European Journal of Heart Failure

European Journal of Heart Failure 2004 6(4):421-426; doi:10.1016/j.ejheart.2003.11.011

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© 2004 European Society of Cardiology

Impact of atrial fibrillation on mortality and readmission in older adults hospitalized with heart failure

Ali Ahmed^a,*, Phillip Thornton^b, Gilbert J. Perry^c, Richard M. Allman^d and James F. DeLong^e

^a Division of Gerontology and Geriatric Medicine, Department of Medicine, School of Medicine, Department of Epidemiology and International Health, School of Public Health, Center for Aging and Geriatric Heart Failure Clinic, University of Alabama at Birmingham (UAB), Section of Geriatrics and Geriatric Heart Failure Clinic, Veteran Affairs Medical Center (VAMC), and Heart Failure Project, Alabama Quality Assurance Foundation (AQAF) 1530 3rd Ave South, CH-19, Ste-219, Birmingham, AL, USA
^b Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, and Division of Gerontology and Geriatric Medicine, Department of Medicine, School of Medicine, and Geriatric Heart Failure Clinic UAB, Birmingham, AL, USA
^c Section of Cardiology and Heart Failure Clinic, BVAMC, and Division of Cardiovascular Medicine, Department of Medicine, Schools of Medicine UAB, Birmingham, AL, USA
^d Birmingham/Atlanta Geriatric Research Education and Clinical Center, Department of Veterans Affairs, Division of Gerontology and Geriatric Medicine, Department of Medicine and Center for Aging, UAB and AQAF Birmingham, AL, USA
^e Birmingham AL, USA

^* Corresponding author. Tel.: +1-205-934-9632; fax: +1-205-975-7099. E-mail address: aahmed{at}uab.edu

	Abstract

Top Notes Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Acknowledgments References

 
Background: Atrial fibrillation is common in older adults with heart failure. It is known to adversely affect outcomes.

Aim: To examine the associations of atrial fibrillation with 4-year mortality and 30-day readmission in older adults hospitalized with heart failure.

Methods: Patients were Medicare beneficiaries 65 years of age and older discharged with a primary diagnosis of heart failure. Baseline data were obtained by retrospective chart reviews and data on mortality and readmission were obtained from Medicare administrative files. Presence of atrial fibrillation was confirmed using electrocardiogram during hospital admission. Using Cox proportional hazards models we estimated bivariate and multivariable (adjusted for various patient and care covariates) hazards ratios (HR) and 95% confidence intervals (CI) for 4-year mortality and 30-day readmission of patients with atrial fibrillation compared with those without.

Results: Patients (n=944) had a mean age (±S.D.) of 79 (±7) years, 61% were women, 18% African–Americans, 25% had atrial fibrillation by admission electrocardiogram, 64% died within 4 years, and 8% were readmitted. Patients with atrial fibrillation had a 52% increased risk of 4-year mortality (adjusted HR=1.52; 95%CI=1.11–2.07). Atrial fibrillation was also associated with higher risk of readmission (unadjusted HR=1.64; 95%CI=1.01–2.68). However, the association lost its statistical significance after adjustment for various patient and care variables (adjusted HR=2.09; 95%CI=0.94–4.65).

Conclusion: Presence of atrial fibrillation was associated with significant increased risk of long-term mortality in older adults hospitalized with heart failure and was associated with a non-significant higher risk of hospital readmission.

Key Words: Atrial fibrillation • Electrocardiogram • Heart failure

Received June 4, 2003; Revised October 9, 2003; Accepted November 25, 2003

	1. Introduction

Top Notes Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Acknowledgments References

 
Atrial fibrillation is common among older adults and is associated with poor outcomes. Heart failure is also common among older adults and associated with poor outcomes. Furthermore, atrial fibrillation is a common co-morbid condition in patients with heart failure [1–4]. This is of particular import in the elderly since there is an age-related increase in the incidence of both atrial fibrillation and heart failure [5–8]. Atrial fibrillation in patients with heart failure has been variously described to increase mortality in those with mild to moderate heart failure and not adversely affect mortality in those with severe heart failure [4]. The purpose of this study was to determine the impact of atrial fibrillation on 4-year mortality and 30-day readmission in older adults with heart failure.

	2. Methods

Top Notes Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Acknowledgments References

 
2.1. Subjects
The subjects of this study were hospitalized Medicare beneficiaries discharged with a primary diagnosis of heart failure between January and December 1994 from eleven Alabama hospitals. Medicare program is federally administered by the United States Centers for Medicare and Medicaid Services. The vast majority of the beneficiaries are persons 65 years of age and older. Younger adults with certain disabilities such as on chronic renal dialysis also qualify for Medicare benefits. For the purpose of this study, we excluded all persons younger than 65 years of age. Of the 1091 patients discharged with a primary diagnosis of heart failure, those who died during hospitalization (N=74) and those who did not have data on admission electrocardiogram (N=63) were excluded.

2.2. Study design
The study involves retrospective review of medical records and follow-up of mortality and readmission data of hospitalized older Americans discharged with a primary diagnosis of heart failure. The details of the study design have been described elsewhere [9,10]. Briefly, the chart review was conducted by the Alabama Quality Assurance Foundation (AQAF), as a part of a heart failure quality improvement project. AQAF is contracted by the Centers for Medicare and Medicaid Services to ensure quality of care received by Medicare beneficiaries in Alabama. Data were abstracted from patients’ medical records by a trained study nurse at each participating hospital. Reliability and validity of the data were verified by random re-abstraction of 5% of the charts by another study nurse and one of the physician members of the project. The concordance rates for both reliability and validity on key variables were 95% or more. Data were abstracted on patient demographics, medical history and hospital course.

2.3. Diagnosis of heart failure
The AQAF identified patients discharged with a primary discharge diagnosis of heart failure based on the International Classification of Diseases, 9th Revision codes 428 (principal discharge diagnosis of ‘Heart Failure’) or ICD-9-CM code 402.91 (principal discharge diagnosis of ‘Hypertensive Heart Disease with Congestive Heart Failure’). We verified the diagnosis of heart failure by the presence of one of the following: (i) history of heart failure; (ii) symptoms (dyspnea, dyspnea of exertion, orthopnea, paroxysmal nocturnal dyspnea); (iii) signs (jugular venous distension, third heart sound, displaced point of maximum cardiac impulse, or pulmonary râles); or (iv) radiographic evidence (cardiomegaly, pulmonary venous congestion or pulmonary edema) of heart failure; or (v) being treated with digoxin and diuretics. Of the 1091 patients with heart failure, one thousand seventy eight (99%) patients met two or more of above criteria and 937 (86%) met three or more criteria.

2.4. Diagnosis of atrial fibrillation
The diagnosis of atrial fibrillation was based on electrocardiogram performed during hospital admission. Patients with a past history of atrial fibrillation were considered to have atrial fibrillation if they had atrial fibrillation at the time of hospital admission. In addition to atrial fibrillation, the electrocardiographic rhythms were described as normal sinus rhythm, atrial flutter, supraventricular tachycardia, and other undermined rhythms.

2.5. Data on mortality and readmission
The mortality data were obtained from the AQAF using the Centers for Medicare and Medicaid Services membership lists (Denominator File). Heart failure related 30-day readmission data were ascertained by AQAF using the claims history of the study subjects for all heart failure admissions to any acute care hospital in Alabama. The readmission data are likely to be very complete as approximately 98% of the subjects in the original heart failure projects were Alabama beneficiaries compared with typical rate of 92% for in-state beneficiaries hospitalized in Alabama.

2.6. Statistical analysis
For descriptive analyses, we compared baseline demographic and clinical characteristics of the study patients by the presence or absence of atrial fibrillation during hospital admission. We tested statistical significance using Pearson's Chi square test and Student's t-test as appropriate. We compared unadjusted 4-year survival for patients with and without atrial fibrillation using Kaplan–Meier survival analyses, and tested statistical significance using log rank test. We then estimate risk of 4-year mortality and 30-day hospital readmission for patients with atrial fibrillation compared with those without. To estimate adjusted hazard ratios, we developed a Cox proportion hazards model. Covariates in the model included age, sex, race, history of heart failure, admission pulse 100 beats per minute or greater, admission systolic blood pressure 140 mm mercury or greater, left ventricular systolic dysfunction, discharge use of ACE inhibitors and digoxin, three or more comorbidities (diabetes, hypertension, coronary artery disease and chronic obstructive pulmonary disease), care by cardiologist and hospital. Using the same model, we also estimated bivariate and multivariable hazards ratios and 95% confidence intervals for 30-day readmission for patients with vs. without atrial fibrillation. Statistical significance was based on two-tailed alpha 0.05. The SPSS for Windows, Release 11.0.1 [11] was used to analyze the data.

	3. Results

Top Notes Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Acknowledgments References

 
3.1. Patient characteristics
Patients had a mean age of 79 years, 580 (61%) were female and 174 (18%) were African–American. Two hundred thirty three (25%) patients had atrial fibrillation by admission electrocardiogram. Two hundred fifty eight (27%) patients had history of atrial fibrillation, and atrial fibrillation was confirmed by admission electrocardiogram in 146 patients (57%). Of these patients with electrocardiogram confirmed atrial fibrillation at admission were less likely to have history of hypertension and diabetes, and more likely to be on digoxin. Table 1 demonstrated various patient characteristics by the presence or absence of atrial fibrillation at baseline. The mean (±standard deviation) arterial blood pressure was 149 (±32) mmHg and the mean pulse rate was 92 (±22) beats per minute. Compared with patients without atrial fibrillation on admission electrocardiogram, those with atrial fibrillation had lower mean blood pressure (by 5 mmHg; P=0.035), and higher mean pulse rate (by 8 beats per minute; P<0.001).

View this table: [in this window] [in a new window]   Table 1 Baseline patient characteristics by atrial fibrillation

 
3.2. Association between atrial fibrillation and 4-year mortality
Six hundred and five (64%) patients died within 4 years after hospital discharge. Of the 233 patients with electrocardiogram confirmed atrial fibrillation, 166 (71%) died within 4 years. In comparison, 439 of the 711 patients without atrial fibrillation (62%) died within 4 years, and the difference was statistically significant (P=0.009). The mean (±S.D.) 4-year survival for patients who had atrial fibrillation by admission electrocardiogram was 742 days (±38 days) compared with 840 (±22) days for those without atrial fibrillation (log rank P=0.008). Fig. 1 demonstrates that the cumulative probability of 4-year post-discharge survival declined by 24% in patients with atrial fibrillation (29% vs. 38% for those without atrial fibrillation; log rank P=0.008).

View larger version (17K): [in this window] [in a new window] [Download PowerPoint slide]   Fig. 1 Kaplan–Meier survival curves for 4-year survival of elderly heart failure patients with and without atrial fibrillation (AF).

 
Older adults hospitalized with heart failure who also had atrial fibrillation at admission had a 27% greater risk of dying within 4 years of hospital discharge compared with those without atrial fibrillation (unadjusted hazards ratio=1.27; 95% confidence interval=1.07–1.52). After adjustment for various patient and care variables, the risk of 4-year mortality increased by 52% (adjusted hazards ratio=1.52; 95% confidence interval=1.11–2.07). The other covariates associated with higher mortality are demonstrated in Table 2. Fig. 2 demonstrates the comparative survival curves adjusted at means of covariates. The cumulative probability of 4-year post-discharge survival for patients with atrial fibrillation was 23% compared with 38% for those without atrial fibrillation, representing a decline in probability of survival by 39%.

View this table: [in this window] [in a new window]   Table 2 Crude and adjusted* risk of 4-year mortality for older adults with heart failure

 

View larger version (16K): [in this window] [in a new window] [Download PowerPoint slide]   Fig. 2 Adjusted survival curves at means of covariates for 4-year survival of elderly heart failure patients with and without atrial fibrillation (AF).

 
3.3. Association between atrial fibrillation and 30-day readmission
Older adults with heart failure and atrial fibrillation were 64% more likely to be hospitalized for heart failure exacerbation within 1 month after hospital discharge (unadjusted hazards ratio=1.64; 95% confidence interval=1.01–2.68). After adjustment for various patient and care variables, the point estimate of the risk of 30-day re-hospitalization remained high (adjusted hazards ratio=2.09), however, the association lost its statistical significance (95% confidence interval=0.94–4.65). The other covariates significantly associated with heart failure related hospitalization within 30 days of hospital discharge were left ventricular systolic dysfunction (positively) and discharge use of ACE inhibitors (negatively). Atrial fibrillation was not associated with 90-day or 1-year hospital readmission due to worsening heart failure.

	4. Discussion

Top Notes Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Acknowledgments References

 
The main results of our study are as follows: (1) Multivariable analysis revealed that presence of atrial fibrillation in hospitalized older adults with heart failure was associated with an increased risk of 4-year all-cause mortality; and (2) Univariate analysis revealed that presence of atrial fibrillation in hospitalized older adults with heart failure was associated with an increased risk of 30-day heart failure related hospital readmission. Older adults hospitalized with heart failure are known to have severe disease and poor prognosis. In our study, 64% died within 4 years of hospital discharge. However, even in this cohort of patients with severe heart failure, presence of atrial fibrillation increased the mortality rate to 71%.

Previous studies have varied with regards to the impact of atrial fibrillation on survival in heart failure. Van den Berg et al. reviewed six studies to examine the impact of atrial fibrillation on heart failure, and concluded that the presence of atrial fibrillation was not independently associated with poor outcomes in patients with severe heart failure. The presence of atrial fibrillation was not associated with reduced survival among the participants of the Veterans Affairs Vasodilator-Heart Failure Trials (V-HeFT) I and II [1]. Similarly, Mahoney et al. found that atrial fibrillation had no impact on mortality in advanced heart failure (NYHA class III and IV) patients who were referred for possible heart transplantation [12]. Both of these populations differed substantially from the population in the present study. Our patients were older, did not have exclusively systolic dysfunction, and were cared for in both teaching and non-teaching hospital settings. As such, they represent a broader spectrum of the entire heart failure population than those in the above mentioned trials. In contrast, patients in clinical trials or transplant populations tend to be younger, have fewer co-morbidities, and are predominantly cared for in academic centers. The prevalence of hypertension was rather low in our study population, which is very likely due to retrospective medical record review design of our study. Unlike in clinical trials of heart failure in which a history of hypertension is actively sought, we captured only what clinicians had documented in the process of routine care. In the multivariable model, we adjusted for history of hypertension and admission systolic blood pressure 140 mmHg or higher, neither of which seemed to be independently associated with outcomes in our study.

The presence of exclusively systolic dysfunction in the transplant and heart failure clinical trials may also account for the disparity with our results. It has been suggested that atrial fibrillation may have less of an impact on prognosis in more advanced heart failure. In a study of heart failure patients with left ventricular systolic dysfunction, atrial fibrillation was associated with higher 1-year mortality only in those patients with a pulmonary capillary wedge pressure lower than 16 mmHg. Atrial fibrillation was independently associated with increased mortality in the Studies of Left Ventricular Dysfunction (SOLVD) Prevention and Treatment trials, similar to the findings in the present study [13]. Similarly, atrial fibrillation was a predictor of increased mortality in a study of older adults with heart failure and prior myocardial infarction [14].

Several limitations of this secondary analysis need to be acknowledged. We had no data on use of anticoagulants and antiarrhythmic drugs. The adverse effects of class I antiarrhythmic drugs was already known several years before the present study period [15,16]. We also had no data on functional status of the patients, or patient or physician preferences. In our study, atrial fibrillation was diagnosed during hospital admission. It is possible that some patients without atrial fibrillation at the time of hospital admission developed atrial fibrillation during the follow up, and similarly, some patients with atrial fibrillation underwent spontaneous or pharmacological cardioversion to normal sinus rhythm. This misclassification likely occurred at random, and resulted in the underestimation of the mortality differences between the groups, and, therefore does not pose any major threat to the validity of our results. Despite these limitations, this study has several important strengths. Most heart failure patients are older adults [5–7,17,18]. To our knowledge, this is the first study to examine the association between atrial fibrillation and heart failure in hospitalized older adults. The study sample size, inclusion of heart failure patients with systolic and diastolic dysfunction, and hospitals from both urban and rural settings are other strengths of this study.

There is currently no evidence for the best treatment approach for the management of patients with heart failure and atrial fibrillation. In the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study, approximately 23% of the patients had heart failure at baseline. The overall results of this study did not demonstrate any mortality differences between patients randomized to rate control vs. rhythm control [19]. However, in this study, rate control was associated with better outcomes in patients 65 years and older, and in those with coronary artery disease. The study also demonstrated a trend for better outcomes for patients with hypertension and left ventricular ejection fraction 55% or greater. In another randomized trial of rate control vs. rhythm control in patients with atrial fibrillation, about half of the patients had a history of heart failure [20]. However, in this study, no sub-group analysis was performed among patients with heart failure. The overall results of this study did not demonstrate any statistically significant differences in mortality between the groups. Because most heart failure patients are older adults and older adults with heart failure are likely to be female and have diastolic dysfunction, control of ventricular rate along with anticoagulation seems to be a reasonable approach [21]. Beta blockers are considered superior to digitalis glycosides for rate control in patients with heart failure and atrial fibrillation because of their ability to control heart rate during physical activity and exercise, and their favorable effect on long-term survival in patients with left ventricular systolic dysfunction [22]. Future studies of heart failure and atrial fibrillation should include older adults with diastolic dysfunction.

	Acknowledgments

Top Notes Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Acknowledgments References

 
Dr Ahmed is supported by a National Institute of Health Mentored Patient-Oriented Research Career Development Award 1-K23-AG19211-01 entitled ‘Heart Failure and Beta-Blocker Use in Older Adults. Supported in part by a grant from the Southeast Center of Excellence in Geriatric Medicine.

	Notes

Top Notes Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Acknowledgments References

 
CMS Disclaimer: The analyses upon which this publication is based were performed under Contract Number 500-02-AL02, entitled ‘Utilization and Quality Control Peer Review Organization for the State (Commonwealth) of Alabama,’ sponsored by the Centers for Medicare and Medicaid Services (CMS, formerly HCFA), Department of Health and Human Services (DHHS). The content of this publication does not necessarily reflect the views or policies of the DHHS, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government. The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the CMS, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this contractor. Ideas and contributions to the author concerning experience in engaging with issues presented are welcomed.

	References

Top Notes Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Acknowledgments References

 

1. Carson P.E., Johnson G.R., Dunkman W.B., Fletcher R.D., Farrell L., Cohn J.N. The influence of atrial fibrillation on prognosis in mild to moderate heart failure. The V-HeFT Studies. The V-HeFT VA Cooperative Studies Group. Circulation (1993) 87(6 Suppl):VI102–VI110.[Medline]
2. Benjamin E.J., Wolf P.A., D'Agostino R.B., Silbershatz H., Kannel W.B., Levy D. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation (1998) 98(10):946–952.[Abstract/Free Full Text]
3. Middlekauff H.R., Stevenson W.G., Stevenson L.W. Prognostic significance of atrial fibrillation in advanced heart failure. A study of 390 patients. Circulation (1991) 84(1):40–48.[Abstract/Free Full Text]
4. van den Berg M.P., van Gelder I.C., van Veldhuisen D.J. Impact of atrial fibrillation on mortality in patients with chronic heart failure. Eur J Heart Fail (2002) 4(5):571–575.[Abstract/Free Full Text]
5. Aronow W.S. Management of the older person with atrial fibrillation. J Gerontol A Biol Sci Med Sci (2002) 57(6):M352–M363.[Web of Science][Medline]
6. Wolf P.A., Abbott R.D., Kannel W.B. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke (1991) 22(8):983–988.[Abstract/Free Full Text]
7. Furberg C.D., Psaty B.M., Manolio T.A., Gardin J.M., Smith V.E., Rautaharju P.M. Prevalence of atrial fibrillation in elderly subjects (the Cardiovascular Health Study). Am J Cardiol. (1994) 74(3):236–241.[CrossRef][Web of Science][Medline]
8. Senni M., Tribouilloy C.M., Rodeheffer R.J., et al. Congestive heart failure in the community: trends in incidence and survival in a 10-year period. Arch Intern Med (1999) 159(1):29–34.[Abstract/Free Full Text]
9. DeLong J., Allman R., Sherrill R., Schiesz N. A congestive heart failure project with measured improvement in care. Eval Health Prof (1998) 21(4):472–486.[Abstract/Free Full Text]
10. Ahmed A., Allman R.M., DeLong J.F., Bodner E.V., Howard G. Age-related underutilization of left ventricular function evaluation in older heart failure patients. South Med J (2002) 95(7):695–702.[Web of Science][Medline]
11. SPSS for Windows, Rel. 11.0.0. program]. SPSS Inc.; 2002.
12. Mahoney P., Kimmel S., DeNofrio D., Wahl P., Loh E. Prognostic significance of atrial fibrillation in patients at a tertiary medical center referred for heart transplantation because of severe heart failure. Am J Cardiol (1999) 83(11):1544–1547.[CrossRef][Web of Science][Medline]
13. Dries D.L., Exner D.V., Gersh B.J., Domanski M.J., Waclawiw M.A., Stevenson L.W. Atrial fibrillation is associated with an increased risk for mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a retrospective analysis of the SOLVD trials. Studies of Left Ventricular Dysfunction. J Am Coll Cardiol (1998) 32(3):695–703.[Abstract/Free Full Text]
14. Aronow W.S., Ahn C, Kronzon I. Prognosis of congestive heart failure after prior myocardial infarction in older persons with atrial fibrillation vs. sinus rhythm. Am J Cardiol (2001) 87(2):224–225. A8–9.[CrossRef][Web of Science][Medline]
15. Flaker G.C., Blackshear J.L., McBride R., Kronmal R.A., Halperin J.L., Hart R.G. Antiarrhythmic drug therapy and cardiac mortality in atrial fibrillation. The stroke prevention in atrial fibrillation investigators. J Am Coll Cardiol (1992) 20(3):527–532.[Abstract]
16. Falk R.H. Proarrhythmia in patients treated for atrial fibrillation or flutter. Ann Intern Med (1992) 117(2):141–150.[Abstract/Free Full Text]
17. Kannel W.B., Ho K., Thom T. Changing epidemiological features of cardiac failure. Br Heart J (1994) 72(2 Suppl):S3–9.[Free Full Text]
18. Aronow W.S., Ahn C., Gutstein H. Prevalence of atrial fibrillation and association of atrial fibrillation with prior and new thromboembolic stroke in older patients. J Am Geriatr Soc (1996) 44(5):521–523.[Web of Science][Medline]
19. Wyse D.G., Waldo A.L., DiMarco J.P., et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med (2002) 347(23):1825–1833.[Abstract/Free Full Text]
20. Van Gelder I.C., Hagens V.E., Bosker H.A., et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med (2002) 347(23):1834–1840.[Abstract/Free Full Text]
21. Maisel W.H., Stevenson L.W. Atrial fibrillation in heart failure: epidemiology, pathophysiology, and rationale for therapy. Am J Cardiol (2003) 91(6A):2D–8D.[Web of Science][Medline]
22. Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). J. Am. College Cardiol 2001;38(7):2101–2013.

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