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National Heart Foundation of Australia and
Cardiac Society of Australia and New Zealand:
Australian clinical guidelines for the
management of heart failure 2018
John J Atherton
1
, Andrew Sindone
2
, Carmine G De Pasquale
3
, Andrea Driscoll
4,5
, Peter S MacDonald
6
, Ingrid Hopper
7
,
Peter Kistler
8
, Tom G Briffa
9
, James Wong
10
, Walter P Abhayaratna
11
, Liza Thomas
12
, Ralph Audehm
13
, Phillip J Newton
14
,
Joan O’Loughlin
15
, Cia Connell
16
, Maree Branagan
16
The National Heart Foundation of Australia and the Cardiac
Society of Australia and New Zealand have developed
new guidelines to assist Australian clinicians in the care of
adult patients with heart failure (HF). The guidelines are based on
current evidence, and replace the 2011 guidelines for the preven-
tion, detection and management of chronic HF in Australia.
1
This executive summary provides important recommendations
together with their strength of evidence and guidance for their
implementation in clinical practice (practice points). The full clin-
ical guidelines are available in Heart, Lung and Circulation at
https://doi.org/10.1016/j.hlc.2018.06.1042.
2
Definition of heart failure
HF is a complex clinical syndrome with typical symptoms and
signs that generally occur on exertion but may also occur at rest
(particularly when recumbent). HF is secondary to an abnormality
of cardiac structure or function that impairs the ability of the heart
to fill with blood at normal pressure or eject blood sufficient to fulfil
the needs of the metabolising organs. Following clinical diagnosis,
HF is generally categorised according to whether it is associated
with a reduced left ventricular ejection fraction (LVEF) below
50% (heart failure with reduced ejection fraction [HFrEF]) or pre-
served LVEF of 50% or more (heart failure with preserved ejection
fraction [HFpEF]) (Box 1).
Method
The National Heart Foundation of Australia, in partnership with
the Cardiac Society of Australia and New Zealand, appointed an
expert writing group. The HF guideline development working
group comprised an executive and four writing groups covering
the topics of diagnosis; pharmacological management; devices and
surgery; and non-pharmacological management. The working
group comprised a broad mix of health professionals, including
cardiologists (including an electrophysiologist), nurses, general
practitioners, a clinical pharmacologist and general physician, an
exercise health and professional epidemiologist, and a consumer
representative.
In addition, a reference group including representatives from
stakeholder groups, potential endorsing organisations and
regional experts provided input into the scope and content of the
guideline.
A draft of the guideline was open for a 21-day period of public
consultation in April 2018 to capture stakeholder views and
facilitate engagement. Appropriate governance processes
were followed to ensure transparency, minimise bias, manage
conflict of interest and limit other influences during guideline
development.
Abstract
Introduction: Heart failure (HF) is a clinical syndrome that is
secondary to an abnormality of cardiac structure or function.
These clinical practice guidelines focus on the diagnosis and
management of HF with recommendations that have been
graded on the strength of evidence and the likely absolute
benefit versus harm. Additional considerations are presented as
practice points.
Main recommendations:
Blood pressure and lipid lowering decrease the risk of
developing HF. Sodiumeglucose cotransporter 2 inhibitors
decrease the risk of HF hospitalisation in patients with type 2
diabetes and cardiovascular disease.
An echocardiogram is recommended if HF is suspected or
newly diagnosed.
If an echocardiogram cannot be arranged in a timely fashion,
measurement of plasma B-type natriuretic peptides
improves diagnostic accuracy.
Angiotensin-converting enzyme inhibitors,
b
-blockers and
mineralocorticoid receptor antagonists improve outcomes in
patients with HF associated with a reduced left ventricular
ejection fraction. Additional treatment options in selected
patients with persistent HF associated with reduced left
ventricular ejection fraction include switching the
angiotensin-converting enzyme inhibitor to an angiotensin re-
ceptor neprilysin inhibitor; ivabradine; implantable cardioverter
defibrillators; cardiac resynchronisation therapy; and atrial
fibrillation ablation.
Multidisciplinary HF disease management facilitates the
implementation of evidence-based HF therapies. Clinicians
should also consider models of care that optimise medication
titration (eg, nurse-led titration).
Changes in management as a result of the guideline: These
guidelines have been designed to facilitate the systematic
integration of recommendations into HF care. This should
include ongoing audit and feedback systems integrated into
work practices in order to improve the quality of care and
outcomes of patients with HF.
1
Royal Brisbane and Women’s Hospital and University of Queensland, Brisbane, QLD.
2
Concord Repatriation General Hospital, Sydney, NSW.
3
Flinders Medical Centre, Flinders
University, Adelaide, SA.
4
Deakin University, Melbourne, VIC.
5
Austin Health, Melbourne, VIC.
6
St Vincent’s Hospital, Sydney, NSW.
7
Monash University, Melbourne, VIC.
8
The
Alfred Hospital, Melbourne.
9
University of Western Australia, Perth, WA.
10
Royal Melbourne Hospital, Melbourne, VIC.
11
Canberra Hospital, Canberra, ACT.
12
Westmead Private
Hospital, Sydney, NSW.
13
University of Melbourne, Melbourne, VIC.
14
Western Sydney University, Sydney, NSW.
15
Consumer Representative, Perth, WA.
16
National Heart
Foundation of Australia, Melbourne, VIC. john_atherton@health.qld.gov.au jdoi: 10.5694/mja18.00647 jPublished online 02/08/2018
Guideline summary
MJA 2018
1
Key evidence-based recommendations
Each recommendation is presented with a Grading of Recom-
mendations Assessment, Development and Evaluation (GRADE)
strength of recommendation and quality of evidence.
3
Practice
points are also provided.
Prevention of heart failure
Blood pressure
4
and lipid
5
lowering according to published
guidelines is recommended, to decrease the risk of cardio-
vascular events and the risk of developing HF. GRADE:
Strong; Evidence: High.
Sodiumeglucose cotransporter 2 inhibitors are recommended
in patients with type 2 diabetes mellitus associated with car-
diovascular disease and insufficient glycaemic control despite
metformin, to decrease the risk of cardiovascular events and
decrease the risk of HF hospitalisation.
6
GRADE: Strong;
Evidence: High.
Angiotensin-converting enzyme (ACE) inhibitors are recom-
mended in patients with left ventricular systolic dysfunction,
to decrease the risk of developing HF.
7
GRADE: Strong;
Evidence: High.
Diagnosis of heart failure
Plasma B-type natriuretic peptide (BNP) or N-terminal
proBNP levels are recommended for diagnosis in patients
with suspected HF when the diagnosis is uncertain.
8
GRADE:
Strong; Evidence: High.
A transthoracic echocardiogram is recommended in patients
with suspected HF, to improve diagnostic accuracy, and in
patients with a new diagnosis of HF, to assess cardiac struc-
ture and function (including the measurement of LVEF), assist
in classification and therefore guide management.
9
GRADE:
Strong; Evidence: Low.
<Practice point: The diagnostic work-up of a patient with
suspected HF is summarised in Box 2. The single most
useful investigation is the echocardiogram. However, if the
diagnosis is unclear and an echocardiogram cannot be
arranged in a timely fashion, measurement of either
plasma BNP or N-terminal proBNP has been shown to
improve diagnostic accuracy.
2
<Practice point: Evaluation of coronary arteries should be
guided by the presence or absence of symptoms of coro-
nary artery disease and the pre-test probability of coronary
artery disease.
<Practice point:Box 3 lists red flags where early specialist
referral may be considered.
Management of heart failure
The management of acute HF should be guided by the patient’s
vital signs, oxygen saturation, and the presence or absence of
congestion and hypoperfusion. Management includes intravenous
diuretics in most patients accompanied by the selected use of
oxygen therapy (if hypoxaemic), positive pressure ventilation,
vasodilators and inotropes.
2
Effective long term management of
HF is key to decreasing hospitalisation and improving survival.
Although a number of evidence-based interventions exist for
HFrEF (Box 4 and Box 5), none have been shown to reduce
mortality in HFpEF.
Pharmacological management of chronic heart failure
An ACE inhibitor is recommended in all patients with HFrEF
associated with an LVEF 40%, unless contraindicated or not
tolerated, to decrease mortality and decrease hospitalisation.
10
GRADE: Strong; Evidence: High.
A
b
-blocker (specifically bisoprolol, carvedilol, controlled or
extended release metoprolol or nebivolol) is recommended in
all patients with HFrEF associated with an LVEF 40% unless
contraindicated or not tolerated, and once stabilised with no
or minimal clinical congestion on physical examination, to
decrease mortality and decrease hospitalisation.
11-14
GRADE:
Strong; Evidence: High.
A mineralocorticoid receptor antagonist (MRA) is recom-
mended in all patients with HFrEF associated with an
LVEF 40% unless contraindicated or not tolerated, to
decrease mortality and decrease hospitalisation for HF.
15,16
GRADE: Strong; Evidence: High.
An angiotensin receptor blocker (ARB) is recommended
in patients with HFrEF associated with an LVEF 40% if
an ACE inhibitor is contraindicated or not tolerated,
to decrease the combined endpoint of cardiovascular mor-
tality and HF hospitalisation.
17
GRADE: Strong; Evidence:
Moderate.
An angiotensin receptor neprilysin inhibitor (ARNI) is
recommended as a replacement for an ACE inhibitor (with at
least a 36-hour washout window) or an ARB in patients with
HFrEF associated with an LVEF 40% despite receiving
maximally tolerated or target doses of an ACE inhibitor (or
ARB) and a
b
-blocker (unless contraindicated), with or
without an MRA, to decrease mortality and decrease hospi-
talisation.
18
GRADE: Strong; Evidence: High.
Ivabradine should be considered in patients with HFrEF
associated with an LVEF 35% and with a sinus
rate 70 bpm, despite receiving maximally tolerated or target
doses of an ACE inhibitor (or ARB) and a
b
-blocker (unless
1 Heart failure diagnostic criteria
Heart failure with reduced ejection fraction
Symptoms signs of heart failure
and
LVEF < 50%*
Heart failure with preserved ejection fraction
Symptoms signs of heart failure
and
LVEF 50%
and
Objective evidence of:
<relevant structural heart disease (LV hypertrophy, left atrial
enlargement)
and/or
<diastolic dysfunction, with high filling pressure demonstrated
by any of the following:
invasive means (cardiac catheterisation)
echocardiography
biomarker (elevated BNP or NT proBNP)
exercise (invasive or echocardiography)
*If LVEF mildly reduced (LVEF, 41e49%), additional criteria required (eg, signs of
heart failure; diastolic dysfunction with high filling pressure demonstrated by
invasive means or echocardiography or biomarker testing). BNP ¼B-type
natriuretic peptide; LV ¼left ventricular; LVEF ¼left ventricular ejection fraction;
NT ¼N-terminal. u
Guideline summary
MJA 2018
2
contraindicated), with or without an MRA, to decrease the
combined endpoint of cardiovascular mortality and HF hos-
pitalisation.
19
GRADE: Strong; Evidence: High.
A diuretic should be considered in patients with HF and
clinical symptoms, or signs of congestion, to improve
symptoms and manage congestion.
20
GRADE: Strong;
Evidence: Very low.
Unless a reversible cause has been corrected, neurohormonal
antagonists (ACE inhibitors or ARBs or ARNIs,
b
-blockers and
MRAs) should be continued at target doses in patients with
HF associated with a recovered or restored ejection fraction, to
decrease the risk of recurrence.
21
GRADE: Strong; Evidence:
Low.
<Practice point: Aim for the target doses used in the rando-
mised controlled trials (RCTs) that showed the benefits of
these drugs. Most of the RCTs were conducted in patients
with HF associated with an LVEF < 35e40%; however,
post hoc analyses of patients with HF associated with a
mild reduction in LVEF (LVEF, 41e49%) enrolled in RCTs
have reported similar benefits with
b
-blockers and drugs
that antagonise the renineangiotensinealdosterone sys-
tem.
22-24
<Practice point: Patients with HFpEF are generally
older with multiple comorbidities. The main aims of
treatment are to improve symptoms and quality of life
and decrease hospitalisation. Although the evidence
for neurohormonal antagonists is less robust, these
agents are often used to manage comorbidities. Low dose
spironolactone may be considered to decrease HF
hospitalisation.
25
Non-pharmacological management
Referral to a multidisciplinary HF disease management pro-
gram is recommended in patients with HF associated with
high risk features, to decrease mortality and rehospitalisa-
tion.
26
GRADE: Strong; Evidence: High.
3 When to consider early referral in the community setting
(red flags)
Symptoms
Orthopnoea
Paroxysmal nocturnal dyspnoea
Syncope
Ischaemic chest pain
Signs
Tachycardia (heart rate > 100 bpm)
Bradycardia (heart rate < 40 bpm)
Hypotension (systolic blood pressure < 90 mmHg)
Hypoxaemia
Gallop rhythm
Significant heart murmur
Investigations
Evidence of ischaemia or infarction on 12-lead electrocardiogram
Pulmonary oedema on chest x-ray
Raised cardiac troponin level
Moderate or severe valvular heart disease on echocardiography
Left ventricular ejection fraction 40%
Ischaemia on stress testing u
2 Diagnostic work-up of a patient with suspected heart failure
ACEI ¼angiotensin-converting enzyme inhibitor; ARB ¼angiotensin receptor blocker; BNP ¼B-type natriuretic peptide; CXR ¼chest x-ray; ECG ¼electrocardiogram;
EUC ¼electrolytes/urea/creatinine; FBC ¼full blood count; HFpEF ¼heart failure with preserved ejection fraction; HFrEF ¼heart failure with reduced ejection fraction;
HTN ¼hypertension; LFTs ¼liver function tests; MRA ¼mineralocorticoid receptor antagonist; NTproBNP ¼N-terminal pro B-type natriuretic peptide. Adapted with permission
from Tomlinson S, Atherton JJ. Heart failure ethe crucial role of the GP. Medicine Today 2018; 19: 19-27. u
Guideline summary
MJA 2018
3
In areas where access to a face-to-face multidisciplinary HF
disease management program after discharge is limited,
patients should be followed up with a multidisciplinary tele-
monitoring or telephone support program.
27
GRADE: Strong;
Evidence: Moderate.
<Practice point: These programs should focus on high risk
patients, especially those recently discharged after hospi-
talisation for HF. Patient and carer education, including
self-management, should commence soon after diagnosis,
be patient-centred appropriate to their level of health lit-
eracy, and be revised continually for life.
Nurse-led medication titration is recommended in patients
diagnosed with HFrEF who have not achieved maximum
tolerated doses of ACE inhibitors, ARBs, ARNIs,
b
-blockers
or MRAs, to decrease hospitalisation.
28
GRADE: Strong; Evi-
dence: High.
Regular performance of up to moderate intensity (ie, breathe
faster but hold conversation) continuous exercise is recom-
mended in patients with stable chronic HF, particularly those
with reduced LVEF, to improve physical functioning and
quality of life and to decrease hospitalisation.
29
GRADE:
Strong; Evidence: High.
4 Evidence summary for management of heart failure with reduced ejection fraction
2
Treatment effect All patients
Selected patients
Strong recommendation Weak recommendation
Decrease morbidity/mortality ACEI (or ARB*)
b
-blocker
†
MRA
Switch ACEI or ARB to ARNI (LVEF 40%)
Ivabradine (SR 70 bpm, LVEF 35%)
Multidisciplinary HF disease management
Nurse-led medication titration
ICD (IHD, LVEF 35%)
CRT (SR, QRS 130 ms, LVEF 35%)
AF ablation (paroxysmal/persistent AF,
LVEF 35%)
CABG (IHD, LVEF 35%)
VAD (intractable severe HF)
Heart transplantation (intractable severe HF)
ICD (DCM, LVEF 35%)
CRT (AF, QRS 130 ms, LVEF 35%)
Hydralazine þnitrates
N-3 polyunsaturated fatty acids
Improve symptoms Diuretics (congested)
Exercise training (also decreases hospitalisation)
Intravenous iron (iron deficient)
Digoxin (refractory symptoms)
ACEI ¼angiotensin-converting enzyme inhibitor; AF ¼atrial fibrillation; ARB ¼angiotensin receptor blocker; ARNI ¼angiotensin receptor neprilysin inhibitor; CABG ¼coronary
artery bypass graft surgery; CRT ¼cardiac resynchronisation therapy; DCM ¼dilated cardiomyopathy; ICD ¼implantable cardioverter defibrillator; IHD ¼ischaemic heart disease;
LVEF ¼left ventricular ejection fraction; MRA ¼mineralocorticoid receptor antagonist; SR ¼sinus rhythm; VAD ¼ventricular assist device. *ARB should only be used if ACEI is
contraindicated or not tolerated. †Carvedilol, bisoprolol, metoprolol succinate, nebivolol. u
5 Management of patients with heart failure with reduced ejection fraction (HFrEF)*
ACEI ¼angiotensin-converting enzyme inhibitor; ARB ¼angiotensin receptor blocker; ARNI ¼angiotensin receptor neprilysin inhibitor; CRT ¼cardiac resynchronisation therapy;
ICD ¼implantable cardioverter defibrillator; LVEF ¼left ventricular ejection fraction; MRA ¼mineralocorticoid receptor antagonist. * HFrEF refers to patients with symptoms
signs of heart failure associated with and LVEF < 50% (unless otherwise specified). yARB should only be used if ACEI is contraindicated or not tolerated. zCarvedilol, bisoprolol,
metoprolol succinate, nebivolol.
ˇ
Commencing MRA usually avoided if serum K > 5 mmol/L or CrCl < 30 mL/m. BICD and/or CRT. Adapted with permission from Tomlinson S,
Atherton JJ. Heart failure ethe crucial role of the GP. Medicine Today 2018; 19: 19-27. u
Guideline summary
MJA 2018
4
<Practice point: Exercise can be considered as soon as prac-
tical in clinically stable patients. An initial period of su-
pervision may be warranted to verify individual responses
and tolerability.
Devices, surgery and percutaneous procedures
Cardiac resynchronisation therapy (CRT) is recommended in
patients with HFrEF associated with sinus rhythm, an
LVEF 35% and a QRS duration 150 ms despite optimal
medical therapy, to decrease mortality, decrease hospital-
isation for HF, and improve symptoms.
30,31
GRADE: Strong;
Evidence: High.
CRT should be considered in patients with HFrEF associated
with sinus rhythm, an LVEF 35% and a QRS duration of
130e149 ms despite optimal medical therapy, to decrease
mortality, decrease hospitalisation for HF, and improve
symptoms.
30
GRADE: Strong; Evidence: Moderate.
CRT should be considered in patients with HFrEF associated
with an LVEF of 50% accompanied by high grade atrio-
ventricular block requiring pacing, to decrease hospitalisation
for HF.
32
GRADE: Weak; Evidence: Moderate.
CRT is contraindicated in patients with a QRS
duration < 130 ms, because of lack of efficacy and possible
harm.
33
GRADE: Strong Against; Evidence: Moderate.
<Practice point: Resynchronisation of ventricular contraction
is achieved by pacing both the left and the right ventricles
simultaneously. The benefit is greater in patients with a
broader QRS duration,
30,31
and in some studies for left
bundle branch block morphology and prolonged PR in-
terval.
31,34
If CRT is performed in patients in atrial fibril-
lation (AF), measures are required to ensure at least
92% biventricular capture.
35
An implantable cardioverter defibrillator (ICD) should be
considered as a primary prevention indication in patients with
HFrEF associated with ischaemic heart disease and an
LVEF 35%, to decrease mortality.
36,37
GRADE: Strong;
Evidence: Moderate.
An ICD may be considered as a primary prevention indication
in patients with HFrEF associated with dilated cardiomyop-
athy and an LVEF 35%, to decrease mortality.
37-39
GRADE:
Weak; Evidence: Low.
Coronary artery bypass graft surgery should be considered
in patients with HFrEF associated with ischaemic heart
disease and an LVEF 35% if they have surgically correct-
able coronary artery disease, to improve symptoms (eg, re-
lief of angina and HF symptoms) and decrease morbidity
and long term mortality.
40
GRADE: Strong; Evidence:
Moderate.
<Practice point: The benefits must be balanced against the
short term morbidity and mortality risk related to coronary
artery bypass graft surgery. Factors unrelated to the
severity of HF —including age, frailty and comorbidities —
are important contributors to surgical risk.
Surgical aortic valve replacement is recommended in patients
with severe aortic stenosis or severe aortic regurgitation and HF
in the absence of major comorbidities or frailty, to improve
symptoms and decrease mortality.
41
GRADE: Strong; Evidence:
Low.
Transcatheter aortic valve implantation should be consid-
ered in patients with severe aortic stenosis and HF at in-
termediate to high operative mortality risk, or considered
inoperable for surgical aortic valve replacement, and who
are deemed suitable for transcatheter aortic valve implan-
tation following assessment by a heart team, to improve
symptoms and decrease mortality.
42-45
GRADE: Strong;
Evidence: Moderate.
Referral to a specialist centre for consideration of ventricular
assist device implantation should be considered in patients
with intractable, severe HF despite guideline-directed medical
and pacemaker therapy, and who do not suffer from major
comorbidities, to decrease mortality.
46
GRADE: Strong;
Evidence: Moderate.
<Practice point: Timing of implantation of ventricular assist
devices and patient selection are critical to achieving a
successful outcome. Longer term harms including disabling
stroke, bleeding and infection remain major limitations.
Referral for heart transplant assessment should be consid-
ered in patients with HF associated with intractable New
York Heart Association class IIIeIV symptoms who have
exhausted all alternative therapies and who do not have
overt contraindications, to decrease mortality.
47
GRADE:
Strong; Evidence: Low.
Comorbidities in heart failure
Pharmacological therapy aiming for a resting ventricular rate
of 60e100 bpm should be considered in patients with HF
associated with AF and a rapid ventricular response.
48,49
GRADE Strong; Evidence: Low.
<Practice point:
b
-Blockers and/or digoxin are generally
favoured for ventricular rate control. Consider non-
dihydropyridine calcium entry blockers in patients with
HFpEF to control the ventricular rate of AF; however,
these drugs should be avoided in patients with HFrEF.
Catheter ablation for AF (either paroxysmal or persistent)
should be considered in patients with HFrEF associated with
an LVEF 35%, who present with recurrent symptomatic AF,
to decrease mortality and hospitalisation for HF.
49,50
GRADE:
Strong; Evidence: Moderate.
<Practice point: Consider oral amiodarone in patients
with HF associated with AF, to facilitate attainment
and maintenance of sinus rhythm (with or without
electrical cardioversion), improve symptoms, or guide
decisions regarding the need for more invasive ap-
proaches (eg, AF catheter ablation or atrioventricular
node ablation).
Adaptive servoventilation is not recommended in patients
with HFrEF and predominant central sleep apnoea because of
increased all-cause and cardiovascular mortality.
51
GRADE:
Strong Against; Evidence: Moderate.
<Practice point: Although clinicians may consider positive
pressure ventilation to improve quality of life and
decrease sleepiness in patients with predominant
obstructive sleep apnoea, the primary aim in patients
with predominant central sleep apnoea should be to treat
the HF.
Erythropoietin should not be used routinely for the treatment
of anaemia in patients with HF, because of an increased risk of
thromboembolic adverse events.
52
GRADE: Strong Against;
Evidence: Moderate.
In patients with HFrEF associated with persistent symptoms
despite optimised therapy, iron studies should be performed
and, if the patient is iron deficient (ie, ferritin < 100 mg/L, or
Guideline summary
MJA 2018
5
ferritin 100e300 mg/L with transferrin saturation < 20%),
intravenous iron should be considered, to improve symptoms
and quality of life.
53
GRADE: Strong; Evidence: Moderate.
<Practice point: If iron deficiency is diagnosed, one should
consider investigation for gastrointestinal pathology,
including peptic ulcer and malignancy (especially if also
anaemic). Intravenous ferric carboxymaltose was evalu-
ated in most of the RCTs, usually involving one to two
doses between 500 mg and 1000 mg. Re-check iron studies
after 4 months.
Palliative care in heart failure
Referral to palliative care should be considered in patients
with advanced HF to alleviate end-stage symptoms,
improve quality of life and decrease rehospitalisation.
Involvement of palliative care should be considered early in
the trajectory towards end-stage HF.
54
GRADE: Strong;
Evidence: High.
<Practice point: In patients with an ICD, discussions con-
cerning deactivation should occur between the patient,
family and cardiologist. Patients should be encouraged to
have an advanced care plan, regardless of clinical status
and soon after diagnosis.
Competing interests: A full conflict of interest register is available at: https://www.heartfoundation.
org.au/for-professionals/clinical-information/atrial-fibrillation.
Provenance: Not commissioned; externally peer reviewed. n
ª2018 AMPCo Pty Ltd. Produced with Elsevier B.V. All rights reserved.
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