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National High Blood Pressure Education Program This set of slides is provided by the U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service.

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Presentation on theme: "National High Blood Pressure Education Program This set of slides is provided by the U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service."— Presentation transcript:

1 National High Blood Pressure Education Program This set of slides is provided by the U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service National Institutes of Health National Heart, Lung, and Blood Institute National High Blood Pressure Education Program Full text of JNC VI may be downloaded from the NHLBI web site. NIH Publication No November 1997

2 National High Blood Pressure Education Program National Heart, Lung, and Blood Institute (NHLBI) publications fall within the public domain (as do all Government publications). Hence, they are not copyrighted and may be reproduced or reprinted. NHLBI does ask, however, that reprinted material include a credit line acknowledging NHLBI as the source. Communications and Public Information Branch Office of Prevention, Education, and Control NIH Publication No November 1997

3 DISCLAIMER The appearance of rotating Ads on this web site bears no relationship to JNC VI. The slide set is provided for educational purposes. It may be disseminated freely, but may NOT to be used for commercial or product endorsement purposes. MedSlides Board of Directors

4 National High Blood Pressure Education Program The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) NIH Publication No November 1997

5 slide 5 Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Henry R. Black, M.D., Chair of Chapter 1 Rush-Presbyterian-St. Lukes Medical Center Jerome D. Cohen, M.D., Chair of Chapter 2 St. Louis University Health Sciences Center Norman M. Kaplan, M.D., Chair of Chapter 3 University of Texas Southwestern Medical School Keith C. Ferdinand, M.D., Chair of Chapter 4 Heartbeats Life Center Aram V. Chobanian, M.D. Boston University Harriet P. Dustan, M.D. University of Vermont College of Medicine Ray W. Gifford, Jr., M.D. Cleveland Clinic Foundation Marvin Moser, M.D. Yale University School of Medicine Executive Committee: Sheldon G. Sheps, M.D., Chair Mayo Clinic and Mayo Foundation and Mayo Medical School

6 slide 6 National High Blood Pressure Education Program Coordinating Committee Agency for Health Care Policy and Research American Academy of Family Physicians American Academy of Insurance Medicine American Academy of Neurology American Academy of Ophthalmology American Academy of Physician Assistants American Association of Occupational Health Nurses American College of Cardiology American College of Chest Physicians American College of Occupational and Environmental Medicine American College of Physicians American College of Preventive Medicine American Dental Association Health Care Financing Administration Health Resources and Services Administration International Society on Hypertension in Blacks National Black Nurses Association, Inc. National Center for Health Statistics, Centers for Disease Control and Prevention National Heart, Lung, and Blood Institute National Hypertension Association National Institute of Diabetes and Digestive and Kidney Diseases National Kidney Foundation National Medical Association National Optometric Association National Stroke Association NHLBI Ad Hoc Committee on Minority Populations Society for Nutrition Education U.S. Department of Veterans Affairs American Diabetes Association American Dietetic Association American Heart Association American Hospital Association American Medical Association American Nurses Association, Inc. American Optometric Association American Osteopathic Association American Pharmaceutical Association American Podiatric Medical Association American Public Health Association American Red Cross American Society of Health-System Pharmacists American Society of Hypertension Association of Black Cardiologists Citizens for Public Action on High Blood Pressure and Cholesterol, Inc. Council on Geriatric Cardiology

7 slide 7 JNC VI Table of Contents 1.Introduction 2.Blood Pressure Measurement and Clinical Evaluation 3.Prevention and Treatment of High Blood Pressure 4.Special Populations and Situations

8 slide 8 Purpose of the JNC VI Report To use evidence-based medicine and consensus to report on contemporary approaches to hypertension prevention and control for use by primary care clinicians.

9 slide 9 Progress of the National High Blood Pressure Education Program Increased awareness, treatment, and control Decreased morbidity and mortality from stroke and coronary heart disease (CHD)

10 slide 10 Public Health Challenges for the National High Blood Pressure Education Program Prevent blood pressure rise with age Decrease prevalence Increase awareness and detection Improve control Reduce cardiovascular risks

11 slide 11 Public Health Challenges for the National High Blood Pressure Education Program (continued) Recognize importance of controlled isolated systolic hypertension Recognize importance of high-normal blood pressure Reduce demographic variations Improve opportunities for treatment

12 slide 12 Awareness, Treatment, and Control of High Blood Pressure in Adults*

13 slide 13 The decline in age-adjusted mortality for stroke in the total population is 59.0%. *Age-adjusted to the 1940 U.S. census population. Percent Decline in Age-Adjusted* Mortality Rates for Stroke by Sex and Race: United States,

14 slide 14 The decline in age-adjusted mortality for CHD in the total population is 53.2%. *Age-adjusted to the 1940 U.S. census population. Percent Decline in Age-Adjusted* Mortality Rates for CHD by Sex and Race: United States,

15 slide 15 Incidence of Reported End-Stage Renal Disease Therapy, * *Provisional data. Adjusted for age, race, and sex.

16 slide 16 Prevalence of Heart Failure, by Age, and

17 slide 17 Summary of Chapter 1 Hypertension awareness, treatment, and control rates have increased over the past 3 decades. The rates of increase have lessened since JNC V. Age-adjusted mortality for stroke and CHD declined during this time but now appear to be leveling. The incidence of end-stage renal disease and the prevalence of heart failure are increasing.

18 slide 18 Summary of Chapter 1 (continued) Randomized controlled trials provide the best method of estimating benefit of treatment and source of information for clinical policy, but they have limitations. Prevention and treatment of hypertension and target organ disease remain important public health challenges that must be addressed.

19 slide 19 Blood Pressure Measurement Patients should be seated with back supported and arm bared and supported. Patients should refrain from smoking or ingesting caffeine for 30 minutes prior to measurement. Measurement should begin after at least 5 minutes of rest. Appropriate cuff size and calibrated equipment should be used. Both SBP and DBP should be recorded. Two or more readings should be averaged.

20 slide 20 Advantages of Self-Measurement Identifies white-coat hypertension Assesses response to medication Improves adherence to treatment Potentially reduces costs Usually provides lower readings than those recorded in clinic (hypertension is defined as SBP > 135 or DBP > 85 mm Hg)

21 slide 21 Ambulatory Measurement Ambulatory monitoring can provide: –readings throughout day during usual activities –readings during sleep to assess nocturnal changes –measures of SBP and DBP load Ambulatory readings are usually lower than in clinic (hypertension is defined as SBP > 135 or DBP > 85 mm Hg)

22 slide 22 Classification of Blood Pressure for Adults

23 slide 23 Recommendations for Followup Based on Initial Measurements

24 slide 24 Evaluation Objectives To identify known causes To assess presence or absence of target organ damage and cardiovascular disease To identify other risk factors or disorders that may guide treatment

25 slide 25 Evaluation Components Medical history Physical examination Routine laboratory tests Optional tests

26 slide 26 Medical History Duration and classification of hypertension Patient history of cardiovascular disease Family history Symptoms suggesting causes of hypertension Lifestyle factors Current and previous medications

27 slide 27 Physical Examination Blood pressure readings (2 or more) Verification in contralateral arm Height, weight, and waist circumference Funduscopic examination Examination of the neck, heart, lungs, abdomen, and extremities Neurological assessment

28 slide 28 Laboratory Tests and Other Diagnostic Procedures Determine presence of target organ damage and other risk factors Seek specific causes of hypertension

29 slide 29 Laboratory Tests Recommended Before Initiating Therapy Urinalysis Complete blood count Blood chemistry (potassium, sodium, creatinine, and fasting glucose) Lipid profile (total cholesterol and HDL cholesterol) 12-lead electrocardiogram

30 slide 30 Optional Tests and Procedures Creatinine clearance Microalbuminuria 24-hour urinary protein Serum calcium Serum uric acid Fasting triglycerides LDL cholesterol Glycosolated hemoglobin Thyroid-stimulating hormone Plasma renin activity/ urinary sodium determination Limited echocardiography Ultrasonography Measurement of ankle/arm index

31 slide 31 Examples of Identifiable Causes of Hypertension Renovascular disease Renal parenchymal disease Polycystic kidneys Aortic coarctation Pheochromocytoma Primary aldosteronism Cushing syndrome Hyperparathyroidism Exogenous causes

32 slide 32 Components of Cardiovascular Risk in Patients With Hypertension Major Risk Factors: Smoking Dyslipidemia Diabetes mellitus Age older than 60 years Sex (men or postmenopausal women) Family history of cardiovascular disease

33 slide 33 Clinical Risk Factors for Stratification of Patients With Hypertension Heart diseases Stroke or transient ischemic attack Nephropathy Peripheral arterial disease Retinopathy

34 slide 34 Risk Stratification

35 slide 35 Treatment Strategies and Risk Stratification

36 slide 36 Summary of Chapter 2 Blood pressure classified as optimal, normal, high-normal, or stages 1, 2, or 3. Recommendations for detection, confirmation, and evaluation remain consistent with those in the JNC V report. In self-monitoring and ambulatory measurement, hypertension is now defined as SBP >135 mm Hg and DBP 85 mm Hg.

37 slide 37 Summary of Chapter 2 (continued) New sections discuss genetics and clinical clues to identifiable causes of hypertension. New tables list cardiovascular risk factors and describe risk stratification.

38 slide 38 Primary Prevention Primary prevention offers an opportunity to interrupt the costly cycle of managing hypertension. A population-wide approach can reduce morbidity and mortality. Most patients with hypertension do not sufficiently change their lifestyle or adhere to drug therapy enough to achieve control. Blood pressure rise with age is not inevitable. Lifestyle modifications have been shown to lower blood pressure.

39 slide 39 Goal of Hypertension Prevention and Management To reduce morbidity and mortality by the least intrusive means possible. This may be accomplished by achieving and maintaining: –SBP < 140 mm Hg –DBP < 90 mm Hg –controlling other cardiovascular risk factors

40 Continue adding agents from other classes. Consider referral to a hypertension specialist. Not at Goal Blood Pressure Substitute drug from different class Not at Goal Blood Pressure Initial Drug Choices Algorithm forTreatment of Hypertension Not at Goal Blood Pressure Begin or Continue Lifestyle Modifications No response or troublesome side effects Inadequate response but well tolerated Add agent from different class

41 slide 41 Not at Goal Blood Pressure Algorithm for Treatment of Hypertension (continued) Begin or Continue Lifestyle Modifications Lose weight Limit alcohol Increase physical activity Reduce Sodium Maintain potassium Maintain calcium and magnesium Stop smoking Reduce saturated fat, cholesterol

42 slide 42 Initial Drug Choices Algorithm for Treatment of Hypertension (continued) Not at Goal Blood Pressure (< 140/90 mm Hg) lower goals for patients with diabetes or renal disease Begin or Continue Lifestyle Modifications

43 slide 43 Not at Goal Blood Pressure Initial Drug Choices Uncomplicated Compelling Indications Not at Goal Blood Pressure Algorithm for Treatment of Hypertension (continued) – Start at low dose and titrate upward. – Low-dose combinations may be appropriate. Specific Indications

44 slide 44 Initial Drug Choices* Uncomplicated Diuretics -blockers Algorithm for Treatment of Hypertension (continued) *Based on randomized controlled trials.

45 slide 45 Initial Drug Choices* Algorithm for Treatment of Hypertension (continued) Compelling Indications Heart failure –ACE inhibitors –Diuretics Myocardial infarction -blockers (non-ISA) –ACE inhibitors (with systolic dysfunction) Diabetes mellitus (type 1) with proteinuria –ACE inhibitors Isolated systolic hypertension (older persons) –Diuretics preferred –Long-acting dihydropyridine calcium antagonists *Based on randomized controlled trials.

46 slide 46 Initial Drug Choices Specific indications for the following drugs: Algorithm for Treatment of Hypertension (continued) ACE inhibitors Angiotensin II receptor blockers -blockers - -blockers -blockers Calcium antagonists Diuretics

47 slide 47 Specific Drug Indications Angina – -blockers – Calcium antagonists Atrial tachycardia and fibrillation – -blockers – Nondihydropyridine calcium antagonists Some antihypertensive drugs may have favorable effects on comorbid conditions: Heart failure –Carvedilol –Losartan Myocardial infarction –Diltiazem –Verapamil

48 slide 48 Specific Indications (continued) Cyclosporine-induced hypertension –Calcium antagonists Diabetes mellitus (1 and 2) with proteinuria –ACE inhibitors (preferred) –Calcium antagonists Diabetes mellitus (type 2) –Low-dose diuretics Dyslipidemia -blockers Prostatism (benign prostatic hyperplasia) -blockers Renal insufficiency (caution in renovascular hypertension and creatinine 3 mg/dL [ mol/L]) –ACE inhibitors Some antihypertensive drugs may have favorable effects on comorbid conditions:

49 slide 49 Specific Indications (continued) Essential tremor –Noncardioselective -blockers Hyperthyroidism – -blockers Migraine – Noncardioselective -blockers – Nondihydropyridine calcium antagonists Osteoporosis – Thiazides Perioperative hypertension – -blockers Some antihypertensive drugs may have favorable effects on comorbid conditions:

50 slide 50 Not at Goal Blood Pressure (< 140/90 mm Hg) No response or troublesome side effects Inadequate response but well tolerated Substitute another drug from different class Add second agent from different class (diuretic if not already used) Not at Goal Blood Pressure (<140/90 mmHg) Initial Drug Choices Algorithm for Treatment of Hypertension (continued)

51 slide 51 Not at Goal Blood Pressure (< 140/90 mm Hg) Continue adding agents from other classes. Consider referral to a hypertension specialist. Substitute drug from different class Add second agent from different class Algorithm for Treatment of Hypertension (continued)

52 Continue adding agents from other classes. Consider referral to a hypertension specialist. Not at Goal Blood Pressure Substitute drug from different class Not at Goal Blood Pressure Initial Drug Choices Algorithm for Treatment of Hypertension Not at Goal Blood Pressure Begin or Continue Lifestyle Modifications No response or troublesome side effects Inadequate response but well tolerated Add agent from different class

53 slide 53 Lifestyle Modifications For Prevention and Management Lose weight if overweight. Limit alcohol intake. Increase aerobic physical activity. Reduce sodium intake. Maintain adequate intake of potassium. For Overall and Cardiovascular Health Maintain adequate intake of calcium and magnesium. Stop smoking. Reduce dietary saturated fat and cholesterol.

54 slide 54 Pharmacologic Treatment Decreases cardiovascular morbidity and mortality based on randomized controlled trials. Protects against stroke, coronary events, heart failure, progression of renal disease, progression to more severe hypertension, and all-cause mortality.

55 slide 55 Special Considerations in Selecting Drug Therapy Demographics Coexisting diseases and therapies Quality of life Physiological and biochemical measurements Drug interactions Economic considerations

56 slide 56 Drug Therapy A low dose of initial drug should be used, slowly titrating upward. Optimal formulation should provide 24-hour efficacy with once-daily dose with at least 50% of peak effect remaining at end of 24 hours. Combination therapies may provide additional efficacy with fewer adverse effects.

57 slide 57 Classes of Antihypertensive Drugs ACE inhibitors Adrenergic inhibitors Angiotensin II receptor blockers Calcium antagonists Direct vasodilators Diuretics

58 slide 58 Combination Therapies -adrenergic blockers and diuretics • ACE inhibitors and diuretics • Angiotensin II receptor antagonists and diuretics • Calcium antagonists and ACE inhibitors • Other combinations

59 slide 59 Followup Follow up within 1-2 months after initiating therapy. Recognize that high-risk patients often require high dose or combination therapies and shorter intervals between changes in medications. Consider reasons for lack of responsiveness if blood pressure is uncontrolled after reaching full dose. Consider reducing dose and number of agents after 1 year at or below goal.

60 slide 60 Causes for Inadequate Response to Drug Therapy Pseudoresistance Nonadherence to therapy Volume overload Drug-related causes Associated conditions Identifiable causes of hypertension

61 slide 61 Guidelines for Improving Adherence to Therapy Be aware of signs of nonadherence. Establish goal of therapy. Encourage a positive attitude about achieving goals. Educate patients about the disease and therapy. Maintain contact with patients. Encourage lifestyle modifications. Keep care inexpensive and simple.

62 slide 62 Guidelines for Improving Adherence to Therapy (continued) Integrate therapy into daily routine. Prescribe long-acting drugs. Adjust therapy to minimize adverse affects. Continue to add drugs systematically to meet goal. Consider using nurse case management. Utilize other health professionals. Try a new approach if current regime is inadequate.

63 slide 63 Hypertensive Emergencies and Urgencies Emergencies require immediate blood pressure reduction to prevent or limit target organ damage. Urgencies benefit from reducing blood pressure within a few hours. Elevated blood pressure alone rarely requires emergency therapy. Fast-acting drugs are available.

64 slide 64 Drugs Available for Hypertensive Emergencies Vasodilators Nitroprusside Nicardipine Fenoldopam Nitroglycerin Enalaprilat Hydralazine Adrenergic Inhibitors Labetalol Esmolol Phentolamine

65 slide 65 Summary of Chapter 3 Modifying lifestyles in populations can have a major protective effect against high blood pressure and cardiovascular disease. Lowering blood pressure decreases death from stroke, coronary events, and heart failure; slows progression of renal failure; prevents progression to more severe hypertension; and reduces all-cause mortality. A diuretic and/or a -blocker should be chosen as initial therapy unless there are compelling or specific indications for another drug.

66 slide 66 Summary of Chapter 3 (continued) Management strategies can improve adherence through the use of multidisciplinary teams. The reductions in cardiovascular events demonstrated in randomized controlled trials have important implications for managed care organizations. Management of hypertensive emergencies requires immediate action whereas urgencies benefit from reducing blood pressure within a few hours.

67 slide 67 Special Populations Racial and ethnic groups Children and adolescents Women Older persons

68 slide 68 Racial and Ethnic Groups

69 slide 69 Children and Adolescents Blood pressure at 95th or higher percentile is considered elevated. Lifestyle modifications should be recommended. Drug therapy should be prescribed for higher levels of blood pressure. Attempts should be made to determine other causes of high blood pressure and other cardiovascular risk factors.

70 slide 70 95th Percentile of Blood Pressure by Selected Ages and Height in Girls

71 slide 71 95th Percentile of Blood Pressure by Selected Ages and Height in Boys

72 slide 72 Women Clinical trials have not demonstrated significant differences between men and women in treatment response and outcomes. Some women using oral contraceptives may have significant increases in blood pressure. High blood pressure in not a contraindication to hormone replacement therapy.

73 slide 73 Pregnant Women Chronic hypertension is high blood pressure present before pregnancy or diagnosed before 20th week of gestation. Preeclampsia is increased blood pressure that occurs in pregnancy (generally after the 20th week) and is accompanied by edema, proteinuria, or both. ACE inhibitors and angiotensin II receptor blockers are contraindicated for pregnant women. Methyldopa is recommended for women diagnosed during pregnancy.

74 slide 74 Antihypertensive Drugs Used in Pregnancy

75 slide 75 Antihypertensive Drugs Used in Pregnancy (continued)

76 slide 76 Older Persons Hypertension is common. SBP is better predictor of events than DBP. Pseudohypertension and white-coat hypertension may indicate need for readings outside office. Primary hypertension is most common cause, but common identifiable causes (e.g., renovascular hypertension) should be considered.

77 slide 77 Older Persons (continued) Therapy should begin with lifestyle modifications. Starting doses for drug therapy should be lower than those used in younger adults. Goal of therapy is the same (< 140/90 mm Hg) although an interim goal of SBP < 160 mm Hg may be necessary.

78 slide 78 Special Situations Cardiovascular diseases Renal disease Diabetes mellitus Dyslipidemia Sleep apnea Bronchial asthma Gout Surgery Various chemical agents

79 slide 79 Cardiovascular Diseases Cerebrovascular disease –Indication for treatment, except immediately after ischemic cerebral infarction Coronary artery disease –Benefits of therapy well established Left ventricular hypertrophy –Antihypertensive agents (except direct vasodilators) indicated –Reduced weight and decreased sodium intake beneficial

80 slide 80 Cardiovascular Diseases (continued) Cardiac failure –ACE inhibitors, especially with digoxin or diuretics, shown to prevent subsequent heart failure Peripheral arterial disease –Limited or no data available

81 slide 81 Renal Disease Hypertension may result from renal disease that reduces functioning nephrons. Evidence shows a clear relationship between high blood pressure and end-stage renal disease. Blood pressure should be controlled to < 130/85 mm Hg or lower (< 125/75 mm Hg) in patients with proteinuria in excess of 1 gram per 24 hours. ACE inhibitors work well to control blood pressure and slow progression of renal failure.

82 slide 82 Diabetes Mellitus Drug therapy should begin along with lifestyle modifications to reduce blood pressure to < 130/85 mm Hg. ACE inhibitors, -blockers, calcium antagonists, and low dose-diuretics are preferred. Insulin resistance or high peripheral insulin levels may cause hypertension, which can be treated with lifestyle changes, insulin-sensitizing agents, vasodilating antihypertensive drugs, and lipid-lowering agents.

83 slide 83 Dyslipidemia Coexistence of hypertension and dyslipidemia requires aggressive management. Emphasis should be on weight loss; reduced intake of saturated fat, cholesterol, sodium, and alcohol; and increased physical activity. Lifestyle changes and hypolipidemic agents should be used to reach appropriate goals.

84 slide 84 Sleep Apnea Obstructive sleep apnea is more common in patients with hypertension and is associated with several adverse clinical consequences. Improved hypertension control has been reported following treatment of sleep apnea.

85 slide 85 Bronchial Asthma or Chronic Airway Disease Elevated blood pressure is common in acute asthma and is possibly related to treatment with systemic corticosteroids or -agonists. -blockers and - -blockers may exacerbate asthma. ACE inhibitors only rarely induce bronchospasm. Over-the-counter medications are generally safe in limited doses for patients on drug therapy.

86 slide 86 Gout Diuretics can increase serum uric acid levels. Diuretics should be avoided in patients with gout. Diuretic-induced hyperuricemia does not require treatment in the absence of gout or urate stones.

87 slide 87 Patients Undergoing Surgery When possible, surgery should be delayed until blood pressure is < 180/110 mm Hg. Those not on prior drug therapy may be best treated with cardioselective -blockers before and after surgery. Those with controlled blood pressure should continue medication until surgery and begin as soon after surgery as possible.

88 slide 88 Cocaine and Amphetamines Cocaine abuse must be considered in patients presenting to the emergency department with hypertension-related problems. Nitroglycerin is indicated to reverse cocaine-related coronary vasoconstriction. Acute amphetamine toxicity is similar to that of cocaine but longer in duration. Ongoing cocaine abuse does not appear to cause chronic hypertension.

89 slide 89 Immunosuppressive Agents Immunosuppressive regimens produce widespread vasoconstriction in both transplant and nontransplant situations. Treatment is based on vasodilation including dihydropyridine calcium antagonists.

90 slide 90 Erythropoietin Erythropoietin often increases blood pressure in treatment of patients with end-stage renal disease. Management includes optimal volume control, antihypertensive agents, and reducing erythopoietin dose or changing method of administration.

91 slide 91 Other Chemical Agents That May Induce Hypertension Mineralocorticoids and derivatives Anabolic steroids Monoamine oxidase inhibitors Lead Cadmium Bromocriptine

92 slide 92 Summary of Chapter 4 Racial and ethnic groups are growing segments of our society. The prevalence of hypertension and control rates differ across groups. Clinicians should be aware of social and cultural factors when managing hypertension. Guidelines are provided for management of children and women with hypertension. In older persons, diuretics are preferred and long-acting dihydropyridine calcium antagonists may be considered.

93 slide 93 Summary of Chapter 4 (continued) Specific therapy for patients with left ventricular hypertrophy, coronary artery disease, and heart failure are outlined. Patients with renal insufficiency with greater than 1 g/day of proteinuria should be treated to a goal of 125/75 mm Hg; those with less proteinuria should be treated to 130/85 mm Hg. ACE inhibitors have additional renoprotective effects. Patients with diabetes should be treated to a therapy goal of below 130/85 mm Hg.

94 slide 94 A population-wide strategy to reduce overall blood pressure by only a few mm Hg could affect overall cardiovascular morbidity and mortality as much as or more than treatment alone. A Population-Wide Strategy


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