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Angina pectoris

  • it is the chest pain resulting from myocardial ischemia caused by inadequate myocardial blood and O2 supply
  • this is due to obstruction of coronary blood flow because of arthrosclerosis, cad, coronary artery spasm, and condition increasing myocardial oxygen consumption
  • stable angina
    • also called exertional angina
    • it occur with activity or emotional stress
    • it is relieved with rest or nitroglycerin
  • unstable angina
    • also called preinfraction angina
    • it occur with unpredictable  degree of exertion or emotion
    • Increase in occurrence , duration, and severity over time
    • Pain may not be relive with nitroglycerin

  • Variant angina
    • It is otherwise known as prinzmetal’s or vasospastic  angina
    • Occur due to coronary artery spasm
    • May occur in rest
    • ST segment elevation noted on the ECG
  • Intractable angina
    • A chronic , incapacitating angina that is unresponsive to intervention or treatment
  • Post infraction angina
    • Occur after MI, when residual ischemia may cause episode of angina
Signs and symptoms(S/S)
  • Chest pain can develop slowly or quickly
  • Pain can be mild or moderate
  • Substernal, crushing, squeezing pain , which radiate to the shoulder, arm, jaw, neck, and back
  • Pain usually last less than 5min but in prinzmetal’s angina and some case it may last up to 15 to 20 min
  • Pain usually relived by rest or nitroglycerin
  • Other signs like
    • Tachycardia and palpitation
    • Dyspnea
    • Pallor
    • Sweating
    • Dizziness, and fainting
    • Hypertension
    • GI disturbance
  • ECG :- ST segment depression with T wave inversion during an episode of pain (in prinzmetal’s angina ST segment elevation noted on the ECG)
  • TMT test which show changes in ECG and vital sign during testing
  • Cardiac enzyme , and troponin show normal
  • Cardiac catheterization can do to know the patency of coronary artery
  • Assess pain
  • Provide bed rest in semi fowler’s position
  • Administer O2 as required
  • Obtain 12 lead ECG
  • Administer nitroglycerin -: to reduce O2 requirement of myocardium, for coronary vasodilatation and to reduce pain
  • Provide continuous cardiac monitoring
  • Instruct the patient regarding purpose diagnostic and surgical procedure
  • Teach the client to identify angina precipitating event
  • Instruct the client to stop activity and take rest if chest pain occur and take nitroglycerin as require
Sublingual administration of NTG
  • Take sips of water before giving medication because dryness may inhibit absorption of medicine
  • Instruct the client to place the medicine under the tong and leave until fully dissolve
  • Instruct the client to take one tablet for pain and repeat every 5 min for a total of 3 doses and seek medical help immediately, if pain is not relieved with in 15 minute
  • Client may get staining or burning sensation in the mouth and headache that will subside after few minute ; staining and burning sensation in the mouth indicate tablet is fresh.
  • Check for the expiry date of medicine because it may occur within 6months after opening the bottle
  • Instruct the patient to take Tylenol (pcm) for headache
  • Medication has photo sensitivity so keep in dark place and keep away from children reach
Sustained release medication (enteric coated medication)
  • Instruct the client to swallow and not to chew or crush the tablet because it is enteric coated

Trans-lingual medication

  • It comes as spray , it can be sprayed to the oral mucosa
  • Instruct the client to avoid inhalation of the spray

Trans –mucosal (buccal medication )

  • It can be placed b/w upper lips and gum buccal area means, area b/w cheek and gum

Trans-dermal patch

  • Instruct the client to apply the patch to a hair less area
  • Use a new patch in a different sight each day
  • Remove the patch after 12 to 14 hrs to allow patch free hour for tolerance
  • Avoid excessive perspiration
  • If patch is pealed out do not reapply same

Topical oinment

  • Instruct the client to remove oinment of previous dose
  • Instruct the client squeeze the ribbon of oilment on to the applicator paper
  • Spread the oinment over a 6inch*6inch area and use chest, abdomen, back, upper arm, or anterior thigh and cover with a plastic wrap for proper absorption
  • Apply over a non hairy area Select different area each time
  • Do not touch with hand directly, and don’t massage the area vigorously to prevent sudden absorption
  • Don’t apply on chest in the area of defibrillator or Cardioversion machine placement because of skin burns

Other medicine

  • Anti hypertensive
  • Anti platelet (aspirin )
  • Provide dietary instruction like low cholesterol, low fat, and no added salt
  • Adequate exercise and rest
  • Avoid smoking and mental stress


  • Occur when myocardial tissue is abruptly and severely deprived of O2
  • Ischemia can lead to necrosis of myocardial tissue . if blood flow is not restored
  • Infraction does not occur instantly but evolves over several hours
  • obvious physical changes do not occur in the heart until 6 hr after the infraction, when the infracted area appears blue and swollen
  • After 48hr, the infraction turn gray with yellow streaks as neutrophils invade the tissue
  • 8 to10 days after infraction, granulation tissue forms
  • Over 2 to 3 months, the necrotic area develops in to a scar, scar tissue permanently change the size and shape of the entire left ventricle
Location of MI
  • Obstruction in the LAD result in anterior or sepal mi or both
  • Obstruction in the circumflex artery result in lateral wall MI
  • Obstruction in the posterior descending artery result in posterior wall MI
  • Obstruction in the marginal artery result in inferior wall MI
ECG change
  • There will be ST elevation with T wave inversion
  • abnormal Q wave
  • hours to day after MI, ST and T wave changes will return to normal but Q waves usually remain permanent
  • anterior wall MI_ changes in V2 to V4
  • extensive anterior wall MI –changes in V1 to V6
  • lateral wall MI – changes in L1, aVL,V5, and V6
  • inferior wall MI- changes in L2, L3 and aVF
  • posterior wall MI- changes in L2, L3, aVF, and V1
Risk factor of MI
  • atherosclerosis
  • CAD
  • Elevated cholesterol level
  • Smoking
  • Physical inactivity
  • Obesity
  • Hyper tension
  • Impaired glucose tolerance (DM)
  • Stress
Diagnostic study
  • Same like angina plus  elevated cardiac enzyme
  • Exercise tolerance test done to evaluate the need of medical therapy or to detect the ability to with stand stress
  • Cardiac catheterization to identify stenosis
  • Chest pain; Substernal, crushing, squeezing pain , which radiate to the shoulder, left arm, jaw, neck, and back
  • it occur without any cause usually in morning
  • pain is unrelieved by rest or NTG and relived only opioids
  • pain last more than 30 minute
  • nausea, vomiting
  • diaphoresis
  • dyspnea
  • dysrhythmias
  • feeling of fear and anxiety (apprehension)
  • pallor, cyanosis, coolness of extremity
  • dysrhythmias
  • heart failure
  • cardiogenic shock
  • pulmonary edema
  • thrombophlebitis
  • Pericarditis
  • Mitral valve insufficiency
  • Ventricular rupture
  • Pericardial effusion
  • Plural effusion
  • Dressler’s syndrome – (A combination of Pericarditis, pericardial effusion, and pleural effusion, which can occur several weeks to months following an MI )

Management for Dressler’s syndrome are administration of steroid and aspirin

Management of MI
  • Provide semi fowler’s position
  • Assess vital sign
  • Administer oxygen
  • Obtain ECG
  • Maintain iv access line
  • Connect in cardiac monitor continuously
  • Administer morphine sulfate and nitroglycerin
  • Actions of morphine sulfate
    • Reduce pain
    • Reduce pneumal congestion
    • Vasodilation
    • Provide sedation
    • And reduce anxiety
  • Administer thrombolytic therapy (which may be prescribe with in 6 hours of the event)
    • Ex:- streptokinease,
    • Monitor BT, CT, and assess for any bleeding history
    • Monitor for any bleeding if client is receiving thrombolytics
  • Administer Beta-blocker ex:-properanol

Action of beta-blocker

  • Decrease myocardial contractility
  • Slow down heart rate
  • Increase myocardial perfusion
  • Monitor for cardiac dysrhythmias
  • Monitor distal, peripheral pulse and skin temperature
  • Monitor I/O chart
  • Assess respiratory status
  • Auscultate breathing sound for crackles or wheezing or signs of heart failure because of accumulation of fluid in the lung
  • Maintain bed rest for 1st 24 hrs 36 hr gradually allow the client to stand for voiding, use bed commode for defecating
  • Provide ROM exercise to prevent thrombus formation
  • Bring the patient out of bed for 30 minute for 3 times a day
  • Ambulation can provide in his room and to the bathroom and then to the hallway for 3 time a day after one week
  • Monitor for complication
  • Encourage the client to verbalize his feeling
  • Teach the pt regarding the imp of follow up , medication, and life style modification


Inability of heart to maintain adequate circulation to meet metabolic needs of the body because of the impaired pumping capacity

  1. Acute (sudden or gradual onset)

Chronic (gradually)

  1. Rt ventricular failure (CHF)

Lt ventricular failure

Because of 2 ventricle represent  2 separate pumping system responsible for one to fail alone. Most heart failure begin with left ventricle failure and progress to failure of both

  1. forward failure (is inadequate out put of affected ventricle causes decreased perfusion to vital organ )

Backward failure  (blood backs behind the affected ventricle cause increase pressure in the atrium

Compensatory mechanism with heart failure are
  • Increased HR
  • Na and water retention
  • Arterial vasoconstriction or contraction
  • Myocardial hypertrophy
S/S of Rt side heart failure
  • Signs of Rt failure will be evident  in the systemic circulation
  • Pitting, dependent edema, in the feet, legs, sacrum, back, buttocks
  • Ascites from portal hypertension
  • Tenderness of right upper quadrant, organomegaly
  • Distended neck vein
  • Pulsus alternans
  • Abdominal pain, bloating
  • Anorexia, nausea
  • Fatigue
  • Weight gain
  • Nocturnal dieresis
S/s of Lt side heart failure
  • Signs of Lt side failure will be evident in the pulmonary system
  • Cough, which may become productive with frothy sputum
  • Dyspnea on exertion
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Presence of crackles or rales on auscultation
  • Tachycardia
  • Pulsus alternans
  • Fatigue, pallor
  • Cyanosis
  • Confusion and disorientation
  • Signs of cerebral anoxia
  • acute anxiety
  • apprehension
  • pulmonary edema
  • profuse sweating
  • hypocapnia due to hyperventilation
  • nasal flaring
  • use of accessory breathing muscle
  • cold, clammy skin
  • tachypnea
  • provide high fowler’s position with leg in dependent position to reduce pulmonary congestion and relieve edema
  • connect the patient to ventilator if necessary
  • administer oxygen
  • prepare the patient for intubation to maintain, patent airway
  • assess LOC
  • monitor Vital signs
  • monitor heart rate and cardiac rhythm
  • medication
    • D digitalis   ex digoxine is the drug of choice
    • D diuretic
    • D dilator  – bronchodilator or vasodilator (morphine sulfate )
    • D dopamine or doubtamine
    • D diet
  • Administer morphine sulfate to
    • provide sedation,
    • reduce, anxiety,
    • reduce pneumal congestion
    • and for both vaso and bronchodilation
  • Administer diuretic eg: lasix to
    • To reduce pre load in the heart
    • To reduce circulatory blood volume,
    • to enhance renal execration of sodium and water
    • to decrease pulmonary congestion
  • Digitalis
    • To increase ventricular contractility their by increasing cardiac out put
  • Dopamine or doubtamine
    • To increase cardiac contractility and enhance stroke volume
  • Insert Foley’s cath
  • Maintain I/O chart
  • Monitor weight and peripheral pulse
  • Restrict fluid and sodium
  • Monitor ABG and electrolyte level
    • Following the acute episode
  • Eliminate the risk factor for developing HF
  • Adherence with medical regiment
  • Avoid OTC medication
  • Avoid large amount of coffee
  • Decrease fat, cholesterol, and sodium rich diet
  • Give potassium rich diet if potassium is low due to lasix
  • Monitor daily weight if it increases more than 2 pound/day indicate HF


  • It is the failure or heart to pump adequate blood,  thereby reducing cardiac output and compromising tissue perfusion
  • Necrosis of 40% left ventricle occur, usually as a result of occultation of major coronary vessel
  • Hypotension, systolic pressure <90mmofhg
  • Renal failure, urine output <30ml/hr
  • Cold and clammy skin
  • Poor peripheral pulses
  • Tachycardia
  • Tachypnea
  • Pulmonary congestion
  • Confusion
  • Restlessness
  • And chest discomfort
  • Administer of morphine sulfate to decrease pulmonary congestion and to relive pain
  • Prepare for intubation and mechanical ventilation
  • Give diuretic, digitalis vasopressin and positive inotropic (amrinone milrinone to decrease work load of heart and to decrease preload )
  • Prepare the client for insertion of intraarotic balloon pump (IABP), if prescribed , to facilitate emptying of the left ventricle and improve cardiac output
  • Prepare the patient for reperfusion procedure such as PTAC, or CABG
  • Monitor ABG level and prepare to treat imbalance
  • Monitor urinary output
  • Assist to the insertion of swan-ganz catheter to assess heart failure and to check CVP

Inflammatory diseases of the heart


  • Acute or chronic inflammation of the pericardium
  • In chronic condition inflammation leads to thickening of pericardium, which construct the heart and cause compression
  • It result in the loss of pericardial elasticity and accumulation of fluid within the sac. It result cardiac tamponade, and cardiac failure
  • idiopathic origin
  • infections
  • Any invasive procedure

  • Pericardial pain – sharp penetrating type pain in the anterior chest that radiate to the Lt side of the chest, neck, shoulder, or back
  • Pain aggravated by breathing , particularly during inspiration
  • Pain is worsen in supine position and may be relieved by leaning forward
  • Pericardial friction rub on auscultation (producing by the rubbing of inflamed pericardial layer)
  • Fever, chills,
  • Increased WBC and ESR count
  • Fatigue and malaise
  • Assess the nature of pain
  • Position the client in high fowler’s position or sitting upright with leaning forward
  • Administer pain medication, NSAID, corticosteroid, but avoid aspirin and anticoagulant, which increase the cardiac tamponade .
  • Auscultate for pericardial friction rub
  • Identify the causative organism and administer antibiotics
  • Administer diuretic and digoxin in patient with chronic Pericarditis


  • It is the acute or chronic inflammation of the myocardium as the result of Pericarditis, systemic infection, and allergic response
  • Fever
  • Pericardial frication rub
  • Fatigue
  • Dyspnea
  • Tachycardia
  • Chest pain
  • Signs of HF
  • Upright position with leaning forward
  • Administer oxygen
  • Administer pain medication, NSAID, and salicylates
  • Should have adequate bed rest
  • Monitor for cardiac dysrhythmias and give antidysrhythmic drug
  • Administer digoxin
  • Administer antibiotics according to the causative organism
  • Limit activity and avoid over exerction to decrease the workload of the heart
  • Cardiac failure
  • Cardiomyopathy
  • Thrombus formation
  • Inflammation of inner line of heart and valve
Pre-disposing  factor
  • IV drug abuser
  • Patient with valve replacement
  • Mitral valve prolapsed
  • Any other structural defect
  • Infection, any invasive procedure, or surgery
  • Portal entry for the infecting organism, including oral cavity, neglected mouth or any dental procedure in previous 3 to 6 months
  • Fever
  • Anorexia
  • Weight loose
  • Fatigue
  • Heart failure
  • Cardiac murmurs
  • Embolic complication from vegetation fragments traveling through the circulation
  • Petechiae
  • Hemorrhages in the nail beds
  • Osler’s nodes (reddish tender lesions) on the pads of the fingers, hands and toes
  • janeway’s node (non tender hemorrhagic lesions) on the finger, toes, nose, or ear lobs
  • splenomegaly
  • clubbing of the finger
  • Pt should be in adequate bed rest, balanced rest with activity to prevent thrombus formation
  • Give antiembolism stocking
  • Administer antibiotics after conforming the organism by blood C/S
  • Assess the signs of HF and emboli
  • S/S of emboli
    • Splenic emboli – left epigastric abdominal pain, which may radiate to the left shoulder and rebound abdominal tenderness
    • Renal emboli – flank pain radiating to the groin, Hematuria, and pyuria
    • CNS emboli – confusion, disorientation, restlessness, dysphagia, and aphasia
    • Pulmonary emboli – pleuritic chest pain, dyspnea, and cough.
Patient education
  • Adhere with medicine regimen
  • Not neglect mouth care
  • Instruct the patient to brush mouth twice daily
  • Instruct the patient to rinse the mouth well
  • Instruct the patient to avoid irrigation device, electric toothbrush, and flossing because these activity can cause the gum to bleed, allowing bacteria to enter the mucous membrane and blood stream
  • Prophylactic antibiotics before any invasive procedure

Cardiac tamponade

  • A pericardial effusion occur when the space between the parietal and visceral layers of the pericardium fill with fluid
  • Tamponade restrict ventricular filling and decrease cardiac output
  • Normal amount of pericardial fluid is 15 to 20 ml
  • Pulses paradoxes
  • Increased CVP
  • Jugular vein distention with clear lung
  • Distant, muffled heart sound
  • Decrease cardiac output
  • Client need to be admit in ICCU for hemodynamic monitoring
  • Administer IV fluids to manage decreased cardiac out put
  • Prepare the client for ECHO and X ray
  • Prepare the client for pericardiocentesis to withdraw pericardial fluid
  • Monitor for recurrence of tamponade, if there prepare the patient  for pericardial window, or pericardiectomy
Valvular heart diseases
  • It occur when the heart valves cannot fully open (stenosis), or close completely (insufficiency or regurgitation)
  • Prevent efficient blood flow through the heart
Procedure for valvular diseases
  1. Balloon valvuloplasty it is an invasive procedure, balloon catheter is passed from the femoral vein through the atrial septum to the mitral valve or through femoral artery to the aortic valve. Balloon is inflated to enlarge the orifice. Monitor for bleeding from catheter insertion site. Monitor for systemic emboli. And monitor for the signs of a regurgitant valve by  monitoring cardiac rhythm, heart sound, and cardiac output
  2. Mitral annuloplasty :- tightening and suturing the malfunctioning valve to eliminate or markedly reduce regurgitation
  • Commissurotomy / valvotomy:- accomplished with cardiopulmonary bypass during open heart surgery. The valve is visualized, thrombi are removed from the atria, fused leaflets are incised, and calcium is debrided from the leaflets, thus widening the orifice
Valve replacement surgery
  1. Mechanical prosthetic valve­ :- prosthetic valve are very durable but can fail. There is a chance of thromboembolism, so patient should take lifelong anticoagulant medication
  2. Bioprosthetic valve :- biological graft are xenografts (valves from other species), porcine valves (pig), bovine valves (cow), or homografts (human cadavers). There are little risk for clot formation, therefore long term anticoagulation therapy is not necessary

Nursing responsibility pre opp

  • Anticoagulation medicine should be withheld  72 hr prior to the surgery, with the doctor order

Post operative implementation

  • Monitor the sigs of bleeding and cardiac out put
  • Administer digoxin to maintain cardiac output and avoid AF
Client instruction following valve replacement
  • Maintain bed rest
  • Administer anticoagulant if mechanical valves are inserted
  • Instruct the client to concern hazard related anticoagulation therapy and notify bleeding or bruising to physician
  • Should have good oral hygiene to prevent endocarditic
  • Instruct the patient to brush mouth twice daily
  • Instruct the patient to rinse the mouth well
  • Instruct the patient to avoid irrigation device, electric toothbrush, and flossing because these activity can cause the gum to bleed, allowing bacteria to enter the mucous membrane and blood stream
  • monitor incision and report any drainage
  • avoid dental procedure for six months
  • heavy lifting more than 10 pound should be avoided
  • if a prosthetic valve was inserted , a soft audible (Lap- dup )clicking sound may be heard
  • instruct the patient to avoid injury to the sternal incision while driving or exercise
  • should have prophylactic antibiotics before any surgery and inform health care professional regarding the valve replacement
  • wear media alert bracelet

Mitral stenosis 

 Main cause of mitral stenosis is rheumatic fever .patient may be  asymptomatic initially; symptoms occur when the orifice is reduced by 50%.

  • Dyspnea
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Dry cough
  • Rumbling apical diastolic murmurs
  • Rt sided heart failure
  • Hepatomegaly
  • Neck vein distension
  • Pitting peripheral edema
  • Hemoptysis and pulmonary edema, and pulmonary hypertension and congestion progress
  • Development ofAF should be informed to doctor
  • Administer prescribed treatment for heart failure
  • Administer oxygen
  • Give propped up position
  • Provide low sodium diet
  • Give diuretic and digoxin, antibiotics, anticoagulant, and antidysrrhythmic
  • Prepare the patient for Commissurotomy, valvotomy or valve replacement.

Mitral valve prolapsed

  • Signs of Lt VF
  • Fatigue
  • Chest pain
  • Tachycardia
  • Palpitation
  • Dyspnea
  • Systolic click
  • Administer propranolol (inderal) for dyspnea and chest pain as prescribed
  • Administer prophylactic antibiotics as prescribed
  • Other management are similar to mitral valve stenosis

Aortic stenosis

  • Signs of Lt VF
  • Fatigue
  • Chest pain
  • Tachycardia
  • Palpitation
  • Dyspnea
  • Systolic click
  • Harsh systolic crescendo- decrescendo murmur (it is the murmur of steady increasing intensity with sudden termination)
  • Administer prescribed management for HF
  • Administer oxygen
  • Administer diuretic, and digoxin
  • Provide low salt diet
  • Administrate antibiotics if endocarditic present
  • Prepare the patient for valve replacement

Tricuspid stenosis

  • Easily fatigued
  • Effort intolerance
  • Cyanosis
  • Signs of Rt sided heart failure
  • Symptoms of decreased cardiac output
  • Ascites
  • Hepatomegaly
  • Peripheral edema
  • Rumbling systolic murmur
  • Jugular vein distention with clear lung fields
  • Administer prescribed management for HF
  • Administer oxygen
  • Administer diuretic, and digoxin
  • Provide low salt diet
  • Administrate antibiotics if endocarditic present
  • Prepare the patient for valve replacement

Pulmonary stenosis

  • Signs of Rt sided heart failure
  • Dyspnea
  • Syncope
  • Fatigue
  • Ascites
  • Hepatomegaly
  • Peripheral edema
  • Systolic thrill heard at left sternal boar
  • Administer prescribed management for HF
  • Administer oxygen
  • Administer diuretic, and digoxin
  • Provide low salt diet
  • Administrate antibiotics if endocarditic present
  • Prepare the patient for valve replacement or Commissurotomy, or valvotomy


It is the disorder of myocardium characterized by weakened heart muscle; it can be acute or chronic


  • Dilated Cardiomyopathy

This is the common type heart eject less than 40% of blood from the ventricle (normal is 70%). It leads to decrease cardiac output and heart failure


  • sings of Lt ventricular heart failure
  • weakness and fatigue
  • activity in tolerance
  • chest pain
  • dysrhythmias
  • eventually signs of Rt sided heart failure
  • Administer oxygen
  • Administer diuretic, and digoxin, vasodilator, and antidysrhythmic
  • Avoid alcohol because it has cardiac depressant  effect
  • Instruct the client to report the signs of dyspnea, or fainting, which may indicate dysrhythmias
 Surgical management
  • Heart transplantation


  • Hypretropic Cardiomyopathy (HCM)

It is characterized by massive ventricular hypertrophy, leading to hypercontraction of the left ventricle and rigid ventricle valve


  • Exertional dyspnea
  • Syncope
  • Chest pain; that occur at rest, is prolonged, is unrelated to exertion and is not relieved by nitrates
  • Dysrhythmias
  • Symptomatic treatment, similar to the care of the client with MI
  • Avoid alcohol
  • Should report any symptoms of dizziness, or fainting, which indicate dysrhythmias
  • administer beta blocker and calcium antagonists to decrease the outflow obstruction, and to decrease HR
  • vasodilators and cardiac glycosides (digoxin)are contra contraindicate
surgical management
  • ventriculomyotomy or muscle resection with mitral valve replacement
  • restrictive Cardiomyopathy

It is characterized by restriction of filling of the ventricles

S/S     (signs and symptom and management  is same as dilated  Cardiomyopathy)

  • sings of Lt ventricular heart failure
  • weakness and fatigue
  • activity in tolerance
  • chest pain
  • dysrhythmias
  • eventually signs of Rt sided heart faliur
  • Administer oxygen
  • Administer diuretic, and digoxin, vasodilator, and antidysrhythmic
  • Avoid alcohol because it has cardiac depressant  effect
  • Instruct the client to report the signs of dyspnea, or fainting, which may indicate dysrhythmias
 Surgical management

Heart  transplantation


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