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Royal College Exam > Cardiology > Flashcards

Cardiology Flashcards

1
Q

For elective PCI and high risk of bleeding, when do you reassess DAPT regimen?

A

1 month if BMS, 3 months if DES then SAPT.

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2
Q

For elective PCI and low risk of bleeding, when do you reassess DAPT regimen?

A

At 6 months. If high risk disease or angiographic features that increase thrombotic events, then extend to 3 years, otherwise SAPT after 6 months.

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3
Q

How do you change from ACEi to ARNI?

A

Stop ACEi. Wait 36 hours washout period, then start. Not required if changing from ARB to ARNI.

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4
Q

How does murmur of HoCM change with passive leg raise and handgrip?

A

Reduced murmur (increased venous return and increased afterload).

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5
Q

How does the murmur of HoCM change with valsalva?

A

Increased murmur due to decreased venous return.

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6
Q

How does Ticagrelor compare to Prasugrel for efficacy and bleeding risk in STEMI?

A

Major bleeding not significantly different. Prasugrel had lower death, MI and stroke at 1 year. (ISAR-REACT 5, Sept 2019).

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7
Q

How long do you need to hold Clopidogrel/ Ticagrelor and prasugrel pre-op?

A

C/T - 5-7 days, prasugrel 7-10 days.

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8
Q

How long is first medical contact to balloon time for STEMI in a PCI capable hospital?

A

< 90 minutes.

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9
Q

How long is first medical contact to balloon time for STEMI in a PCI non-capable hospital?

A

<120 minutes.

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10
Q

How long is first medical contact to fibrinolytics time if fibrinolysis is chosen?

A

< 30 minutes.

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11
Q

How long should you delay ELECTIVE non-cardiac surgery post PCI?

A

BMS - at least 1 months.

DES - at least 3 months.

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12
Q

How many additional years of life expectancy do you need to qualify for ICD?

A

reasonable QoL and life expectancy > 1yr.

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13
Q

How often do you repeat echo in severe asymptomatic valvular disease?

A

6-12 months.

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14
Q

In NSTE-ACS, when should you consider early invasive (cath +/- PCI within 48hr)? What are the advantages?

A

Int/High risk patients as per TIMI/GRACE. Reduces risk of re-hospitalization for ACS but NO MORTALITY BENEFITS

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15
Q

What ECG findings make GXT uninterpretable?

A

Resting ST abnormalities (ST depression > 1mm), Digoxin use, LBBB, Pre-excitation, Pacing

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16
Q

What are 3 contraindications for Prasugrel?

A
  1. Age > 75
  2. Body weight < 60kg
  3. Hx of TIA/Stroke
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17
Q

What are 3 highest LR+ for thoracic aortic dissection?

A
  1. Focal neuro deficits (LR+ 6.6 - 33).
  2. Pulse deficits/differential BP (LR+ 5.7).
  3. Enlarged mediastinum on CXR (LR+ 2.0).
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18
Q

What are angiographic factors that increase risk of stent thrombosis and require longer DAPT?

A
  1. Multiple stents (>=3).
  2. Long lesion length (>60mm total stent length).
  3. Complex lesions (bifulcation with 2 stents, CTO).
  4. Left main/Prox LAD.
  5. Multivessel PCI.
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19
Q

What are BP and HR targets for aortic dissection?

A

HR 60-65, BP < 120 systolic.

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20
Q

What are causes of new afib?

A

PIRATES

P - Pulmonary (PE, COPD), Post op, Pericarditis
I - Ischemic, idiopathic, iatrogenic (central line)
R - Rheumatic
A - Anemia, Alcohol, Age, Autonomic tone
T - HyperThyroid
E - Endocarditis, Elevated BP, Electrocution
S - Sepsis, Sleep apnea, sick sinus syndrome

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21
Q

What are class I indications for valve intervention for aortic stenosis?

A

Severe AS with symptoms
Severe AS with LVEF < 50%
> moderate but undergoing other CV surgery.

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22
Q

What are clinical factors that increase risk of stent thrombosis and require longer DAPT?

A 
Prior MI
Diabetes on meds/insulin
CKD (CrCl < 60)
Prior stent thrombosis
Current smoker
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23
Q

What are contraindications to coronary CT angiogram?

A

ACS, Severe structural heart disease (AS or HCM) - have to slow HR < 60 with BB for test, Standard dye precautions (renal, pregnancy, allergy).

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24
Q

What are contraindications to persantine stress testing?

A

Asthma, severe COPD.

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25
Q

What are contraindications to treadmill stress testing?

A
  1. Recent MI (<4 days)
  2. Unstable Angina
  3. Severe symptomatic LV dysfunction
  4. Life-threatening arrhythmia
  5. Acute pericarditis
  6. PE
  7. Severe (or symptomatic) aortic stenosis
  8. Uninterpretable baseline ECG
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26
Q

What are criteria of severe mitral stenosis?

A

MV area < 1.5cm2 (very severe < 1cm2)
Mean gradient > 10mmHg
Diastolic pressure half time >= 150ms

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27
Q

What are criterias for cardioversion in new onset afib requiring 3 weeks of anticoagulation? What do you treat after cardioversion?

A

Valvular afib (of any duration)
NVAF < 12 hours, RECENT stroke (within 6 mon)
NVAF Duration 12-48 hours, CHADS >= 2
NVAF duration > 48 hours

Either anticoagulate for 3 weeks, or TEE to exclude LA thrombus. AC x 4 weeks post DC cardioversion, then re-evaluate using CHADS65

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28
Q

What are criteria for cardioversion in new onset afib without 3 weeks of anticoagulation? What do you treat after cardioversion?

A

Hemodynamically unstable AFIB
NVAF < 12 hours, no stroke/TIA (within 6 months)
NVAF 12-48 hours, CHADS < 2

Need 4 weeks of AC post cardioversion. Then re-evaluate based on CHADS65.

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29
Q

What are the criteria for SEVERE aortic stenosis?

A

Mean gradient >= 40mmHg
Max jet velocity >= 4m/s
AVA < 1.0cm2.

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30
Q

What are driving restrictions for advanced CHF (NYHA IV, LVADs)?

A

No driving.

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31
Q

What are driving restrictions for recurrent syncope unexplained?

A

Private 3 months syncope free.

Commercial 12 months syncope free.

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32
Q

What are driving restrictions for VT/VF with no reversible cause?

A

Private 6 months

Commercial NO DRIVING

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33
Q

What are driving restrictions post ICD insertion?

A

1st prophylaxis: 1 month private
2nd prophylaxis: 6 months

Commercial NONE

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34
Q

What are features/locations of arterial ulcers?

A

Punched out, on tip of toes/fingers.

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35
Q

What are high risk features on treadmill testing?

A

> =2mm ST depression (downsloping/horizontal)
ST depression with < 5 METs, or persistent > 3min into recovery
Exercise induced ST elevation, VT/VF, or sBP decrease > 10mmHg
Inability to reach sBP > 120 with exercise.

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36
Q

What are indications and contraindications for mitral balloon commisurotomy?

A

Severe MS + NYHA III or IV symptoms + favourable anatomy

Contraindicated if LA thrombus, >= mod MR

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37
Q

What are indications for anticoagulation for mitral stenosis?

A

Prior embolic event
Left atrial thrombus
Afib (paroxysmal or chronic)

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38
Q

What are indications for CRT?

A

NYHA II-IV symptoms on OMT > 3 months +
sinus rhythm +
LBBB with QRS >= 130MS
+ LVEF <= 35%

Can consider QRS > 150ms (if no LBBB), afib, elderly age/frailty, chronic RV pacing with reduced EF

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39
Q

What are indications for ICD for secondary prevention?

A
  1. VT/VF cardiac arrest
  2. Sustained VT with significant structural heart disease
  3. Sustained VT > 48hr post MI/revasc

*sustained VT: > 30s or hemodynamically significant

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40
Q

What are indications for ICD in HFrEF for primary prevention?

A

LVEF < 35% if 3 months of optimal medical therapy, NYHA II-IV symptoms (do not do NYHA IV if not candidate for advanced therapies)

LVEF < 30%, NYHA I but ischemic cardiomyopathy

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41
Q

What are indications for ICD in HOCM?

A

Sustained VT or prior cardiac arrest
FMHx of sudden death
LV wall thickness >30mm
Unexplained syncope

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42
Q

What are indications for ISDN + hydralazine?

A

In black patients and other ethnic groups intolerant of ACEi/ARB

NYHA IV despite maxed medical therapy

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43
Q

What are indications for PPM for sinus nodal dysfunction?

A

Symptomatic sinus bradycardia (spontaneous or drug induced)

Symptomatic tachybrady, chronotropic incompetence

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44
Q

What are indications for sugery for aortic regurgitation? When do you consider concurrent aorta replacement?

A

Severe AR with symptoms (dyspnea etc)
Severe AR with LVEF < 50%
Mod to severe undergoing other CVSx

If aortic diameter > 45mm, may require ascending aortic replacement

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45
Q

What are indications for surgery for mitral stenosis?

A

Severe MS + NYHA III or IV + acceptable surgical risk + contraindicated/failed balloon commissurotomy

Severe MS and other CVSx planned

46
Q

What are indications for surgery for primary mitral regurgitation (repair > replacement)?

A

Severe primary MR with symptoms and EF > 30% (surgery contraindicated if EF < 30%)

Severe asymptomatic primary MR with LVEF 30-60% or dilation (LVESD > 40mm)

Mod to severe MR undergoing other CVsx

47
Q

What are lipid targets for chronic CAD?

A

LDL-C < 2.0 or 50% reduction

48
Q

What are normal Swann Ganz numbers?

A

RA: 7
RV 35/8
PA 35/12/20
PCWP 12

49
Q

What are physical exam findings of constrictive pericarditis? Why do they happen?

A

Rapid filling of ventricles then abrupt cessation due to “strech limit” of pericardium. Fibrous pericardium shields ventricles from changes in intrathoracic pressure. + ventricular interdependence

Rapid Y decent
Square root sign on cath
Kussmaul's sign
Pericardial knock
Often NO pulsus paradoxus
50
Q

What are physical exam findings of restrictive cardiomyopathy? Why do they happen?

A

Myocardial stiffness, normalization of pressure in all chambers. NO ventricular interdependence.

Kussmaul’s sign (stiff RV can’t expand)
Rapid Y descent (RV can’t fill beyond early)
NO pulsus paradoxus (no ventricular interdependence)

51
Q

What are physical exam findings of Tamponade? Why do they happen?

A

RA can’t empty into high pressured RV. Drop in intrathoracic pressure during inspiration transmits to RV and increase RV filling. + Ventricular interdependence

Pulsus paraxoxus
Blunted Y decent on JVP (small Y before you DIE)
Beck’s triad (hypotension, distended JVP, muffled HS)
NO Kussmaul’s sign

52
Q

What are physical exam findings that rule in peripheral arterial disease?

A 
Pulse abnormality in symptomatic leg
Presence of bruits in symptomatic leg
Symptomatic leg cooler to touch
Wounds or sores
Discoloration
53
Q

What are PPM indications for acquired AV block?

A

3rd degree or 2nd degree type 2
Alternating RBBB/LBBB
Permanent AF and symptomatic bradycardia
Symptomatic AVB (spontaneous or drug induced)

54
Q

What cardiac conditions cause a variable S1?

A

Afib
AV dissociation
Severe tamponade

55
Q

What causes a paradoxical split S2?

A

LBBB, WPW, Fixed LVOT, AS, HOCM

56
Q

What causes a wide fixed S2?

A

ASD, RV failure

57
Q

What causes a wide split S1?

A

RBBB, ASD, Ebstein’s anomaly

58
Q

What causes a wide split S2?

A

RBBB, LV PPM

59
Q

What counts as VT storm?

A

> 3 episodes of sustained VT (>30s) within 24 hours

60
Q

What criteria do you use for dose reduction of apixaban?

A

2/3 of:

age >= 80
weight <= 60kg
Cr >= 133

61
Q

What criteria do you use for dose reduction of dabigatran?

A

Age > 75

CrCl 30-49ml/min

62
Q

What criteria do you use for dose reduction of edoxaban?

A

CrCl 30-50ml/min
<=60kg
Concomitant potent P glycoprotein inhibitors

63
Q

What criteria do you use for dose reduction of rivaroxaban?

A

CrCl 30-49mL/min

64
Q

What defines positive treadmill stress testing?

A

> 1 mm horizontal or downsloping ST depression in multiple leads (upsloping non specific)

65
Q

What happens to the murmur of aortic stenosis with passive leg raise? With valsalva? With hand grip?

A

Passive leg raise = louder murmur (increased preload)

Valsalva = softer murmur (reduced preload)

Hand grip = softer murmur (increased afterload)

66
Q

What is a contraindication for Ticagrelor?

A

History of previous intracranial hemorrhage

67
Q

What is coronary artery calcium score used for?

A

Risk stratification of intermediate FRS (10-19%) asymptomatic adults who are not statin candidates based on conventional risk factors.

If CAC > 100, statin recommended

68
Q

What is driving restriction post CABG?

A

SAME AS STEMI
Private: 1 months post D/C
Commercial: 3 months post D/C

69
Q

What is driving restriction post elective PCI?

A

Private: 48 hours
Commercial: 7 days

70
Q

What is driving restriction post NSTEMI with no LV damage or unstable angina?

A

Private: 48 hours with PCI, 7 days without PCI
Commercial: 7 days with PCI, 30 days without PCI

71
Q

What is driving restriction post NSTEMI with wall motion abnormalities?

A

SAME AS STEMI
Private 1 month post D/C
Commericial 3 months post D/C

72
Q

What is driving restriction post STEMI?

A

Private: 1 month post d/c
Commercial: 3 months post d/c

73
Q

What is first line treatment of HOCM?

A

Beta blockers

74
Q

What is indication for Entresto in HFrEF?

A

NYHA II-IV symptoms despite > 3 months of triple therapy (ACEi/ARB, BB, MRA)

75
Q

What is indication to add ivabradine in HFrEF?

A

NYHA II-IV with hospitalization in past 12 months, sinus rhythm with HR >70 despite triple therapy.

76
Q

What is the antiplatelet of choice for thrombolysis?

A

Clopidogrel + ASA.

77
Q

What is the antithrombotic regimen for AF with ACS, but no PCI and CHADS65 +?

A

OAC (riva 15 or 10 if CrCl 30-50, or dabi or warfarin) + clopidogrel for up to 12 months post ACS

Then OAC alone (riva 20, apix 5 bid, dabi, warfarin)

78
Q

What is the antithrombotic regimen for AF with elective PCI with high risk features or ACS with PCI and CHADS65 +?

A

OAC (riva 2.5 bid or warfarin 2-2.5) + ASA + clopidogrel for 1 day - 6 months for ASA.

Then OAC (riva 15 or 10 if CrCl 30-50 or dabi or warfarin) + clopidogrel for up to 12 months

Then OAC alone (riva 20, apix 5 bid, dabi, warfarin)

79
Q

What is the antithrombotic regimen for AF with elective PCI without high risk features but CHADS65 +?

A

OAC (riva 15 or 10 if CrCl 30-50 or dabi or warfarin) + clopidogrel for:
1-12 months post BMS
3-12 months post DES

Then OAC alone (riva 20, apix 5 bid, dabi, warfarin)

80
Q

What is the antithrombotic regimen for AF with elective PCI without high risk features, and CHADS = 0 and age < 65?

A

DAPT x 12 months (min 1 for BMS, 3 for DES)

ASA beyond 12 months. DAPT can be considered from stent/CAD perspective.

81
Q

What is the annual risk of death/MI for patients with high risk features on treadmill test, if untreated?

82
Q

What is the diagnostic criteria for acute pericarditis?

A 
2/4 of
Pleuritic chest pain
Friction rub on exam
ECG shows percarditis
New/worsening pericardial effusion

*if trop +, consider myopericarditis

83
Q

What is the dose of rivaroxaban if used in conjunction with DAPT post stent?

84
Q

What is the dose of Rivaroxaban when used in addition to antiplatelet?

A

15mg PO OD or 10mg if CrCl 30-50ml/min

85
Q

What is the duration of DAPT we should aim for ACS?

A

12 months regardless of bleeding risk.

MIN:
BMS - min 1 month, then ASA
DES - min 3 months, then ASA

86
Q

What is the HR rate target for afib?

A

<110bpm (RACE II trial, 110 = 80)

87
Q

What is the initial treatment for pericarditis?

A

High dose NSAID x 2 weeks (then PRN until pain/CRP resolves)

Colchicine x 3 months (prevents recurrence, COPE trial)

88
Q

What is the minimum DAPT duration for elective PCI (non-ACS)?

A

Aim for 6-12 months.
BMS - min 1 month, then ASA
DES - min 3 months, then ASA

89
Q

What is the size criteria for operative management of thoracic aortic aneurysm for degenerative/bicuspid aortic valve?

90
Q

What is the size criteria for operative management of thoracic aortic aneurysm for Familial aortopathy?

91
Q

What is the treatment for recurrent pericarditis?

A

High dose NSAID x 2 weeks

Colchicine x 6 months (CORP trial)

92
Q

What rules in aortic stenosis? What rules out aortic stenosis?

A

Rule in:
Pulsus tardus e parvus
Mid to late peak murmur
Soft S2

Rule out:
Absence of radiation to right carotid

93
Q

What rules out periphral vascular disease?

A

Absence of any pulse abnormalities

94
Q

What should afib with pre-excitation be treated with?

A

DC cardioversion (or procainamide)

95
Q

What should patients with bioprosthetic valve receive for antithrombotic therapy?

A

Lifelong ASA

3-6 months post implantation: VKA (INR 2.5) in addition to ASA
For TAVI, can do DAPT for 6 months instead of VKA

96
Q

What should patients with mechanical valve receive for antithrombotic therapy?

A

Lifelong ASA + VKA

Need post-op bridging as soon as bleeding risk is acceptable

97
Q

When are PPM indicated after MI?

A

Persistent 3rd degree AV block
Persistent advanced/infranodal 2nd degree AV block (Mobitz II)
2nd degree AV block with alternating BBB
Transient Mobitz II or 3rd degree AVB with associated BBB
Symptomatic 2nd or 3rd degree AV block

98
Q

When are DOACs contraindicated for AFIB?

A

Mechanical valves
Rheumatic mitral stenosis
Moderate to severe non-rheumatic mitral stenosis

99
Q

When does false negatives occur for Persantine stress testing

A

Caffeine or theophylline use (drug interactions)

Severe triple vessel/left main disease - BALANCED ISCHEMIA

100
Q

When is rhythm control preferred over rate control for afib?

A 
Symptoms despite rate control
Hemodynamic instability (DC cardioversion)
101
Q

When should EF be measured after MI/revascularization?

A

1 month post MI and 3 months post revasc

102
Q

When should you consider CABG over PCI?

A 
LM disease (>50%)
Multivessel with diabetes
Multivessel with LV dysfunction

*Less repeat revasc in CABG
Stroke data conflicting (NOBLE vs EXCEL)

103
Q

When should you consider fibrinolysis?

A

PCI isn’t available (>120min away). Ship immediately after lysis to PCI centre within 3-24 hours

104
Q

When should you repeat imaging for thoracic aortic dilation/aneurysm?

A

Serial imaging 6-12 months unless genetic aortopathy (then 6 months)

105
Q

When should you screen for abdominal aortic aneurysm?

A

All men >65-80 ONCE with U/S

106
Q

Which hypertension combo pills are grade A and grade B evidence-based?

A

Grade A - ACE with CCB

Grade B - ARB with CCB or diuretic.

107
Q

What differentiates PE from tamponade on physical exam?

A

Both can have pulsus paradoxus and right heart failure (elevated JVP, peripheral edema).

Tamponade - Variable S1, electrical alternans, reduced amplitudes.

PE - pulmonary hypertension (loud P2, RV heave, TR murmur).

108
Q

What is the onset, peak, and duration of elevated troponin? How do CK and myoglobin compare?

A 
Onset - 3-12 hr
Peak - 18-24 hr
Duration - up to 10 days
CK - duration only 2d
Myoglobin - earlier onset and peak, duration only 1d.
109
Q

In what patients does spironolactone have mortality benefit?

A

RALES = EF<35% NYHA III-IV; also EF<30 NYHA II, or EF<40% if STEMI and HF/DM

110
Q

What are factors that increase the risk of bleeding when deciding on antiplatelet therapy?

A
  1. Demographics - age>65, weight<60kg
  2. Medical conditions - hypertension, liver disease (alcohol), CKD (eGFR<60).
  3. Bleeding - prior bleeding, prior stroke with ICH, OAC and antiplatelets use, NSAIDs/prednisone, anemia, labile INR

Royal College Exam (15 decks)

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