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Abstract
Heart failure (HF) with abnormal left ventricular (LV) ejection fraction should be identified and treated. Treat hypertension with diuretics, angiotensin-converting enzyme (ACE) inhibitors, and β-blockers. Treat myocardial ischemia with nitrates and β-blockers. Treat volume overload and HF with diuretics. Treat HF with ACE inhibitors and β-blockers. Sacubitril/valsartan may be used instead of an ACE inhibitor or ARB in chronic symptomatic HF and abnormal LV ejection fraction. Add isosorbide dinitrate/hydralazine in African Americans with class II to IV HF treated with diuretics, ACE inhibitors, and β-blockers. Exercise training is recommended. Indications for implantable cardioverter-defibrillator and cardiac resynchronization therapy are discussed.
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Affiliation(s)
- Wilbert S Aronow
- Division of Cardiology, Department of Medicine, Westchester Medical Center, New York Medical College, Macy Pavilion, Room 141, Valhalla, NY 10595, USA.
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Aronow WS. Current treatment of heart failure with reduction of left ventricular ejection fraction. Expert Rev Clin Pharmacol 2016; 9:1619-1631. [PMID: 27673415 DOI: 10.1080/17512433.2016.1242067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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3
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Peripheral Arterial Disease. TOPICS IN GERIATRIC REHABILITATION 2013. [DOI: 10.1097/tgr.0b013e31828aef5d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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4
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Aronow WS. Peripheral arterial disease of the lower extremities. Arch Med Sci 2012; 8:375-88. [PMID: 22662015 PMCID: PMC3361053 DOI: 10.5114/aoms.2012.28568] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 10/05/2011] [Accepted: 10/17/2011] [Indexed: 11/17/2022] Open
Abstract
Persons with peripheral arterial disease (PAD) are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from coronary artery disease. Smoking should be stopped and hypertension, dyslipidemia, diabetes mellitus, and hypothyroidism treated. Statins reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolemia. The serum low-density lipoprotein cholesterol should be reduced to < 70 mg/dl. Antiplatelet drugs such as aspirin or clopidogrel, angiotensin-converting enzyme inhibitors, and statins should be given to persons with PAD. β-Blockers should be given if coronary artery disease is present. Cilostazol improves exercise time until intermittent claudication. Exercise rehabilitation programs should be used. Revascularization should be performed if indicated.
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Son JI, Chin SO, Woo JT. Treatment Guidelines for Dyslipidemia: Summary of the Expanded Second Version. J Lipid Atheroscler 2012. [DOI: 10.12997/jla.2012.1.2.45] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Jong-Il Son
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital, Seoul, Korea
| | - Sang Ouk Chin
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital, Seoul, Korea
| | - Jeong-Taek Woo
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital, Seoul, Korea
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Protective vascular treatment of patients with peripheral arterial disease: guideline adherence according to year, age and gender. Canadian Journal of Public Health 2011. [PMID: 20364548 DOI: 10.1007/bf03405572] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To evaluate vasoprotective pharmacological treatment of patients with peripheral arterial disease (PAD) according to: 1) year, 2) age and 3) gender. METHODS An observational retrospective study was conducted to evaluate the systemic vascular treatment of a population-based cohort of patients with PAD > or = 50 years old, discharged from a tertiary-care teaching hospital between January 1, 1997 and December 11, 2006. Data were obtained from the Régie de l'assurance maladie du Québec. Drugs evaluated included antiplatelet agents (APs), statins (STs) and angiotensin converting enzyme inhibitors (ACEIs), and a combination of all three. Proportions of patients treated were compared according to year, age and gender using Chi-square. RESULTS The mean age of the study population (5962 individuals) was 73.2 +/- 9.1 years; 43.8% were women. After hospital discharge, 71.6%, 47.6%, 42.2% and 20.6% were taking respectively, an AP, statin, ACEI or all three. Protective treatment improved significantly from 1997 to 2006. Significantly more subjects 50-64 years used a statin or all three agents, compared to subjects > or = 65 years (statins: 56.6% vs. 45.8%, all three: 26.2% vs. 19.5%; p < 0.001). Significantly more men than women used statins (49.1% vs. 45.6%; p < 0.001) and ACEIs (44.5% vs. 39.3%; p < 0.001). Similarily, use of all three agents was 22.4% for men and 18.2% for women (p < 0.001). CONCLUSIONS Although systemic vascular treatment received by patients with PAD has increased in the past years, it remains suboptimal, particularly for older patients and women. Strategies to improve adherence to treatment guidelines should be developed for these high-risk populations.
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Abstract
People are now living longer, largely because of a combination of falling rates of fertility and mortality, thus producing a greater proportion of older people in society. Thirty times more centenarians were alive in 2000 than in 1900, and the population growth in the elderly segment of society is expected to continue at an exponential rate. Vascular disease is responsible for more than a quarter of all deaths worldwide. More than 80% of individuals who die of coronary heart disease are older than 65 years. Although a myocardial infarction may be perceived as fatal, heart attacks do not always lead to death but to conditions such as congestive heart failure, ischemic cardiomyopathy, and angina, which greatly impact quality of life. These issues are only a few that must be contemplated when considering the clinical and economic effects of preventive therapies in the elderly population.
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Affiliation(s)
- Nicole Ducharme
- Division of Endocrinology, Saint Louis University Medical Center, 1402 South Grand Boulevard, Donco Building, 2nd Floor, St. Louis, MO 63104, USA.
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López-Jiménez L, Camafort M, Tiberio G, Carmona JA, Guijarro C, Martínez-Peñalver F, Monreal M. Secondary Prevention of Arterial Disease in Very Elderly People: Results From a Prospective Registry (FRENA). Angiology 2008; 59:427-34. [DOI: 10.1177/0003319707309299] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is little information on the effectiveness of secondary prevention interventions in very elderly patients. In this article, the incidence of major cardiovascular events during a 12-month follow-up period in a series of consecutive patients with coronary, cerebrovascular, or peripheral artery disease is analyzed. As of October 2006, 1264 patients had been enrolled. Of these, 324 (26%) were ≥75 years of age. Their incidence rate of 22 events per 100 patient-years (95% CI, 17-28) was over 2-fold the 7.9 (95% CI, 6.2-10) found in those <75 years of age. Among them, only chronic heart failure and diabetes were independently associated with an increased risk for major events, whereas the use of angiotensin II antagonists was associated with a lower risk. Patients ≥75 years of age had an over 2-fold higher incidence of major cardiovascular events. The use of angiotensin II antagonists was associated with a lower risk.
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Affiliation(s)
| | | | | | | | | | | | - Manuel Monreal
- Hospital Universitari Germans Trias i Pujol, Barcelona (MM), Spain,
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Aronow WS. Treatment of Heart Failure with Abnormal Left Ventricular Systolic Function in the Elderly. Heart Fail Clin 2007; 3:423-36. [PMID: 17905378 DOI: 10.1016/j.hfc.2007.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This article summarizes the four stages of heart failure (HF) as defined by the American College of Cardiology and the American Heart Association and discusses the treatments for elderly patients with HF and abnormal left ventricular systolic function. The article explains the important role of diuretics, the first-line drugs in the treatment of older patients with HF and volume overload. Other treatments described include angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, aldosterone antagonists, isosorbide dinitrate plus hydralazine, digoxin, and calcium channel blockers. The article explains the role each of these plays and reports on studies that have examined and compared various treatments.
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Affiliation(s)
- Wilbert S Aronow
- Department of Medicine, Division of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA.
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Aronow WS. Treatment of Heart Failure with Abnormal Left Ventricular Systolic Function in the Elderly. Clin Geriatr Med 2007; 23:61-81. [PMID: 17126755 DOI: 10.1016/j.cger.2006.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This article summarizes the four stages of heart failure (HF) as defined by the American College of Cardiology and the American Heart Association and discusses the treatments for elderly patients with HF and abnormal left ventricular systolic function. The article explains the important role of diuretics, the first-line drugs in the treatment of older patients with HF and volume overload. Other treatments described include angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, aldosterone antagonists, isosorbide dinitrate plus hydralazine, digoxin, and calcium channel blockers. The article explains the role each of these plays and reports on studies that have examined and compared various treatments.
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Affiliation(s)
- Wilbert S Aronow
- Department of Medicine, Division of Cardiology, Westchester Medical Center, New York Medical College, Macy Pavilion, Room 138, Valhalla, NY 10595, USA.
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11
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Abstract
Peripheral arterial disease (PAD) may be asymptomatic, may be associated with intermittent claudication or may be associated with critical limb ischaemia. Coronary artery disease (CAD) and other atherosclerotic vascular disorders may coexist with PAD. Persons with PAD are at increased risk for all-cause mortality, cardiovascular mortality and mortality from CAD. Smoking should be stopped and hypertension, diabetes mellitus, dyslipidaemia and hypothyroidism treated. HMG-CoA reductase inhibitors (statins) reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolaemia. Antiplatelet drugs such as aspirin or clopidogrel (especially the latter), ACE inhibitors and statins should be given to all persons with PAD. beta-Adrenoceptor antagonists should be given if CAD is present. The phosphodiesterase type 3 inhibitor cilostazol improves exercise time until intermittent claudication. Chelation therapy should be avoided. Correct implementation of medical therapy significantly reduces the excess mortality associated with PAD. In addition, medical therapy may result in significant improvements in walking ability that may obviate the need for lower extremity angioplasty with stenting and bypass surgery.
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Affiliation(s)
- Wilbert S Aronow
- Department of Medicine, Cardiology Division, New York Medical College, Valhalla, New York 10595, USA.
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12
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Abstract
Underlying causes, risk factors, and precipitating causes of heart failure (HF) should be treated. Drugs known to precipitate or aggravate HF such as nonsteroidal antiinflammatory drugs should be stopped. Patients with HF and a low left ventricular ejection fraction (systolic heart failure) or normal ejection fraction (diastolic HF) should be treated with diuretics if fluid retention is present, with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor because of cough, angioneurotic edema, rash, or altered taste sensation, and with a beta blocker unless contraindicated. If severe systolic HF persists, an aldosterone antagonist should be added. If HF persists, isosorbide dinitrate plus hydralazine should be added. Calcium channel blockers should be avoided if systolic HF is present. Digoxin should be avoided in men and women with diastolic HF if sinus rhythm is present and in women with systolic HF. Digoxin should be given to men with systolic HF if symptoms persist, but the serum digoxin level should be maintained between 0.5 and 0.8 ng/mL.
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Affiliation(s)
- Wilbert S Aronow
- Department of Medicine, Division of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, New York 10595, USA.
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Aronow WS. Drug Treatment of Systolic and of Diastolic Heart Failure in Elderly Persons. J Gerontol A Biol Sci Med Sci 2005; 60:1597-605. [PMID: 16424295 DOI: 10.1093/gerona/60.12.1597] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Underlying causes, risk factors, and precipitating causes of heart failure (HF) should be treated. Patients with HF and an abnormal left ventricular ejection fraction (systolic HF) or normal left ventricular ejection fraction (diastolic HF) should be treated with diuretics if fluid retention is present, with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor because of cough, angioneurotic edema, rash, or altered taste sensation, and with a beta blocker unless contraindicated. If severe systolic HF persists, an aldosterone antagonist should be added. If HF persists, isosorbide dinitrate plus hydralazine should be added. Calcium channel blockers should be avoided if systolic HF is present. Digoxin should be avoided in men and women with diastolic HF if sinus rhythm is present and in women with systolic HF. Digoxin should be given to men with systolic HF if symptoms persist, but the serum digoxin level should be maintained between 0.5 and 0.8 ng/ml. Cardiac synchronized pacing should be considered in patients with severe systolic HF despite optimal medical therapy, with sinus rhythm, and with ventricular dyssynchrony.
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Affiliation(s)
- Wilbert S Aronow
- Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY 10595, USA.
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Abstract
Peripheral arterial disease (PAD) may be asymptomatic, may be associated with intermittent claudication, or may be associated with critical limb ischemia. Coronary artery disease (CAD) and other atherosclerotic vascular disorders may coexist with PAD. Persons with PAD are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from CAD. Modifiable risk factors such as cessation of cigarette smoking and control of dyslipidemia, hypertension, and diabetes should be treated. Statins reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolemia. Antiplatelet drugs such as aspirin or clopidogrel, especially clopidogrel, and angiotensin-converting enzyme inhibitors should be given to all persons with PAD. beta-Blockers should be given if CAD is present. Exercise rehabilitation programs and cilostazol improve exercise time until intermittent claudication. Indications for lower-extremity angioplasty, preferably with stenting, or bypass surgery are 1) incapacitating claudication in persons interfering with work or lifestyle; 2) limb salvage in persons with limb-threatening ischemia as manifested by rest pain, nonhealing ulcers, and/or infection or gangrene; and 3) vasculogenic impotence. However, amputation should be performed if tissue loss has progressed beyond the point of salvage, if surgery is too risky, if life expectancy is very low, or if functional limitations diminish the benefit of limb salvage.
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Affiliation(s)
- Wilbert S Aronow
- Divisions of Cardiology and Geriatrics, Department of Medicine, New York Medical College/Westchester Medical Center, Valhalla, NY 10595, USA.
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15
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Abstract
Abstract
Elderly persons after myocardial infarction should have their modifiable coronary artery risk factors intensively treated. Hypertension should be treated with beta blockers and angiotensin-converting enzyme inhibitors. The blood pressure should be reduced to <140/85 mmHg and to ≥130/80 mmHg in persons with diabetes or renal insufficiency. The serum low-density lipoprotein cholesterol should be reduced to <100 mg/dl with statins if necessary. Aspirin or clopidogrel, beta blockers, and angiotensin-converting enzyme inhibitors should be given indefinitely unless contraindications exist to the use of these drugs. Long-acting nitrates are effective antianginal and antiischemic drugs. There are no Class I indications for the use of calcium channel blockers after myocardial infarction. Postinfarction patients should not receive Class I antiarrhythmic drugs, sotalol, or amiodarone. An automatic implantable cardioverter-defibrillator should be implanted in postinfarction patients at very high risk for sudden cardiac death. Hormonal therapy should not be used in postmenopausal women after myocardial infarction. The two indications for coronary revascularization are prolongation of life and relief of unacceptable symptoms despite optimal medical management.
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Affiliation(s)
- Wilbert S Aronow
- Division of Cardiology, New York Medical College, Macy Pavilion, Rm. 138, Valhalla, NY 10595, USA.
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Aronow WS, Ahn C, Gutstein H. Reduction of new coronary events and new atherothrombotic brain infarction in older persons with diabetes mellitus, prior myocardial infarction, and serum low-density lipoprotein cholesterol >/=125 mg/dl treated with statins. J Gerontol A Biol Sci Med Sci 2002; 57:M747-50. [PMID: 12403804 DOI: 10.1093/gerona/57.11.m747] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND We report the incidence of new coronary events and new atherothrombotic brain infarction (ABI) in older men and women with diabetes mellitus, prior myocardial infarction, and a serum low-density lipoprotein (LDL) cholesterol of >/=125 mg/dl treated with statins and with no lipid-lowering drug. METHODS The incidence of new coronary events and of new ABI was investigated in an observational prospective study of 529 diabetics, mean age 79 +/- 9 years, with prior myocardial infarction and a serum LDL cholesterol of >/=125 mg/dl treated with statins (279 persons or 53%) and no lipid-lowering drug (250 persons or 47%). Follow-up was 29 +/- 18 months. RESULTS At follow-up, the stepwise Cox regression model showed that after controlling for other risk factors, the use of statins was associated with a 37% significant independent reduction in the incidence of new coronary events and with a 47% significant independent reduction in the incidence of new ABI. CONCLUSIONS Use of statins was associated with a 37% significant, independent reduction in new coronary events and a 47% significant, independent reduction in new ABI in older men and women with diabetes mellitus, prior myocardial infarction, and a serum LDL cholesterol of >/=125 mg/dl. Elderly diabetics with prior myocardial infarction and increased serum LDL cholesterol should especially be treated with statins.
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Affiliation(s)
- Wilbert S Aronow
- Cardiology Division, Department of Medicine,Westchester Medical Center/New York Medical College, Valhalla, USA.
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Aronow WS. What is the appropriate treatment of hypertension in elders? J Gerontol A Biol Sci Med Sci 2002; 57:M483-6. [PMID: 12145359 DOI: 10.1093/gerona/57.8.m483] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Aronow WS. Should hypercholesterolemia in older persons be treated to reduce cardiovascular events? J Gerontol A Biol Sci Med Sci 2002; 57:M411-3. [PMID: 12084800 DOI: 10.1093/gerona/57.7.m411] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Morley JE, Flaherty JH. It's never too late: health promotion and illness prevention in older persons. J Gerontol A Biol Sci Med Sci 2002; 57:M338-42. [PMID: 12023261 DOI: 10.1093/gerona/57.6.m338] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Affiliation(s)
- C A Miller
- Care & Counseling, Miller/Wetzler Associates, Cleveland, OH, USA
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