiers were used to determine the predictive capability of individual leads and combinations of leads from 862 ECGs from chest pain patients in the emergency department at Lund University Hospital. RESULTS The best individual lead was aVL, with an area under the receiver operating characteristic curve of 75.5%. The best 3-lead combination was III, aVL, and V2, with a receiver operating characteristic area of 82.0%, compared with the 12-lead ECG performance of 80.5%. CONCLUSIONS Our results indicate that leads III, aVL, and V2 are sufficient for computerized prediction of ACS. The present results are likely important in situations where the 12-lead ECG is impractical and for the creation of clinical decision support systems for ECG prediction of ACS.
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Affiliation(s)
- Michael Green
- Department of Theoretical Physics, Lund University, Lund, Sweden.
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Nieminen T, Lehtinen R, Viik J, Lehtimäki T, Niemelä K, Nikus K, Niemi M, Kallio J, Kööbi T, Turjanmaa V, Kähönen M. The Finnish Cardiovascular Study (FINCAVAS): characterising patients with high risk of cardiovascular morbidity and mortality. BMC Cardiovasc Disord 2006; 6:9. [PMID: 16515696 PMCID: PMC1413555 DOI: 10.1186/1471-2261-6-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2006] [Accepted: 03/03/2006] [Indexed: 01/17/2023] Open
Abstract
Background The purpose of the Finnish Cardiovascular Study (FINCAVAS) is to construct a risk profile – using genetic, haemodynamic and electrocardiographic (ECG) markers – of individuals at high risk of cardiovascular diseases, events and deaths. Methods and design All patients scheduled for an exercise stress test at Tampere University Hospital and willing to participate have been and will be recruited between October 2001 and December 2007. The final number of participants is estimated to reach 5,000. Technically successful data on exercise tests using a bicycle ergometer have been collected of 2,212 patients (1,400 men and 812 women) by the end of 2004. In addition to repeated measurement of heart rate and blood pressure, digital high-resolution ECG at 500 Hz is recorded continuously during the entire exercise test, including the resting and recovery phases. About 20% of the patients are examined with coronary angiography. Genetic variations known or suspected to alter cardiovascular function or pathophysiology are analysed to elucidate the effects and interactions of these candidate genes, exercise and commonly used cardiovascular medications. Discussion FINCAVAS compiles an extensive set of data on patient history, genetic variation, cardiovascular parameters, ECG markers as well as follow-up data on clinical events, hospitalisations and deaths. The data enables the development of new diagnostic and prognostic tools as well as assessments of the importance of existing markers.
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Affiliation(s)
- Tuomo Nieminen
- Department of Pharmacological Sciences, Medical School, University of Tampere, Finland
| | - Rami Lehtinen
- Department of Clinical Physiology, Tampere University Hospital and Medical School, University of Tampere, Finland
- Tampere Polytechnic – University of Applied Sciences, Finland
| | - Jari Viik
- Ragnar Granit Institute, Tampere University of Technology, Finland
| | - Terho Lehtimäki
- Laboratory of Atherosclerosis Genetics, Department of Clinical Chemistry, Tampere University Hospital, Finland
- Centre for Laboratory Medicine, Medical School, University of Tampere, Finland
| | - Kari Niemelä
- Heart Centre, Department of Cardiology, Tampere University Hospital, Finland
| | - Kjell Nikus
- Heart Centre, Department of Cardiology, Tampere University Hospital, Finland
| | - Mari Niemi
- Heart Centre, Department of Cardiology, Tampere University Hospital, Finland
| | - Janne Kallio
- Ragnar Granit Institute, Tampere University of Technology, Finland
| | - Tiit Kööbi
- Department of Clinical Physiology, Tampere University Hospital and Medical School, University of Tampere, Finland
| | - Väinö Turjanmaa
- Department of Clinical Physiology, Tampere University Hospital and Medical School, University of Tampere, Finland
| | - Mika Kähönen
- Department of Clinical Physiology, Tampere University Hospital and Medical School, University of Tampere, Finland
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Häggmark S, Haney MF, Jensen SM, Johansson G, Näslund U. ST-segment deviations during pacing-induced increased heart rate in patients without coronary artery disease. Clin Physiol Funct Imaging 2005; 25:246-52. [PMID: 15972028 DOI: 10.1111/j.1475-097x.2005.00613.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION In order to interpret ST-segment changes as an indicator of ischemia in patients with higher heart rates (HRs), the relation between ST-segment levels and HR needs to be well defined in subjects without coronary artery disease. METHODS Eighteen patients with normal ECGs in the catheterization laboratory, after radiofrequency ablation of AV nodal re-entry tachycardia or an accessory pathway were included. Computerized online vectorcardiography (VCG) was performed during step-wise atrial pacing-induced increases in HR up to 150 beats min(-1) (bpm). The ST-vector magnitude (ST-VM) and the relative ST change vector magnitude (STC-VM) were analysed at the J point, J + 20 and J + 60 ms. RESULTS There was no divergence in the course of ST-VM or STC-VM based on J point + 0, 20, or 60 ms during increasing HR. The STC-VM mean values increased progressively during increases in HR above 100 bpm, with an average increase in STC-VM of 15-20 microV per 10 bpm increases in HR. The ST-VM response during HR increases showed a heterogeneous and unpredictable pattern. CONCLUSION The STC-VM increases linearly with rising HRs above 100 bpm. The STC-VM can exceed widely recognized ischemic thresholds during higher HRs in the absence of ischemia. The choice of J point time to ST-VM measurements as tested here is not important for the STC-VM relation to HR at these HR levels. Further clinical testing is needed to improve the diagnostic specificity of STC-VM measurements during increased HRs.
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Affiliation(s)
- Sören Häggmark
- Cardiothoracic Surgery, Heart Centre, University Hospital, Umeå, Sweden.
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Froelicher V, Shetler K, Ashley E. Better decisions through science: exercise testing scores. Curr Probl Cardiol 2003. [DOI: 10.1016/j.cpcardiol.2003.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, Mark DB, McCallister BD, Mooss AN, O'Reilly MG, Winters WL, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol 2002; 40:1531-40. [PMID: 12392846 DOI: 10.1016/s0735-1097(02)02164-2] [Citation(s) in RCA: 838] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, Mark DB, McCallister BD, Mooss AN, O'Reilly MG, Winters WL, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation 2002; 106:1883-92. [PMID: 12356646 DOI: 10.1161/01.cir.0000034670.06526.15] [Citation(s) in RCA: 741] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Abstract
Statistical tools can be used to create scores for assisting in the diagnosis of coronary artery disease and assessing prognosis. General practitioners and internists frequently function as gatekeepers, deciding which patients must be referred to the cardiologist. Therefore, they need to use the basic tools they have available (ie, history, physical examination and the exercise test) in an optimal fashion. Scores derived from multivariable statistical techniques considering clinical and exercise data have demonstrated superior discriminating power compared with diagnosis only using the ST segment response. In addition, by stratifying patients as to probability of disease and prognosis, they provide a more practical management strategy than a response of normal or abnormal. Although computers, as part of information management systems, can calculate complicated equations and derive these scores, physicians are reluctant to trust them. However, when represented as nomograms or simple additive discrete pieces of information, scores are more readily accepted. The scores have been compared with physician judgment and have been found to estimate the presence of coronary disease and prognosis as well as expert cardiologists and often better than nonspecialists. However, the discriminating power of specific variables from the medical history and exercise test remains unclear because of inadequate study design and differences in study populations. Should expired gases be substituted for estimated METs? Should ST/heart rate index be used instead of putting ST depression and heart rate separately into the models? Should right-sided chest leads and heart rate in recovery be considered? There is a need for further evaluation of these easily obtained variables to improve the accuracy of prediction algorithms, especially in women. The portability and reliability of scores must be ensured because access to specialized care must be safeguarded. Assessment of the clinical and exercise test data and application of the newer scores can empower the clinician to assure the cardiac patient access to appropriate and cost-effective cardiologic care.
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Affiliation(s)
- Victor Froelicher
- Cardiology Division, Veterans Affairs Palo Alto Health Care System, Stanford University, Palo Alto, CA 94304, USA.
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