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SPT3 Flashcards

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1
Q

Which gas is considered an important vasodilator of the blood vessels?

A

Nitric oxide

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2
Q

T/F: In a successfully revascularized patient, the exercise test provides additional
information before the patient starts a cardiac rehabilitation program

A

False

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3
Q

A typical treadmill graded exercise test for an individual with PAD would
begin at which speed?

A

2 mph

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4
Q

T/F: A small number of patients with myocardial ischemia present with silent
ischemia

A

True

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5
Q

T/F: Home-based programs have been considered successful interventions in
patients with PAD

A

False

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6
Q

Which of the following sequences are correct in the development of angina
pectoris?

A

Stiff left ventricle, Systolic emptying of left ventricle is

impaired, ECG abnormalities, Symptoms of angina

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7
Q

Design a clinical exercise test for the aerobic assessment of heart failure

A

For a patient with heart failure, I would have them do a 6
minute walk. I would make sure to record their distance
travelled, HR and RPE’s this is so that we can tell just how hard
it is for the patient and ensure that they are not going to put
themselves at risk. Another thing that could be measured
would be their gas exchange to determine peak oxygen uptake.

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8
Q

Typical symptoms of leg pain in patients with claudication include

A

A and B correct

A. Fatigue
B. Cramping

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9
Q

Which of the following benefits are possible after exercise training in
patients with coronary revascularization?

A

All of the above

  • Greater total work performed
  • Improved exercise capacity
  • Improved cardiac performance at rest
  • Increased peripheral muscular adaptations
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10
Q

T/F: Pacemakers that use an accelerometer may have a difficult time in
determining the heart rate response in exercise with an increased treadmill
slope

A

True

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11
Q

T/F: Patients with heart failure may be able to weight train with resistances that
would allow one set of 12-15 repetitions to be completed

A

True

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12
Q

In ECG of patients with heart failure, which of the following are present?

A

Changes in Q-wave in leads V1, V2, V3, V4

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13
Q

T/F: In an ECG of a myocardial infarction, the ST segment will be at the
isoelectric line

A

False

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14
Q

T/F: High-intensity interval training (HIIT) programs may be used as an exercise
program for individuals in early stages of cardiac rehabilitation

A

False

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15
Q

In the management of a myocardial infarction, which drug is considered an
anti-coagulant?

A

Heparin

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16
Q

There is an __ increase in mortality at 1 year for every 30-minute delay in
opening an infarct-related artery once symptoms begin

A

8%

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17
Q

T/F: The United States contributes almost a third of the worldwide economic
burden of heart failure

A

True

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18
Q

T/F: Blood pressure should be monitored in individuals with a pacemaker while
exercising

A

True

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19
Q

T/F: Exercise testing is useful in determining the degree of functional limitations
in patients with PAD

A

True

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20
Q

Signs and symptoms such as difficulty sleeping flat are often found in
patients with

A

Heart failure

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21
Q

Why would a bench press be contraindicated in early phase cardiac
rehabilitation?

A

The valsalva maneuver must be avoided when patients are just
out of the hospital/starting cardiac rehab. If the patient was to
do a bench press they would be putting a lot of strain on their
chest. This is especially bad for those who have had open heart
surgery. This is because they have had their chest cracked open
and they should not be completing any upper body exercise for
at least the !rst 6 weeks.

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22
Q

The main contributor to a coronary syndrome is

A

Atherosclerosis

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23
Q

T/F: Rhythm disorders that involve the SA node are classified as sick sinus
syndrome

A

True

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24
Q

Which of the following frequencies of exercise is recommended for
someone exercising at a low intensity?

A

Daily activity

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25
Q

Stent therapy has a success rate of

A

95%

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26
Q

Which of the following is the predominant factor responsible for increasing
cardiac output during exercise?

A

Heart rate

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27
Q

T/F: Individuals with PAD are at an increased risk for kidney disease

A

True

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28
Q

Which of the following should guide an exercise professional in the
development of an exercise prescription in an individual with a pacemaker?

A

RPE

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29
Q

T/F: Approximately 50% of all cardiovascular deaths are due to coronary heart
disease

A

True

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30
Q

In a 6-minute walking test, which of the following is the test outcome?

A

Distance traveled

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31
Q

T/F: Pharmacological treatment of claudication in patients with PAD has been
largely ineffective

A

True

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32
Q

Describe the process of atherogenesis

A

Smooth muscle cells and !broblasts migrate from the media to
the intima. Monocytes also migrate into the intima after they
have adhered to the injured endothelium. The LDLc enters the
arterial wall and undergoes the process of oxidation. Forming
foam cells that may release their cholesterol into extracellular
space, giving rise to fatty streaks, the earliest visually detectable
lesion of atherosclerosis. Immune system cells, T lymphocytes,
are in the fatty streaks and they are part of the inflammatory

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33
Q

T/F: Chronic anticoagulation therapy is still required after a stent placement

A

False

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34
Q

Which of the following pathophysiologies is present in heart failure?

A

All of the above

  • Reduced ejection fraction
  • Increased left ventricle mass
  • Edema
  • Imbalance of autonomic nervous system
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35
Q

Which of the following is an example of a failure of the heart to relay the
impulse to the ventricles?

A

Block at the AV node

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36
Q

T/F: Ischemic heart disease is the underlying cause of HF in about 60% of the
cases

A

True

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37
Q

T/F: Poor limb functioning in patients with PAD is not related to disability or mortality

A

False

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38
Q

Identify 2 of the arteries for palpating lower extremity pulses in individuals
with PAD

A

femoral and popliteal arteries

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39
Q

T/F: A poor response to exercise training may be indicative of restenosis

A

True

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40
Q

In which condition is it possible to hear a third heart beat?

A

Heart failure

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41
Q

Which of the following arrhythmias is most common in individuals with
pacemakers?

A

None of the above

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42
Q

T/F: Performing a graded exercise test after stent therapy is not considered safe
for the patient

A

False

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43
Q

T/F: It is important for the clinical exercise physiologist to understand the
dynamics of a pacemaker

A

True

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44
Q

Mechanism(s) for improving walking distance in patients with PAD include

A

All of the above

  • Increased pain tolerance
  • Attenuation of atherosclerosis
  • Reduction in blood viscosity
  • Increased collateral circulation
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45
Q

Mechanism(s) for improving walking distance in patients with PAD include

A

All of the above

  • Increased pain tolerance
  • Attenuation of atherosclerosis
  • Reduction in blood viscosity
  • Increased collateral circulation
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46
Q

Which process involves the use of a venous graft from the arm or leg to
increase blood flow to the heart?

A

CABS

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47
Q

T/F: Performing a graded exercise test after stent therapy is not considered safe
for the patient.

A

False

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48
Q

Which of the following pathophysiologies is present in heart failure?

A

All of the above

  • Reduced ejection fraction
  • Increased left ventricle mass
  • Edema
  • Imbalance of autonomic nervous system
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49
Q

Which gas is considered an important vasodilator of the blood vessels?

A

Nitric oxide

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50
Q

T/F: Outpatient cardiac rehabilitation should being within 4-6 weeks after
discharge from the hospital for an acute myocardial infarction.

A

False

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51
Q

T/F: High-intensity interval training (HIIT) programs may be used as an exercise
program for individuals in later stages of cardiac rehabilitation.

A

True

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52
Q

In ECG of patients with heart failure, which of the following are present?

A

Changes in Q-wave in leads V1, V2, V3, V4

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53
Q

T/F: Ischemic heart disease is the underlying cause of HF in about 60% of the
cases.

A

True

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54
Q

T/F: Patients with heart failure can see benefits by engaging in walking and
cycling exercise.

A

True

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55
Q

T/F: Approximately 50% of all cardiovascular deaths are due to coronary heart
disease.

A

True

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56
Q

The main contributor to a coronary syndrome is

A

Atherosclerosis

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57
Q

Which of the following benefits are possible after exercise training in
patients with coronary revascularization?

A

All of the above

  • Greater total work performed
  • Improved exercise capacity
  • Improved cardiac performance at rest
  • Increased peripheral muscular adaptations
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58
Q

T/F: History of symptoms for acute coronary syndromes includes chest pain,
sweating, and anxiety

A

True

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59
Q

In early-phase rehabilitation, which of the following exercises are
contraindicated?

A

Dumbbell bench press

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60
Q

TF: Patients with heart failure may be able to weight train with resistances that
would allow one set of 12-15 repetitions to be completed.

A

True

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61
Q

TF: In patients with HFrEF, an abnormal third heart sound can be heard.

A

True

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62
Q

TF: Following stent therapy, the risk of thrombosis is greater.

A

True

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63
Q

Patients with chronic heart failure may be able to perform ___ minutes of
moderate intensity physical activity.

A

Up to 60 minutes

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64
Q

Which of the following sequences are correct in the development of angina
pectoris?

A

Stiff left ventricle, Systolic emptying of left ventricle is

impaired, ECG abnormalities, Symptoms of angina

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65
Q

Patients with heart failure should exercise at an intensity of

A

A and B correct

A. 60% of heart rate reserve

B. RPE of 11-14

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66
Q

Typical symptoms of leg pain in patients with claudication include

A

A and B

A. Fatigue
B. Cramping

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67
Q

Which of the following is used to determine the severity of PAD?

A

Ankle-brachial index

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68
Q

In a 6-minute walking test, which of the following is the test outcome?

A

Distance traveled

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69
Q

Which of the following is the preferable mode of exercise for patients with
PAD?

A

Walking

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70
Q

Mechanism(s) for improving walking distance in patients with PAD include

A

All of the above

  • Increased pain tolerance
  • Attenuation of atherosclerosis
  • Reduction in blood viscosity
  • Increased collateral circulation
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71
Q

Which of the following is an example of a failure of the heart to relay the
impulse to the ventricles?

A

Block at the AV node

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72
Q

Which of the following arrhythmias is most common in individuals with
pacemakers?

A

Atrial fibrillation

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73
Q

Which of the following should guide an exercise professional in the
development of an exercise prescription in an individual with a pacemaker?

A

RPE

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74
Q

Which of the following frequencies of exercise is recommended for
someone exercising at a low intensity?

A

Daily activity

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75
Q

Which of the following testing protocols is typically used when assessing
patients with a pacemaker?

A

Chronotropic assessment exercise protocol

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76
Q

TF: The majority of patients with PAD are asymptomatic

A

True

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77
Q

TF: Hemodynamic measurement of PAD provides anatomic detail of the
vascular obstruction

A

False

78
Q

TF: Exercise testing is useful in determining the degree of functional limitations
in patients with PAD

A

True

79
Q

TF: Pharmacological treatment of claudication in patients with PAD has been
largely ineffective

A

True

80
Q

TF: Home-based programs have been considered successful interventions in
patients with PAD

A

False

81
Q

TF: A single-chamber pacemaker is typically used when both the atria and
ventricles need external pacing

A

False

82
Q

TF: Accelerometers are used in pacemakers to detect motion in response to
physical activity

A

True

83
Q

TF: Contact sports are recommended for individuals with pacemakers

A

False

84
Q

TF: Pacemakers that use an accelerometer may have a difficult time in
determining the heart rate response in exercise with an increased treadmill
slope

A

True

85
Q

TF: Blood pressure should be monitored in individuals with a pacemaker while
exercising

A

True

86
Q

Which of the following conditions is considered under the umbrella of cardiovascular disease?

A

All of the above

a. Coronary heart disease
b. Hypertension
c. Heart failure

87
Q

Which of the following plays a critical role in maintaining the degree of vasoconstriction?

A

Endothelium

88
Q

Which of the following is a cause of atherosclerosis?

A

All of the above

a. Diabetes mellitus
b. Plasma homocysteine
c. High levels of LDL-C
d. Tobacco use

89
Q

Which of the following indicates a prothrombotic, vasoconstrictive state?

A

All of the above

a. Platelet aggregation
b. Mural thrombi
c. Release of growth factors

90
Q

TF: Approximately 75% of all cardiovascular deaths are a result of coronary heart disease.

A

False

91
Q

TF: Men and women have their first myocardial infarction at the same age.

A

False

92
Q

TF: The endothelium produces nitric oxide, which is a vasoconstrictor of the blood vessel.

A

False

93
Q

TF: HDL-C undergoes oxidation and contributes to atherosclerotic plaque formation after entering the arterial wall.

A

False

94
Q

Which of the following is the second abnormality in the ischemic cascade?

A

Systolic dysfunction

95
Q

Which of the following may be causes of a reduction in the lumen diameter?

A

All of the above

a. Significant atherosclerotic plaque
b. Vasospasm without underlying plaque
c. Vasospasm superimposed over a plaque
d. Thrombus associated with plaque rupture

96
Q

Which of the following is described by cardiac pain that is reproducible and predictable in onset, severity, and means of relief?

A

Stable angina

97
Q

Which of the following may be triggered by ischemia resulting from an atherothrombotic vessel being occluded?

A

All of the above

a. Ventricular tachycardia
b. Ventricular fibrillation
c. Sudden cardiac death

98
Q

TF: The heart contains very few mitochondria and is adapted to anaerobic energy production.

A

False

99
Q

TF: Myocardial tissue is different from skeletal muscle tissue in that it is able to extract nearly all oxygen from the capillary blood flow.

A

True

100
Q

TF: Atypical angina has no relationship with exertion which set is apart from typical angina.

A

True

101
Q

TF: When a coronary blood vessel is occluded for more than 60 minutes, a myocardial infarction ensues.

A

True

102
Q

Which of the following conditions involves a buildup of lipids, macrophages, platelets, and fibrous connective within the coronary arteries?

A

Coronary artery disease

103
Q

Which of the following involves revascularization using a venous graft from an arm or leg to provide blood flow to the myocardium beyond the site of the occluded area in a coronary artery?

A

Coronary artery bypass surgery

104
Q

Which of the following describes the reasons for an individual to elect coronary artery bypass surgery?

A

All of the above

a. Significant left main CAD
b. Three-vessel disease
c. Two-vessel disease with a proximal left anterior descending stenosis
d. Two-vessel disease and impaired left ventricular function

105
Q

Which of the following describes the occlusion rate of a graft after 11 years?

A

40%

106
Q

TF: Coronary artery bypass surgery is reserved for patients with multivessel disease that is not appropriate for angioplasty or stenting

A

True

107
Q

TF: Stent procedures require a multi-night stay in the hospital.

A

False

108
Q

TF: Percutaneous transluminal coronary angioplasty has a low success rate in cases of unstable angina.

A

False

109
Q

TF: Chronic anticoagulation therapy is still required when stent therapy is used to treat CAD.

A

False

110
Q

Which of the following training modes is beneficial for individuals who are severely deconditioned?

A

Moderate-intensity interval training

111
Q

Which of the following may be adaptations that occur in revascularized patients who participate in a supervised exercise program?

A

A and B correct

A. Improved cardiac performance at rest and during exercise

B. Improved aerobic and strength exercise capacity

112
Q

Which of the following should be topics asked about the patient’s surgery at the initial interview with the clinical exercise physiologist?

A

All of the above

a. Excessive or unusual soreness/stiffness
b. Cracking, grinding, or motion in the sternal region
c. Sleep patterns at night
d. Incisions and their responses to activities of daily living

113
Q

Which of the following are improvements in the patient’s tolerance to acute bouts of exercise after surgery?

A

All of the above

a. Improved myocardial blood flow
b. increased maximal heart rate
c. Reduction in ST-segment depression
d. Reduction in exertional hypotension

114
Q

TF: A graded exercise test is required for individuals after a successful bypass surgery for creating an exercise program.

A

False

115
Q

TF: Bed rest after surgery typically leads to a loss of lean body mass in individuals.

A

True

116
Q

TF: Patients in a supervised exercise program typically have fewer hospital readmissions.

A

True

117
Q

TF: 4. Resistance training should be utilized with a light weight that can be performed for 12-15 repetitions.

A

True

118
Q

Which of the following are reasons for the increased in incidence and prevalence of heart failure?

A

A and B correct

a. Aging population
b. Improved survival of patients with CVD

119
Q

Which of the following describes the 5 year mortality rate for heart failure?

A

None of the above

(50%) is the answer

120
Q

Which of the following describes the predominant cause of heart failure due to a reduced ejection fraction?

A

Ischemic heart disease

121
Q

Which of the following describes difficulty sleeping flat or awakening suddenly during the night to “catch my breath?”

A

Paroxysmal nocturnal dyspnea

122
Q

TF: Diastolic dysfunction involves a stiff or less compliant left ventricle that is unable to relax and expand as blood flows during diastole

A

True

123
Q

TF: The left ventricle end-diastolic and end-systolic volumes remain the same with a reduced ejection fraction in patients with heart failure with preserved ejection fraction.

A

False

124
Q

TF: Sympathetic nervous system activity is increased in diastolic heart failure.

A

False

125
Q

TF: A third sound of the heart is not heard in patients with heart failure due to a reduced ejection fraction.

A

False

126
Q

Which of the following is the percentage of reduction of left ventricle ejection fraction?

A

45%

127
Q

Which of the following is calculated as the slope of the relationship of minute ventilation to CO2 production?

A

Ventilatory efficiency

128
Q

Which of the following is the suggested rate of increase in exercise intensity during a GXT in a patient with chronic heart failure?

A

10-15 W/min

129
Q

Which of the following classes of drugs used to treat heart failure can result in nonspecific ST-T wave changes in resting ECG?

A

Digitalis

130
Q

TF: The decrease in ejection fraction is proportional to the amount of myocardium that is no longer functional.

A

True

131
Q

TF: Prediction equations of VO2 are discouraged in patients with chronic heart failure because they tend to overestimate functional capacity.

A

True

132
Q

TF: Patients with stable heart failure may undergo a symptom-limited maximum cardiopulmonary exercise test.

A

True

133
Q

TF: Individuals with heart failure need to engage in cardiorespiratory exercise 4-5 times per week.

A

True

134
Q

Which of the following describes the percentage of patients with PAD that have claudication?

A

35-40%

135
Q

Which of the following is a common risk factor for PAD?

A

All of the above

  • Diabetes
  • Smoking
  • Increased blood viscosity
  • Elevated C-reactive protein
136
Q

Which of the following locations is the most commonly reported area for leg pain?

A

Calf

137
Q

Which of the following arteries would be compromised if the individual experienced pain in the thigh?

A

All of the above

  • Internal iliac artery
  • Common iliac artery
  • Profunda femoral artery
  • Common femoral artery
138
Q

TF: The prevalence rate of PAD is higher in males than females

A

True

139
Q

TF: Abnormal blood flow in the lower extremities is predicated on the severity of the stenosis in PAD

A

True

140
Q

TF: Supervised exercise training is considered a second-line therapy for claudication.

A

False

First-line

141
Q

TF: Noninvasive angiography is needed to diagnose the specific disease location and severity of PAD.

A

True

142
Q

Which of the following provides an objective measure of the severity of PAD?

A

Ankle-brachial index

143
Q

Which of the following arteries is used in the ankle-brachial index?

A

A and B are correct

A. Dorsalis pedis
B. Posterior tibial

144
Q

Which of the following is the first-line option for noninvasive imaging?

A

Computed tomography angiography

145
Q

Which of the following is the most important evaluation for patients with PAD?

A

All of the above

  • Cardiorespiratory endurance
  • Knee extension
  • Handgrip
  • Plantar flexion isometric strength
146
Q

TF: Exercise testing is useful for determining the degree of functional limitation in patients with PAD.

A

True

147
Q

TF: Patients with PAD have lower plantar flexion strength and lower knee extension power than patients without PAD.

A

True

148
Q

TF: The exercise prescription is set according to the individual limitations of the patients with PAD.

A

True

149
Q

TF: Low-intensity exercise training programs have been shown to be similar to high-intensity exercise rehabilitation for improving initial claudication onset.

A

True

150
Q

Which of the following are the most common indicators for a pacemaker implantation?

A

A and B correct

A. SA node dysfunction
B. Conduction block in the AV node

151
Q

Which of the following is the most important component for increasing cardiac output?

A

Heart rate

152
Q

Which of the following symptoms may a person exhibit with SA node dysfunction?

A

A, B, and C correct

A. Fatigue
B. Light-headedness
C. Syncope

153
Q

Which of the following is a complication of heart block if left untreated?

A

All the above

  • Presyncope
  • Syncope
  • Loss of AV synchrony
  • Death
154
Q

TF: Clinical exercise physiologists should understand how a pacemaker will affect the patient’s physiologic response to exercise

A

True

155
Q

TF: AV asynchrony may not allow the ventricles to fill with enough blood before contracting

A

True

156
Q

TF: There is an equal distribution among men and women who need a pacemaker.

A

True

157
Q

TF: The loss of atrial function increases atrial pressure and pulmonary congestion.

A

True

158
Q

Which of the following does AV synchrony and stroke volume provide their most important contributions to cardiac output?

A

At rest

159
Q

Which of the following arrhythmia is most common in patients with sinus node dysfunction?

A

Atrial fibrillation

160
Q

Which of the following is described by the highest rate at which the pacemaker will pace the ventricle in response to a sensor-driven rate?

A

Maximal sensor rate

161
Q

Which of the following is important for the sensors in the pacemaker?

A

All of the above

  • Sensors should rapidly detect acceleration and deceleration
  • The response should be proportionate to the exercise workload and metabolic demands
  • The response should be sensitive to both exercise and non-exercise requirements
  • The response should be specific and not be falsely triggered
162
Q

TF: The pacemaker can set the AV interval based on the heart rate.

A

True

163
Q

TF: In response to exercise, increasing heart rate is the most important factor for increasing cardiac output and oxygen uptake.

A

True

164
Q

TF: The graded exercise test protocol does not need special consideration for formal exercise testing of patients with a pacemaker.

A

False

165
Q

TF: RPE should be used to guide exercise intensity in the exercise prescription.

A

True

166
Q

This layer of the artery has a critical role in maintaining the degree of vasoconstriction

A

Endothelium

167
Q

These are risk factors for the development of atherosclerosis

A

Tobacco, Dyslipidemia, Hypertension, Obesity, Sedentary lifestyle, Diabetes, Metabolic syndrome

168
Q

A myocardial infarction in this chamber of the heart is associated with a high-degree AV block and increased in-hospital morbidity and mortality

A

Right ventricle

169
Q

This drug when used to help treat coronary syndromes increases the risk of bleeding and has no effect on exercise

A

Anti-platelet (aspirin)

170
Q

The is the process of the development of angina pectoris

A

Stiffening of the left ventricle, which impairs diastolic filling of the heart. Systolic emptying of left ventricle is impaired. Localized areas of myocardium develop abnormal contraction patterns. ECG abnormalities associated with altered repolarization occur.

171
Q

This is the 5 year mortality rate for an individual newly diagnosed with heart failure

A

50%

172
Q

This is the common cause of heart failure with reduced ejection fraction

A

Ischemic heart disease (coronary atherosclerosis)

173
Q

This is the recommended frequency of exercise in patients with heart failure

A

4-5 times per week

174
Q

This is the condition that is found when peak heart rate response is less than 62% of age predicted max

A

Chronotropic incompetence

175
Q

This diagnostic test uses expired gases to determine and is an excellent predictor of future risk of death

A

Ventilatory efficiency

176
Q

These are complications of angioplasty

A

Acute vessel closure, thrombotic distal embolism, MI, arrhythmias, dissection of the coronary artery, and bleeding

177
Q

Signs of coronary artery disease include

A

Buildup of lipids, macrophages, platelets, calcium, and fibrous connective tissue within the coronary arteries

178
Q

Coronary artery bypass surgery is beneficial for patents with these conditions

A

Significant left main coronary artery disease, Three-vessel disease, Two-vessel disease with a proximal left anterior descending stenosis, Two-vessel disease and impaired left ventricular function

179
Q

This is the optimal amount of time to wait after bypass surgery to begin exercise testing

A

At least 4 weeks

180
Q

These exercises are recommended 4-6 weeks post-surgery

A

Dumbbell bent-over row, Seated row, Lateral dumbbell raise, Shoulder press, Triceps kickback

181
Q

This is the prevalence of patients with PAD and claudication

A

~35%-40%

182
Q

This process starts the development of PAD

A

Endothelial damage in the arteries of the periphery

183
Q

This is the goal exercise duration for patients with PAD

A

50 minutes

184
Q

These are improvements observed in patients with PAD from a walking program

A

Improved biomechanics, Increased angiogenesis, Reduction in blood viscosity, Attenuation of atherosclerosis, Increased pain tolerance, Improved endothelial function, Activation of fibrinolysis

185
Q

Comorbidities that accompany PAD include these

A

Diabetes, Cardiac disease, Cerebrovascular disease, Heart failure, Pulmonary disease

186
Q

This is the prevalence of pacemakers in individuals over age 65

A

85%

187
Q

Exercise prescription in patients should be based on this variable

A

RPE

188
Q

This is the expected increase in cardiac output from rest to exercise

A

15%-20%

189
Q

Single-lead pacemakers can be used in these situations

A

SA node sends signals too slowly with conduction pathway still intact, Slow ventricular rate in the setting of permanent atrial fibrillation

190
Q

The ideal energy expenditure for an individual with a pacemaker

A

1,000 kcal/week

health science (8 decks)

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