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Psychological Factors in Heart Failure
A Review of the Literature
Kenneth M. A. MacMahon, PhD;
Gregory Y. H. Lip, MD
Arch Intern Med. 2002;162:509-516.
ABSTRACT
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Congestive heart failure (CHF) is the end stage of many diseases of
the heart and a major cause of morbidity and mortality. The incidence of CHF
is increasing steadily as treatment for its coronary antecedents, such as
myocardial infarction, advances. Treatment of CHF generally relies on a battery
of pharmacological interventions, alongside exercise and diet regimens. It
is only in recent years that the psychological impact of heart failure has
been explored, which is reflected by the absence of standardized psychological
assessment for patients with CHF. In this article, we review studies that
have addressed the effects of depression, anxiety, coping style, and level
of social support in CHF. From the available evidence, it appears that patients
generally experience moderate levels of depression, but not greatly heightened
anxiety. Level of social support and style of coping with the disease are,
however, important prognostic factors. It is difficult to draw definitive
conclusions owing to the paucity of literature. Further work examining this
issue is needed if the psychological issues of heart failure are not to be
neglected.
INTRODUCTION
Heart failure is the end stage of many diseases of the heart and is
a major cause of morbidity and mortality.1
Present estimates suggest that approximately 5% of all hospital ward admissions
are accounted for by heart failure, and this percentage is expected to increase
over the coming years. This is the result of both an aging population and
therapeutic advances that have led to increasing numbers of people surviving
acute myocardial infarction (MI).
Despite therapeutic advances in the pharmacological management of heart
failure, the 1-year mortality rate for patients with advanced heart failure
still approaches 40%, which is the same for many of the more aggressive cancers.
Even those with less serious heart failure who can live for many years often
experience considerably impaired quality of life.2
Given the high mortality and morbidity associated with heart failure, it is
not surprising that patients typically report psychological distress, reduced
social functioning, and diminished quality of life.3
Quality of life is increasingly recognized as an important factor when studying
the effects of interventions.4 Furthermore,
psychological factors have also been implicated in precipitating hospitalization
in a notable number of patients with congestive heart failure (CHF). It has
previously been shown that emotional events (such as violent arguments or
threatened separation from family members) preceded admission in 49% of patients
with CHF compared with 24% of patients admitted with other medical conditions.5
The impact of psychological factors on cardiac function has been studied
extensively in the areas of coronary artery disease and acute MI. Debates
over the relationship between type A behavior and coronary artery disease
have been raging for over 30 years.6 Recently,
depression and anxiety following MI have become increasingly recognized and
are now the target of many psychoeducational programs. For example, Dusseldorp
et al7 conducted a meta-analysis of psychoeducational
programs for patients with coronary heart disease, and these programs yielded
a 34% reduction in mortality, a 29% reduction in recurrence of MI, and notably
contributed to better exercise and dietary habits.
Despite the difficulties of living with heart failure and the apparent
success of psychoeducational programs following MI, it is only recently that
clinicians have begun to pay greater attention to the psychosocial issues
of CHF. Some authors now suggest that paying greater attention to the psychological
correlates of chronic illness may pay dividends in terms of reduced number
of hospitalizations by reducing the number of repeated hospitalizations if
morbidity and mortality were influenced by psychological health.8
This review article examines studies that explore the links between psychological
factors such as depression, anxiety, social support and coping styles, and
physical health of patients with CHF.
SEARCH STRATEGY
Articles for inclusion in this review (1965-2000) were identified through
searching for the terms congestive heart failure, depression, anxiety, social support, and coping styles and psychology on the electronic databases MEDLINE, EMBASE, and PsychLit. Further
articles were identified though examination of references lists from articles
to ensure that all relevant studies were included.
Article Inclusion and Exclusion Criteria
Articles were included in this review if they concerned adult (age  18
years) patients with heart failure due to any underlying cause and addressed
issues of depression, anxiety and/or social support. Those articles in which
disease comorbidity was insufficiently distinguished in analyses and in which
other factors (such as impending surgery) were an issue were excluded from
this review.
A total of 23 studies were retrieved; however, 11 of the retrieved studies
did not meet criteria for inclusion in the review. This was mainly because
of a lack of differentiation between heart failure patients among a general
cardiac group (6 studies); the use of patients scheduled to have heart transplantation,
for whom the prospect of major surgery would be expected to have an effect
on psychological variables (3 studies); or insufficient measures of psychological
variables (eg, taking marital status as an indicator of social support without
further questioning as to whether this was a true source of support) (2 studies).
Article Selection and Data Abstraction
The 2 reviewers independently selected suitable studies for inclusion
in this review. If any disagreements occurred between the 2 reviewers, recourse
to a third reviewer was to be made. The data abstracted from each article
related to the complexities of the topic area and included patient demographics,
cardiological status, measurement instruments (eg, depression or anxiety inventories),
as well as data relating to study eligibility, quality, and outcomes.
Study Quality Criteria
Study quality was graded according to design as follows:
Ia: Prospective longitudinal study with sufficient patient number, well-matched
groups, and well-validated measurement instruments.
Ib: Prospective longitudinal study with low patient number, but with
well-matched groups and well-validated measurement instruments.
IIa: Cross-sectional study with sufficient patient number, well-matched
groups, and well-validated measurement instruments.
IIb: Cross-sectional study with low patient number, but with well-matched
groups and well-validated measurement instruments.
IIIa: Prospective, longitudinal study with sufficient patient number,
but with poorly matched groups and/or less well-validated measurement instruments.
IIIb: Prospective, longitudinal study with low patient number, poorly
matched groups, and/or less well-validated measurement instruments.
IVa: Cross-sectional study with sufficient patient number, but with
poorly matched groups and/or less well-validated measurement instruments.
IVb: Cross-sectional study with low patient number, poorly matched groups,
and/or less well-validated measurement instruments.
PSYCHOSOCIAL FACTORS IN HEART FAILURE
Depression
Arguably the most frequently explored topic in cardiac psychology is
that of depression.9 Recent years have seen
a plethora of studies examining the relationship between depression and MI10-11; not surprisingly, the prevalence
of depression among MI survivors is higher than that of the healthy population.12 However, some authors also claim that depression
in itself, independent of other factors such as age, severity of infarct,
or sex, is a risk factor for further cardiac events and eventual mortality.13-15
Besides predicting cardiac events and affecting mortality, it is possible
that depression may contribute to the high readmission rates for patients
with CHF.16-17 Major depression
is associated with noncompliance with medical treatment in younger, chronically
ill, disabled patients18 and in elderly cardiac
patients19-21;
thus, it is possible that noncompliance with treatment regimes may be a major
factor precipitating readmission for CHF.22
One difficulty that emerges when comparing studies is the variety of
self-report and interview measures used to assess levels of depression. Numerous
questionnaires have been developed, such as the Beck Depression Inventory,23 the Center for Epidemiological Studies–Depression
Scale (CES-D),24 the depression scale of the DSM-III-R or DSM-IV; the Hospital
Anxiety and Depression Scale,25 and the Zung
Self-Rating Depression Scale.26 In general,
all of these measures are accepted as being suitable means of assessing depression,
with satisfactory levels of validity and reliability. However, something that
is rarely noted is the inclusion of somatic depression symptoms of fatigue
and insomnia within the diagnostic criteria for depression. While these are
symptoms of depressive state, they are also primary symptoms of CHF.27 It appears that only 1 published study overcomes
this problem by analyzing the data both with and without these criteria.28 Thus, any of the more marginal findings of depression
may need to be treated with some caution.
Anxiety
Despite the fact that anxiety is a condition that frequently presents
co-morbidly with depression,10-40
there is a paucity of literature on anxiety among individuals with heart failure.
Anxiety over the poor prognosis of heart failure makes it seem probable that
this will be a serious difficulty, both for patients and for their carers.41 However, the lack of information in this area makes
it impossible to confirm such a hypothesis.
Anxiety should be of relevance to clinicians because it can negatively
affect the cardiac output of patients with CHF.42
Stress can cause an increase in heart rate, which has a negative effect on
coronary artery perfusion through shorter diastole. Tachycardia reduces myocardial
oxygen supply, while increasing myocardial oxygen demand.43
This can be a spiraling process, with patients becoming increasingly concerned
about their physical state, which feeds back into increased anxiety and even
poorer cardiac output. Concerns about physical capability and anxiety over
taking part in physical activities may also hamper rehabilitation attempts.44
The Role of Social Support
Measuring depression and anxiety in patients with CHF provides an insight
into the general psychological status of patients and may also suggest areas
in which resources should be deployed. However, the impact of these may be
mediated by the level of social support experienced by the patient. Social
support has been shown on numerous occasions to be a protective influence
against adverse events,45 and CHF may be a
condition in which it is also of importance.
Coping Styles
It is also well documented that the manner in which individuals cope
with negative or stressful life events affects their physical and psychological
well-being.46-48
Some authors suggest that coping strategies mediate between stressful events
and such consequences as depression and anxiety.49
Chronic and debilitating illnesses (such as CHF) may lead to stress,
and the patient may turn to a variety of strategies to cope with this stress.
Coping may be defined as cognitive or behavioral attempts to either avoid
a stressful situation or actively do something to alter the situation.50 Coping styles are generally defined as the repeated
way in which the individual responds to stressful encounters.
CROSS-SECTIONAL STUDIES OF DEPRESSION IN HEART FAILURE
Zuccala et al29 reported a study of 53
patients admitted with heart failure and screened for depression with the
CES-D. Severe depressive symptoms were present among 85% of patients; however,
no follow-up was made with patients to examine the longer-term impact of this
finding. Depressive symptoms were also shown to relate to poorer perception
of health status and reduced functional ability, although, interestingly,
no correlation between left-ventricular ejection fraction and depression was
present. Higher CES-D scores also positively correlated with cortisol levels
and negatively correlated with sodium levels and blood lymphocyte count. The
lack of a correlation between depression and the objective measure of the
left ventricular ejection fraction suggests that depression may limit social
or physical activity independent of whether the individual's health is a limiting
factor. Furthermore, the correlation between cortisol level and lymphocyte
count suggests that some of the possible adverse effects of depression on
health status in patients with CHF may be due to neuroendocrine and immune
dysfunction rather than directly left ventricular dysfunction or pulmonary
obstruction.
Majani et al30 studied 152 nondemented
men 70 years or younger with a New York Heart Association (NYHA) class of
III or lower. Levels of depression were assessed through the Cognitive Behavioral
Assessment 2.0 Depression Scale, part of an Italian battery of cognitive and
psychosocial measures. Comparisons were made between normative group scores
for healthy individuals (matched for age and sex) and the heart failure patients
in the study. Because of the low numbers in several of the age groups, comparisons
were only made in the second age class (41-60 years [n = 114]). In this group,
patients showed considerably greater levels of depression than their healthy
counterparts.
The findings of Zuccala et al29 and Majani
et al30 are backed up by those of Havranek
et al,31 who also found that patients with
CHF scored significantly higher on depression assessments than matched control
subjects. Havarek et al31 suggest that identifying
and treating depressed patients with CHF may considerably improve levels of
functioning in these patients, and, consequentially, this may lead to greater
adherence to rehabilitation and medication regimens, which should result in
an improvement in physical health status.
In contrast to the findings of the 3 studies above,29-31
Murberg et al32 did not find that levels of
depression in their sample of patients with CHF differed from normative data.
Murberg et al32 recruited 119 patients (85
men) with a mean age of 66 years and mean NYHA class of 2.4 from an outpatient
clinic. Of the patients, 60% scored within the normal range on the Zung Self-Rating
Depression Scale, with only 2% exhibiting severe symptoms; none of these findings
differ from what would be expected in a normal elderly community sample.
The lack of depressive effect among patients in this sample may be a
reflection of the recruitment method used in this study. Attendees at an outpatient
clinic received letters inviting them to participate in the study, thus resulting
in a self-selecting, healthier, and younger population. Furthermore, it may
be that those who did not volunteer for the study did not do so because they
were experiencing depression or anxiety and did not want this exacerbated
by answering questionnaires dealing with these issues. Thus, it is possible
that this study may underestimate the prevalence of depression among outpatients
with CHF.
Cross-sectional studies suggest that mild to moderate depression is
prevalent across patients hospitalized with heart failure. This concurs with
depression rates of between 30% and 60% in patients hospitalized with any
severe illness, such as coronary heart disease, cancer, or stroke.33-35 Murberg et al,32 however, suggest that depression may not be nearly
so prevalent in an outpatient populations, although this is possibly a reflection
of the relative youth and health of this group.
LONGITUDINAL STUDIES OF DEPRESSION IN HEART FAILURE
Freedland et al28 interviewed 60 patients
with a mean NYHA class of 2.6 admitted with CHF, using a modified version
of the Diagnostic Interview Schedule (DSM-III-R).
Patients were then followed up at 3 and 12 months. Initially, 10 patients
(17%) were found to have a major depressive disorder, even when questions
regarding fatigue and insomnia (common symptoms of CHF) were discounted. Interestingly,
only white patients were found to have depression; none of the black patients
interviewed were diagnosed as having depression. When all patients were grouped
together, the rate of major depression was still significantly higher in the
CHF group than in the general, healthy, geriatric population.
After 1 year, a nonsignificant trend emerged toward higher mortality
rates in the depressed (50% mortality) group than in the nondepressed (29%
mortality) group. However, no control for severity of disease was made, and
it should be noted that those in the depressed group were in slightly poorer
health (NYHA class 2.6 vs 2.8). The lack of a significant effect is probably
the result of a low sample size, but nonetheless, if disease severity were
to be taken into account, it is possible that the effect would disappear.
Koenig36 compared depression in 107 patients
admitted with CHF with 181 patients with other cardiac diseases or medical
problems that were not of a cardiac nature; depression was assessed by the
CES-D and Diagnostic Interview Schedule (DSM-III-R).
Among patients with CHF, the rate of major depression was 36.5%, significantly
higher than in the control group (25.5%). However, this difference was largely
accounted for by low rates of major depression in cardiac patients without
CHF. Furthermore, when severity of illness was taken into account, there was
no longer a significant difference. Minor depression was identified in 21.5%
of CHF patients; this did not differ significantly from the control population
(17.0%).
Compared with nondepressed patients with CHF, depressed patients with
CHF were significantly more likely to be readmitted as inpatients in the following
3 months. Depressed patients were also 50% more likely to die during the following
year (29% vs 20%); however, this effect did not reach statistical significance,
again probably due to the relatively low number of individuals who died during
the 2 years of follow-up. However, when the effects of illness severity were
controlled for, the effects of depression disappeared, and no statistical
differences between the groups remained.
Krumholz et al37 examined 292 patients
65 years or older, who were hospitalized with heart failure. Depression was
assessed using the CES-D. In the year following admission, 49% of the study
sample experienced either cardiovascular death or rehospitalization, most
commonly for heart failure (48% of the cases). In this case no link was seen
between initial levels of depression and readmission or death in the following
year.
Of the longitudinal studies conducted, possibly the most intriguing
is that of Murberg et al38 who followed up
the mortality of patients enrolled in their earlier study.32
Twenty patients died during the 24-month follow-up period, all from cardiac
causes. Depressed mood was found to be a significant predictor of mortality,
with 25% of depressed patients dying, whereas 11.3% of nondepressed patients
died. Disease severity was controlled by measuring N-terminal fragment proatrial
natriuretic factor (ProANF) 1-98 released into the bloodstream during an atrial
stretch, such as that induced by CHF or increased pulmonary pressure. The
ProANF 1-98 level correlates with status of disease, and is believed to be
more reliable than the NYHA classification as a prognostic indicator in patients
with CHF.39 Even when levels of ProANF, sex,
and age were statistically controlled for, depressed mood still emerged as
an independent predictor of mortality.
The study by Murberg et al38 is particularly
interesting because it is the first sufficiently controlled study to indicate
a link between depression and mortality in CHF. In other studies in which
severely ill inpatients are recruited, depression may not be important as
a factor in subsequent mortality and morbidity to emerge as an independent
risk factor; subsequent health is decided almost entirely by the physical
state of the patient. However, in the outpatient population tested by Murberg
et al,38 the relative physical health of the
patients may have been better, and thus depression may play a larger role
in physical health.
Presently, the link between depression and mortality is unclear. Findings
from studies of inpatients demonstrate that the more severe the level of disease,
the greater will be the level of depression, although depression does not
emerge as an independent risk factor. However, the findings in the study of
outpatients by Murberg et al38 suggest that
there may be some link between cardiac death and depression among those with
heart failure, indicating that this topic surely deserves further attention.
A summary of studies examining depression in patients with CHF is given in Table 1.
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Table 1. Summary of Studies Examining Depression in Patients With Congestive
Heart Failure*
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ANXIETY
Interestingly, in the only study to examine anxiety among patients with
CHF,30 no significant differences in the degree
of either state or trait anxiety (as measured by the Cognitive Behavioral
Assessment 2.0 Depression Scale) were found between patients with CHF and
those admitted with other illnesses. Patients with CHF were no higher in degree
of "rumination" and reported less "fears and phobias" and "social anxiety."
However, a particular shortcoming in this study is that it does not report
how many patients were actually aware of their diagnosis and their prognosis
over the coming months or years. Furthermore, it is impossible to tell whether
the lack of a difference in degree of anxiety is a reflection of patients'
acceptance or denial of their illness.8
The evidence from this study30 suggests
that anxiety is not a significant difficulty for heart failure patients. However,
any conclusions from this must be tempered by the observation that this study
was conducted on an inpatient population, and, as seen in the depression literature,
the psychological status of outpatients may differ notably. Again, further
work examining the effects of anxiety on long-term health with various patient
groups is necessary before any further conclusions can be drawn. A summary
of studies examining anxiety, social support, or coping styles in patients
with CHF is given in Table 2.
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Table 2. Summary of Studies Examining Anxiety, Social Support, or Coping
Styles in Patients With Congestive Heart Failure*
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Krumholz et al37 determined whether emotional
support was associated with fatal and nonfatal cardiovascular events in 292
elderly patients (mean age, 80 years). Patients were asked whether they could
count on anyone to provide them with emotional support and, if so, to give
the number of people to whom they could turn to for support. Initial results
suggested that emotional support was not significantly associated with clinical
characteristics; however, in a 1-year follow-up study, lack of emotional support
was significantly associated with risk of fatal and nonfatal cardiovascular
outcomes. When adjustment was made for demographic and clinical factors, social
ties and instrumental support, a lack of social support was still associated
with a significantly higher risk of adverse events. However, a significant
interaction between emotional support and sex was also found, with emotional
support only appearing to be important for women, not for men.
Bennett et al3 assessed social support
in 62 patients admitted with CHF, 23 of whom were rehospitalized in the 6-month
follow-up period. Social support was not shown to be a significant mediating
factor within this cohort, although the results may have been skewed by the
fact that 73% of the patients were married and, overall, patients believed
that they had support all the time. Thus, in a more varied sample, an effect
may be seen.
Presently, it is impossible to tell whether social support is vital
to the patient with CHF. Literature from other areas of health study would
suggest that it is, but until further research is conducted, a definitive
answer cannot be given. To our knowledge, only 1 study examining the association
between coping styles and mortality in patients with CHF is available.52 A total of 119 outpatients with a mean age of 66
years and mean NYHA class of 2.4 were recruited by written invitation and
assessed on 6 subscales of the COPE dispositional inventory.53
Active coping, seeking instrumental support, seeking emotional support, acceptance,
denial, and behavioral disengagement were measured. Following multivariate
analysis, it was found that behavioral disengagement and lack of acceptance
were significantly associated with mortality, even when disease severity (measured
through ProANF levels), sex, and age were controlled for.
Psychological factors can influence biological functioning through several
pathways. One possibility is that coping styles may influence the health behaviors
of an individual; avoiding the reality of the illness may lead to reticence
in adhering to physical and pharmacological treatment regimens. Patients may
effectively deny the severity of their illness and thus not follow the prescribed
treatments for the illness. A second possibility is that the effect on health
is of a more direct nature. Numerous studies have demonstrated that when stress
is uncontrollable for the individual, which may happen if it is not dealt
with in an adaptive manner, increases in circulatory catecholamine levels
occur, something that will affect both immune and cardiac function.54-56
While it is difficult to determine the direction of causality between
coping styles and health in patients with CHF, the existence of such an association
should be of concern to clinicians in their treatment of such patients. Concentrating
efforts on counseling patients in adaptive coping skills, making information
on CHF more available, and ensuring that patients are fully aware of the necessity
of their medications may help to ameliorate the prognosis for patients with
CHF.
CONCLUSIONS
Until recently, the psychological correlates of heart failure have been
somewhat neglected; however, recent years have seen an increasing level of
interest in this area. While the evidence is, at present, inconclusive, studies
that address the main issues of depression, anxiety, social support, and coping
styles are beginning to emerge, and it is hoped that further work will enable
a more definitive profile of the CHF patient to be produced.
The findings in the studies reviewed in this article give some indication
that the prevalence of depression among those with CHF is relatively high;
however, treatment through pharmacological means and consultation with mental
health professionals seems relatively inadequate. Depression appears to be
a fairly strong predictor of repeated admission, independent of initial severity
of illness, which begs the question of whether suitable treatment for depression
might prove cost-effective in the long run by reducing the rate of readmission.36 Furthermore, depression may even be an independent
risk factor for mortality, something that should concern those involved in
the treatment of patients.38 Tackling the reasons
behind this depression through either medication or cognitive behavior therapy
may bring improvements to the individual's quality of life, reduce the number
of hospital admissions, and even lower the rate of mortality.
Anxiety appears to be an overwhelmingly neglected area of study in heart
failure. From the only available study to our knowledge, it seems that anxiety
does not afflict the heart failure patient greatly; however, there are 3 possible
explanations for this. First, it is impossible to generalize from a single
study. Second, it is possible that patients were not aware of their diagnosis
and the consequences of it. And third, patients may be accepting of their
condition and thus may not be anxious for what the future holds. Without further
evidence in this area it is impossible to tell.
The current research also hints that social support and coping styles
may be important, independent factors in mortality and morbidity among patients.
Availability of a large, supportive network and adoption of adaptive coping
styles appear to be related to better physical health and quality of life.
Guiding the mixture of coping styles used by an individual to a more positive
direction is something that suits cognitive behavior therapy well. If coping
styles are an important predictor of mortality, focusing attention on this
area could be particularly beneficial to the patient.
It has been estimated that approximately 68% of all health care costs
are associated with chronic illness and disability.57
The findings of the studies reported in this review article give some hint
that a reliable psychosocial evaluation could be of benefit in improving the
physical health of patients and thus reducing repeated admissions for decompensated
heart failure. Such an evaluation would allow the identification of particular
problems for the patient that might be addressed in the hope of improving
the psychosocial functioning of the patient.
Presently, nonpharmacological interventions tend to focus on aspects
of diet and medication regimen adherence that may improve prognosis, with
only limited use of components addressing emotional factors.58
Findings in studies that have sought to use a component of psychological therapy
to improve patient prognosis demonstrate greater physical improvement in patients
than through pharmacological treatment alone.59-60
However, these studies do not address the question of whether a more focused,
cognitive behavioral intervention examining patient attitudes and beliefs
regarding their illness, medication, and diet would serve the interlinked
purpose of improving both emotional and physical health of the patient. Such
a program has been developed for patients with MI, but presently, no similar
package is available for those with chronic heart failure.61
The present lack of empirical evidence relating to psychological factors
in the etiology and management of heart failure suggests that psychological
factors are neglected in this condition. Further research would clarify the
true picture regarding the general psychological status of patients and, if
difficulties were identified, would afford the development of a standardized
procedure for assessment and treatment of these difficulties. Because of the
aging population and increasing incidence of this condition, it would seem
prudent to invest more resources in the investigation and possible treatment
of psychological factors in heart failure.
AUTHOR INFORMATION
Accepted for publication July 31, 2001.
Dr MacMahon is funded by a postdoctoral research fellowship from Roche,
Welwyn Garden City, England. Drs MacMahon and Lip are undertaking a Cochrane
Review on psychological interventions in congestive heart failure.
Corresponding author: Gregory Y. H. Lip, MD, University Department
of Medicine, City Hospital, Dudley Road, Birmingham B18 7QH, England (e-mail: g.y.h.lip{at}bham.ac.uk).
From the University Department of Medicine, City Hospital, Birmingham,
England.
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