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Amer. Acad. Family Phys.:Diagnostic approach to palpitations

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  • Amer. Acad. Family Phys.:Diagnostic approach to palpitations

    Copyright 2005 Gale Group, Inc.
    ASAP
    Copyright 2005 American Academy of Family Physicians
    American Family Physician

    February 15, 2005

    SECTION: No. 4, Vol. 71; Pg. 743 ; ISSN: 0002-838X

    IAC-ACC-NO: 129353014

    LENGTH: 4098 words

    HEADLINE: Diagnostic approach to palpitations.

    BYLINE: Abbott, Allan V.

    AUTHOR-ABSTRACT:
    Palpitations--sensations of a rapid or irregular heartbeat--are most often
    caused by cardiac arrhythmias or anxiety. Most patients with arrhythmias do not
    complain of palpitations. However, any arrhythmia, including sinus tachycardia,
    atrial fibrillation, premature ventricular contractions, or ventricular
    tachycardia, can cause palpitations. Palpitations should be considered as
    potentially more serious if they are associated with dizziness, near-syncope, or
    syncope. Nonarrhythmic cardiac problems, such as mitral valve prolapse,
    pericarditis, and congestive heart failure, and noncardiac problems, such as
    hyperthyroidism, vasovagal syncope, and hypoglycemia, can cause palpitations.
    Palpitations also can result from stimulant drugs, and over-the-counter and
    prescription medications. No cause for the palpitations can be found in up to 16
    percent of patients. Ambulatory electrocardiographic (ECG) monitoring usually is
    indicated if the etiology of palpitations cannot be determined from the patient
    's history, physical examination, and resting ECG. When palpitations occur
    unpredictably or do not occur daily, an initial two-week course of continuous
    closed-loop event recording is indicated. Holter monitoring for 24 to 48 hours
    may be appropriate in patients with daily palpitations. Trans-telephonic event
    monitors are more effective and cost-effective than Holter monitors for most
    patients.

    BODY:

        An increased or abnormal awareness of the heartbeat, palpitations are a
    common symptom in patients presenting to family physicians. Palpitations can be
    symptomatic of life-threatening cardiac arrhythmias. (1) However, most
    palpitations are benign. In one retrospective study (2) in a family practice
    setting, there was no difference in the rates of morbidity or mortality among
    patients with palpitations compared with matched control subjects.

        Although there are many possible cardiac etiologies, palpitations can be
    associated with noncardiac causes such as fever, anemia, or drug use, and can
    occur in anxious but otherwise normal persons. The differential diagnoses of
    palpitations are summarized in Table 1.

        Consensus or evidence-based guidelines for diagnosing and managing
    palpitations have not been developed. However, recent studies of palpitation
    etiology provide improved evidence that can guide a family physician through
    diagnosis. In a prospective cohort study (1) of 190 patients at a university
    medical center who complained of palpitations and were followed for one year, an
    etiology was determined in 84 percent of the patients.

        Of these patients, 43 percent had palpitations caused by cardiac causes (40
    percent had an arrhythmia, 3 percent had other cardiac causes), 31 percent had
    palpitations caused by anxiety or panic disorder, 6 percent had palpitations
    caused by street drugs or prescription and over-the-counter medications, and 4
    percent had palpitations caused by other noncardiac causes. No specific cause of
    the palpitations could be identified in 16 percent of the patients. Psychiatric
    and emotional illnesses such as anxiety, panic, and somatization disorders may
    be underlying problems in many patients. (1)

        Although arrhythmias frequently cause palpitations, most patients with
    arrhythmias do not actually notice their arrhythmia and are unlikely to report
    having palpitations. (3)

        This article describes the more common presentations of palpitations and a
    rational approach to patient evaluation, and provides evidence for making
    decisions about ambulatory monitoring.

        Etiology of Palpitations

        CARDIAC ARRHYTHMIAS

        Palpitations can result from many arrhythmias, including any bradycardia and
    tachycardia, premature ventricular and atrial contractions, sick sinus syndrome,
    advanced arteriovenous block, or ventricular tachycardia. Episodes of
    ventricular tachycardia and supraventricular tachycardia may be perceived as
    palpitations but also can be asymptomatic or lead to syncope. Palpitations
    associated with dizziness, near-syncope, or syncope suggest tachyarrhythmia and
    are potentially more serious.

        Some patients notice "pounding" or "jumping" palpitations when they are
    quietly sitting or lying down. This symptom may result from premature
    contractions, especially premature ventricular contractions. Orthostatic
    intolerance or inadequate cerebral perfusion on upright posture may result in
    palpitations, tachycardia, altered mentation, headache, nausea, pre-syncope,
    and, occasionally, syncope. Orthostatic intolerance is most common in women of
    childbearing age. (4)

        ANXIETY OR PANIC DISORDER

        The prevalence of panic disorder in patients with palpitations is 15 to 31
    percent. (1,5,6) Panic disorder is diagnosed on the basis of information in the
    patient's history and is characterized by recurrent unexpected panic attacks.
    Panic disorder is more likely to be diagnosed in women of childbearing age
    because these patients somatize more frequently, present to emergency
    departments more often, and have increased hypochondriacal concerns about their
    health. (7) Palpitations are most persistent in persons who have many minor
    daily irritants and are highly sensitive to bodily sensations. (8)

        A screening questionnaire (Figure 1) (9) to help identify patients whose
    palpitations are more likely to result from panic disorder was validated among
    patients referred for Holter monitoring. A score of more than 21 points on the
    questionnaire is 81 percent sensitive and 80 percent specific for panic
    disorder. To explain it another way, if, overall, 25 percent of patients have
    panic disorder as the cause of their palpitations, then 57 percent with more
    than 21 points have panic disorder compared with only 7 percent of those with 21
    or fewer points. (9)

        A simpler screening tool for panic disorder, consisting of a single
    question, also has been developed. The question is, "Have you experienced brief
    periods, for seconds or minutes, of an overwhelming panic or terror that was
    accompanied by racing heartbeats, shortness of breath, or dizziness?" (10) The
    physician must remember that panic disorder and significant arrhythmias are not
    mutually exclusive, and that cardiac evaluation still may be necessary in
    patients with suspected panic disorder. In addition, some patients or physicians
    may find it difficult to determine whether the feeling of anxiety or panic
    started before or after the palpitations. Therefore, true arrhythmic causes must
    be ruled out before the diagnosis of anxiety or panic disorder can be accepted
    as the cause of the palpitations. (1,11,12)

        Some physicians may prematurely blame palpitations on anxiety. In one study
    (13) of patients with supraventricular tachycardia, two thirds of the patients
    were diagnosed with panic, stress, or anxiety disorder, and one half of the
    patients had an unrecognized arrhythmia on the initial evaluation; this was
    particularly true among young women.

        Catecholamines increase at times of intense emotional experience, with
    intense exercise, and in conditions such as pheochromocytoma. Ventricular
    tachycardias or supraventricular tachycardias can be triggered by this
    catecholamine increase. An increase of vagal tone after exercise occasionally
    can lead to episodes of atrial fibrillation. (14) Thus, even in cases where
    panic disorder is suggested, electrocardiography (ECG) or ambulatory ECG
    monitoring is important.

        NONARRHYTHMIC CARDIAC CAUSES

        Conditions in this category include valvular diseases such as aortic
    insufficiency or stenosis, atrial or ventricular septal defect, congestive heart
    failure, cardiomyopathy, and congenital heart disease. These conditions can
    predispose the patient to arrhythmia and to palpitations. Pericarditis, a rare
    cause of palpitations, can cause chest pain that may change with position.

        EXTRACARDIAC CAUSES

        The physician should examine the patient for extracardiac causes. The
    patient may have obvious associated illness with fever, dehydration,
    hypoglycemia, anemia, or evidence of thyrotoxicosis. Use of drugs such as
    cocaine, and alcohol, caffeine, and tobacco can precipitate palpitations. The
    use of ephedra and ephedrine also has been associated with palpitations. (15)
    Many prescription medications, including digitalis, phenothiazine, theophylline,
    and beta agonists, can cause palpitations.

        Initial Clinical Evaluation

        HISTORY AND PHYSICAL EXAMINATION

        The cause of palpitations often can be determined through a careful history
    and physical examination. Patients may describe palpitations in a variety of
    ways, such as a fluttering, pounding, or uncomfortable sensation in the chest or
    neck, or simply an increased awareness of the heartbeat. Because the patient's
    description is often vague, knowing the circumstances, precipitating factors,
    and associated symptoms may be helpful for the physician in diagnosis. For
    example, a patient who describes single "skipped" beats is likely to be having
    benign premature ventricular contractions. The physician should consider the
    differential diagnoses of palpitations (Table 1) while questioning the patient.
    Certain clinical findings and possible associated conditions are listed in Table
    2.

        Because physicians usually do not get the chance to examine the patient
    during an episode of palpitations, the physical examination primarily serves to
    determine if there are cardiac or other abnormalities present that might
    predispose the patient to palpitations. Careful examination of the heart may
    reveal murmurs, extra sounds, or cardiac enlargement. Mitral valve prolapse,
    which is commonly associated with palpitations, is suggested by a midsystolic
    click. (16) The physician should look for evidence of hyperthyroidism (e.g.,
    nervousness, heat intolerance), drug use, or other serious illnesses. Finally,
    in the occasional patient who has palpitations with exercise, examination of the
    patient after he or she exercises may reveal an arrhythmia or murmur that is
    exacerbated by the resulting increased heart rate and cardiac output.

        ECG EVALUATION

        A 12-lead ECG evaluation is appropriate in all patients who complain of
    palpitations. In the event that the patient is experiencing palpitations at the
    time of the ECG, the physician may be able to confirm the diagnosis of
    arrhythmia. Many ECG findings warrant further cardiac investigation. These
    findings include evidence of previous myocardial infarction, left or right
    ventricular hypertrophy, atrial enlargement, atrial ventricular block, short PR
    interval and delta waves (Wolff-Parkinson-White syndrome), or prolonged QT
    interval. Occasionally, the finding of an isolated premature ventricular
    contraction or premature atrial contraction warrants further monitoring or
    exercise testing. Some common arrhythmias associated with palpitations are shown
    in Figures 2 through 5.

        [FIGURES 2-5 OMITTED]

        Further Diagnostic Testing

        In patients at low risk for coronary heart disease who have no
    palpitation-associated symptoms such as dizziness, and who have negative
    physical examination and ECG findings, palpitations may need no further
    evaluation unless the episodes persist or the patient remains anxious for an
    explanation. Blood tests may be appropriate in the following conditions:
    complete blood cell count for suspected anemia or infection, electrolytes for
    arrhythmia from suspected electrolyte imbalance, and thyroid-stimulating hormone
    for suspected hyperthyroidism or hypothyroidism.

        ECG exercise testing is appropriate in patients who have palpitations with
    physical exertion and patients with suspected coronary artery disease or
    myocardial ischemia. Findings from the physical examination or ECG may suggest
    the need for echocardiography to evaluate structural abnormalities and
    ventricular function.

        High-risk patients, who require ECG monitoring, include those with organic
    heart disease or any heart abnormality that could predispose the patient to
    arrhythmias. Patients with a family history of arrhythmia, syncope, or sudden
    death also may be at higher risk. The results of one study (17) of 24-hour ECG
    monitoring showed that ventricular tachycardia was associated with previous
    myocardial infarction, idiopathic dilated cardiomyopathy, significant valvular
    lesions, and hypertrophic cardiomyopathies.

        If the etiology of palpitations is not apparent after the history, physical
    examination, and ECG are completed, the physician should consider ambulatory
    cardiac monitoring. Figure 6 is an algorithm that can be used in the evaluation
    of patients with palpitations.

        [FIGURE 6 OMITTED]

        CONTINUOUS ECG MONITORS

        The Holter monitor is a simple ECG monitoring device that is worn
    continuously to record data for 24 or 48 hours. The patient must keep a diary of
    any symptoms that occur during the monitoring. (17) Holter monitors typically
    are the most expensive of the monitoring devices, and are maintained and
    operated by hospitals or larger outpatient clinics.

        TRANSTELEPHONIC EVENT MONITORS

        Transtelephonic event monitors transmit recordings by telephone to a central
    station. As with Holter monitors, patients wear continuous-loop event monitors,
    but unlike Holter monitors, these save data only for the previous and subsequent
    few minutes when the patient manually activates the monitor. These monitors are
    smaller than a Holter monitor (i.e., the size of a beeper) and may miss
    arrhythmias that are asymptomatic, or that occur during sleep or with syncope.
    Another type of transtelephonic monitor is not worn continuously but is carried
    by the patient and held to the chest when palpitations are perceived. This
    monitor records ECG data for about two minutes and is likely to miss the onset
    of arrhythmia.

        Choosing an Ambulatory Monitoring Device

        The results of a review (18) of studies comparing Holter monitors and
    transtelephonic event monitors in the diagnosis of palpitations found that the
    diagnostic yield was 66 to 83 percent when event monitors were used for
    monitoring, and 33 to 35 percent when Holter monitors were used. Furthermore,
    event monitors have been found to be significantly more cost effective than
    Holter monitors. (19,20) The results of retrospective and prospective trials
    (19,20) showed that 83 to 87 percent of patients had diagnostic transmissions
    within the first two weeks of using a transtelephonic event monitor.

        Evidence supports the use of an initial two-week course of continuous
    closed-loop event recording to monitor for palpitations. Holter monitoring for
    24 hours is an alternative to event monitoring in patients who reliably
    experience palpitations every day, or who are not willing to wear an event
    monitor for two weeks, and if event monitoring is not available locally. When
    palpitations are sustained or poorly tolerated, a referral to a cardiologist for
    an electrophysiologic evaluation may be warranted. (21)

        Management

        In patients with arrhythmias, the most common finding on ambulatory
    monitoring is benign atrial or ventricular ectopic beats associated with normal
    sinus rhythm. (20-22) Normal sinus rhythm alone is found in about one third of
    patients. Many patients with palpitations have ventricular premature
    contractions or brief episodes of ventricular tachycardia; if the evaluation of
    the heart is otherwise normal, these findings are not associated with increased
    mortality. (23) Appropriate patient education is indicated in these patients.
    The treatment of sustained arrhythmias involves pharmacologic or invasive
    electrophysiologic management and is beyond the scope of this article.

        If the patient is diagnosed with a non-cardiac, psychiatric, or
    nonarrhythmia cardiac etiology, the underlying condition is managed according to
    the diagnosis. In some patients, a thorough history, physical examination,
    diagnostic testing, and cardiac monitoring all fail to reveal any abnormality or
    etiology for palpitations. These patients should be advised to abstain from
    caffeine and alcohol, as well as foods or stressful situations that appear to
    trigger palpitations. Fortunately, the majority of patients with palpitations
    have benign diagnoses and can be treated with reassurance.

       STRENGTH OF RECOMMENDATIONS



       Key clinical recommendation                      Label     References



       Most patients with palpitations are diagnosed

         with an arrhythmia or panic disorder.          C         1

       The identification of panic disorder in

         patients with palpitations can be

         assisted with the use of screening

         questionnaires.                                C         9

       Unless palpitations occur daily, event

         monitors are more cost effective

         than 24-hour or 48-hour Holter

         monitors in the diagnosis of

         intermittent

         arrhythmias.                                   B         19

       Patients with palpitations caused by

         premature ventricular contractions,

         who have a normal heart evaluation,

         have no increased mortality.                   B         23



       A = consistent, good-quality patient-oriented evidence;

       B = inconsistent or limited-quality patient-oriented evidence;

       C = consensus, disease-oriented evidence, usual practice,

       opinion, or case series. See page 639 for more  information.



       TABLE 1



       Differential Diagnosis of Palpitations



       Arrhythmias



       Atrial fibrillation/flutter

       Bradycardia caused by advanced arteriovenous

         block or sinus node dysfunction

       Bradycardia-tachycardia syndrome

         (sick sinus syndrome)

       Multifocal atrial tachycardia

       Premature supraventricular

         or ventricular contractions

       Sinus tachycardia or arrhythmia

       Supraventricular tachycardia

       Ventricular tachycardia

       Wolff-Parkinson-White syndrome



       Psychiatric causes



       Anxiety disorder

       Panic attacks



       Drugs and medications



       Alcohol

       Caffeine

       Certain prescription and over-the-counter

         agents (e.g., digitalis, phenothiazine,

         theophylline, beta agonists)

       Street drugs (e.g., cocaine)

       Tobacco



       Nonarrhythmic cardiac causes



       Atrial or ventricular septal defect

       Cardiomyopathy

       Congenital heart disease

       Congestive heart failure

       Mitral valve prolapse

       Pacemaker-mediated tachycardia

       Pericarditis

       Valvular disease (e.g., aortic insufficiency,

         stenosis)



       Extracardiac causes



       Anemia

       Electrolyte imbalance

       Fever

       Hyperthyroidism

       Hypoglycemia

       Hypovolemia

       Pheochromocytoma

       Pulmonary disease

       Vasovagal syndrome



       NOTE: The categories of palpitations are arrang ed from

       most common to least common; within the categor ies,

       conditions are listed in alphabetical order.



       TABLE 2



       Key Clinical Findings with Palpitations

       and Suggested Diagnoses



       Finding                         Suggested diagn osis



       Single "skipped" beats          Benign ectopy

       Feeling of being unable to      Ventricular pre mature contractions

         catch one's breath

       Single pounding sensations      Ventricular pre mature contractions

       Rapid, regular pounding in      Supraventricula r arrhythmias

         neck

       Palpitations that are worse     Benign ectopy o r atrial fibrillation

         at night

       Palpitations associated with    Psychiatric eti ology or

         emotional distress              catecholamine-sensitive arrhythmia

       Palpitations associated with    Coronary heart  disease

         activity

       General anxiety                 Panic attacks

       Medication or recreational      Drug-induced palpitations

         drug use

       Rapid palpitations with         Supraventricula r arrhythmia, atrial

         exercise                        fibrillation

       Positional palpitations         Atrioventricula r nodal tachycardia,

                                         pericarditis

       Heat intolerance, tremor,       Hyperthyroidism

         thyromegaly

       Palpitations since              Supraventricula r tachycardia

         childhood

       Rapid, irregular rhythm         Atrial fibrilla tion, tachycardia with

                                         variable bloc k

       Palpitations terminated by      Supraventricula r tachycardia

         vagal maneuvers

       Heart murmur                    Heart valve dis ease

       Midsystolic click               Mitral valve pr olapse

       Friction rub                    Pericarditis



       NOTE: The information in this table is based on  clinical

       experience and not on the results of clinical t rials.

        REFERENCES

        (1.) Weber BE, Kapoor WN. Evaluation and outcomes of patients with
    palpitations. Am J Med 1996;100:138-48.

        (2.) Knudson MP. The natural history of palpitations in a family practice. J
    Fam Pract 1987;24:357-60.

        (3.) Barsky AJ. Palpitations, arrhythmias, and awareness of cardiac
    activity. Ann Intern Med 2001;134(9 pt 2):832-7.

        (4.) Ali YS, Daamen N, Jacob G, Jordan J, Shannon JR, Biaggioni I, et al.
    Orthostatic intolerance: a disorder of young women. Obstet Gynecol Surv
    2000;55:251-9.

        (5.) Chignon JM, Lepine JP, Ades J. Panic disorder in cardiac outpatients.
    Am J Psychiatry 1993;150:780-5.

        (6.) Barsky AJ, Cleary PD, Coeytaux RR, Ruskin JN. Psychiatric disorders in
    medical outpatients complaining of palpitations. J Gen Intern Med 1994;9:306-13.

        (7.) Jeejeebhoy FM, Dorian P, Newman DM. Panic disorder and the heart: a
    cardiology perspective. J Psychosom Res 2000;48:393-403.

        (8.) Barsky AJ, Ahern DK, Bailey ED, Delamater BA. Predictors of persistent
    palpitations and continued medical utilization. J Fam Pract 1996;42:465-72.

        (9.) Barsky AJ, Ahern DK, Delamater BA, Clancy SA, Bailey ED. Differential
    diagnosis of palpitations. Preliminary development of a screening instrument.
    Arch Fam Med 1997;6:241-5.

        (10.) Ballenger JC. Treatment of panic disorder in the general medical
    setting. J Psychosom Res 1998;44:5-15.

        (11.) Barsky AJ, Cleary PD, Coeytaux RR, Ruskin JN. The clinical course of
    palpitations in medical outpatients. Arch Intern Med 1995;155:1782-8.

        (12.) Zimetbaum P, Josephson ME. Evaluation of patients with palpitations. N
    Engl J Med 1998;338:1369-73.

        (13.) Lessmeier TJ, Gamperling D, Johnson-Liddon V, Fromm BS, Steinman RT,
    Meissner MD, et al. Unrecognized paroxysmal supraventricular tachycardia.
    Potential for misdiagnosis as panic disorder. Arch Intern Med 1997;157:537-43.

        (14.) Coumel P. Clinical approach to paroxysmal atrial fibrillation. Clin
    Cardiol 1990;13:209-12.

        (15.) Shekelle PG, Hardy ML, Morton SC, Maglione M, Mojica WA, Suttorp MJ,
    et al. Efficacy and safety of ephedra and ephedrine for weight loss and athletic
    performance: a meta-analysis. JAMA 2003;289:1537-45.

        (16.) Duren DR, Becker AE, Dunning AJ. Long-term follow-up of idiopathic
    mitral valve prolapse in 300 patients: a prospective study. J Am Coll Cardiol
    1988;11:42-7.

        (17.) Wolfe RR, Driscoll DJ, Gersony WM, Hayes CJ, Keane JF, Kidd L, et al.
    Arrhythmias in patients with valvar aortic stenosis, valvar pulmonary stenosis,
    and ventricular septal defect. Results of 24-hour ECG monitoring. Circulation
    1993;87(2 suppl):189-101.

        (18.) Zimetbaum PJ, Josephson ME. The evolving role of ambulatory monitoring
    in general clinical practice. Ann Intern Med 1999;130:848-56.

        (19.) Fogel RI, Evans JJ, Prystowsky EN. Utility and cost of event recorders
    in the diagnosis of palpitations, presyncope, and syncope. Am J Cardiol
    1997;79:207-8.

        (20.) Kinlay S, Leitch JW, Neil A, Chapman BL, Hardy DB, Fletcher PJ, et al.
    Cardiac event recorders yield more diagnoses and are more cost-effective than
    48-hour Holter monitoring in patients with palpitations. A controlled clinical
    trial. Ann Intern Med 1996;124(1 pt 1):16-20.

        (21.) Zimetbaum PJ, Kim KY, Josephson ME, Goldberger AL, Cohel DJ.
    Diagnostic yield and optimal duration of continuous-loop event monitoring for
    the diagnosis of palpitations. A cost-effectiveness analysis. Ann Intern Med
    1998;128:890-5.

        (22.) Zimetbaum PJ, Kim KY, Ho KK, Zebede J, Josephson ME, Goldberger AL.
    Utility of patient-activated cardiac event recorders in general clinical
    practice. Am J Cardiol 1997;79:371-2.

        (23.) Kennedy HL, Whitlock JA, Sprague MK, Kennedy LJ, Buckingham TA,
    Goldberg RJ. Long-term follow-up of asymptomatic healthy subjects with frequent
    and complex ventricular ectopy. N Engl J Med 1985;312:193-7.

        * Patient information: A handout on heart palpitations, written by the
    author of this article, is provided on page 755.

        ALLAN V. ABBOTT, M.D., is professor of clinical family medicine at the Keck
    School of Medicine of the University of Southern California, Los Angeles, where
    he is associate dean for curriculum and continuing medical education. Dr. Abbott
    received his medical degree from Indiana University School of Medicine and
    completed a residency in family medicine at UCLA San Bernardino Medical Center,
    Calif.

        Address correspondence to Allan V. Abbott, M.D., 1975 Zonal Ave., KAM 317,
    Los Angeles, CA 90033 (e-mail: [email protected]). Reprints are not available from
    the author.

        The author indicates that he does not have any conflicts of interest.
    Sources of funding: none reported.

        Figures 2 through 5 used with permission from Allan V. Abbott, M.D.

        This article is one in a series on problem-oriented diagnosis coordinated by
    the Department of Family Medicine at the University of Southern California, Los
    Angeles, Calif.
    Knowledge is power ... Stay informed!
    YOU can make a difference - all you have to do is try!

    Dx age 12 current age 46 and counting!
    lost: 5 family members to HCM (SCD, Stroke, CHF)
    Others diagnosed living with HCM (or gene +) include - daughter, niece, nephew, cousin, sister and many many friends!
    Therapy - ICD (implanted 97, 01, 04 and 11, medication
    Currently not obstructed
    Complications - unnecessary pacemaker and stroke (unrelated to each other)
Working...
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