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Risk Factors for Heart Disease (Dr. Hazen 7/9/13)

Tuesday, July 9, 2013 – Noon


There are several risk factors for heart disease; some are controllable, others are not. The more risk factors you have, the greater the likelihood that you will have heart disease. By making changes in your lifestyle, you can actually reduce your risk. Dr. Stanley Hazen, Section Head for Preventive Cardiology and Rehabilitation, Vice Chair of Translational Research, Lerner Research Institute, Director for the Center for Cardiovascular Diagnostics and Prevention, answers your heart disease risk factor questions.

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Coronary Artery Disease and Risk Reduction

GeorgeS: It has been said that coronary artery disease is reversible. Do you agree? Please explain if possible? What are the steps to reverse CAD? What role does c-reactive protein play to protect from CAD? What does it mean if a person has a calcium score of 150, all related to the Widower's coronary artery, with zero (0) in the remaining arteries (meaning the total score is 150? Should calcium scoring be done more than once? Thanks.

Stanley_Hazen,_MD,_PhD_: CAD is reversible. However, this is a very slow process with our current medications and approaches. Even with the most potent global risk reducing efforts, including reduction of LDLc (bad cholesterol) to very low levels, the percent reduction rate in CAD when measured in clinical trials is slow. CRP does not protect from CAD. It is associated with increased risk of CAD. It does not appear to be causally linked to CAD, but none-the-less serves as a fingerprint of increased risk (statistically speaking).A calcium score of 150 in an artery means there is calcification (and atherosclerosis) in that artery. If it’s in one artery, we assume it is in all arteries. Atherosclerosis is a systemic disease....think of it more like a Manicotti (tubular pasta), not a focal disease...or like insulation on a wire. A very late manifestation of atherosclerosis is development of calcification and stenosis.

sinaihospital: I have cardiac hypertensive disease, high blood cholesterol, high blood pressure, heart valve problems, ventricular hypertrophy, type 2 diabetes, plus I am over weight. Am I at risk for heart disease and a heart attack? I am 48 years old?

Stanley_Hazen,_MD,_PhD_: You are a mess and a ticking time bomb !!!! Seriously - you should approach your primary care physician or a preventive cardiologist for a global preventive risk reducing effort.

Sigbien: My questions are the following: Can we quantify the correlations between Strokes and Heart Disease and also High Blood Pressure and Strokes or Heart Disease??

Stanley_Hazen,_MD,_PhD_: Stroke and heart attack are both related to high blood pressure and other risk factors like smoking, and diabetes. Interestingly, while cholesterol is of course linked to increased CAD and MI risk, it is not that correlated with risk of stroke. None-the-less, statin therapy is an excellent way to reduce stroke risks (what some have used as evidence to indicate statins do more than simply lowering cholesterol level).Stroke is considered a coronary artery disease (CAD) risk equivalent. That means, the risk of having a heart attack after having a stroke, is the same as the risk of having a second heart attack, after having a first heart attack. Strokes are most often caused by atherosclerotic disease of the vessels to the brain.

snowdave86: How long does it typically take for heart disease to occur in a younger person with a low HDL caused by no physical activity? Is heavy weight training the best form of exercise to raise HDL in prevention of heart disease?

Stanley_Hazen,_MD,_PhD_: Heart disease takes decades to develop. Low LDL is good- and associated with lower risk of heart disease. Aerobic exercise, not weight lifting, is the best approach for cardiovascular fitness and reducing cardiac risks. Save the weights for strength and body sculpting, etc...after the aerobic cardiac benefiting exercises.

Diagnostic Testing

Donjose: I am 32 and African-American with a family history of heart disease and high blood pressure. My mother died at 41, sister had a heart attack at 37 and father, mother and siblings all have high blood pressure. I am 5 '10, 182 and active, and I eat well (no beef, low fat, chicken, turkey, fish diet). I was recently admitted to the hospital with chest pain. I had a slightly elevated troponin level of approximately .02 at time of admission. They said I did not have a heart attack. The previous day, I had a more intensive work out than usual. I had a stress-echo 1 year ago which was negative. As a child, I had scarlet fever. What test would you recommend I have in order to judge any blockages or artery plaque build up? What would be a full plan of action in order to access future cardiac events? What would you do if I was your patient? I am currently uninsured, but will be in three months through employment. Thank you.

Stanley_Hazen,_MD,_PhD_: It is difficult to answer all of your questions in this format – but I can convey several responses

First – with new onset chest discomfort, even though the stress test was negative a year ago, it does not mean you may not be at risk now. I recommend seeing your primary care MD or a cardiologist (can be preventive cardiology clinic here) for further evaluation. This may include after more complete history and physical a stress test. It also would include assessment of your global risk by looking at factors besides the family history such as your BP, lipid panel, and basic chem panel. We (within preventive cardiology clinic) also assess additional markers not yet part of routine clinical screening, but none-the-less that have been associated with increased CVD risks such as Lpa (given the strong family history of premature CVD in family especially), and markers of inflammation, clotting risk, thyroid function, and kidney function.

Donjose: I have my lipid panels and I will be having the inflammation panel on Friday. Height: 5 '10, Weight: 182, Cholesterol: 136, HDL: 42, LDL: 74, Triglycerides: 102. I have my entire basic chem panel right here in front of me. Is there any additional information/advice you can give me based on this added information? I do not have a primary care physician and I am currently uninsured.

Stanley_Hazen,_MD,_PhD_: A lot of questions... do you smoke - if so - don't. Are you hypertensive - normal blood pressure is 120/80. If your BP runs > 130/85 range- and exercising and low salt diet aren't correcting this - see a doctor. Your LDL and TG are looking good. Blood sugar OK? Renal function (creatinine?). Hard to do this remote via webchat.

Cholesterol and Statins

Richard: Your cholesterol recommendations on the website don 't account for size of LDL particles. Newer research suggests LDL may be inconsequential if your particles are A (fluffy) vs. B (small and dense). I'm surprised Cleveland Clinic trots out old conventional thinking about LDL. All depends on risk level.

Stanley_Hazen,_MD,_PhD_: While particle size has some role in risk stratification, it only adds a minor additive effect. The initial primary goal has to be, even when using LDL particle number, to get LDL cholesterol to goal. National guidelines, focus on the LDLc, and suggest LDL particle size and number are optional secondary endpoints - and I agree. A global and comprehensive preventive risk reduction effort that focuses on not just LDLc, but also weight, diet, exercise, blood pressure, blood sugar, and other factors provides by far greater additive value.

Irish: I have an NMR score of 1186 but was told by my cardiologist the size of my particles was the "good size". What does this mean? Should I be concerned? Thank you.

Stanley_Hazen,_MD,_PhD_: Your question is incomplete- but based on the value I am presuming you are referring to a Liposcience (NMR) based LDL particle number. As a general rule of thumb, an LDL particle value of <1000 in a primary prevention subject is good, and < 7800 or so in someone with known CAD is good.

[Note: NMR is a commercial test from Liposcience, Inc. that looks at low density lipoprotein particle concentration and size]

wolfgang: RE: Vytorin. Hello, I am a cardiac patient at Kaiser San Francisco. I have had several MIs, quadruple bypass surgery including stents. I was given a pacemaker/defibrillator. All this is complicated by a rare muscle disorder Polymyositis and a recently diagnosed Secondary Pulmonary Arterial Stenosis. For several years, my doctors had me on a daily dose of Vytorin, and I was feeling great. Now, after taking me off Vytorin, I am taking 24 different pills each day and I am feeling lousy. Do you have any explanation of why Vytorin is bad for me? Thanks and regards, Wolfgang.

Stanley_Hazen,_MD,_PhD_: Polymyositis is an inflammatory process in the muscle. It is accompanied by elevated CK elevation (a muscle enzyme) in the blood. Statins as a side effect can cause muscle inflammation and a similar CK elevation in a small subgroup of subjects. To prevent complicating the monitoring of the chronic disease of polymyositis, it is reasonable to avoid statins, and try and focus on alternative LDL cholesterol lowering approaches.

Weight and Cardiovascular Risk

Edrick25: Am 24 years old with BMI of 32 so should I expect to have cardiovascular diseases?

Stanley_Hazen,_MD,_PhD_: In your lifetime - yes- 75% of all of us experience cardiac disease in our lifetime. No book is totally written. You are 32 - plenty of time to do something about it !!!!


novee: Can I do exercise either before or after taking medicine....(coronary artery disease).

Stanley_Hazen,_MD,_PhD_: Yes. A routine exercise program is an essential part of the therapeutic regimen for anyone with coronary artery disease. You should discuss this with your primary care physician. Or you can be seen in Preventive cardiology clinic where we can evaluate whether you are eligible for cardiac rehabilitation (following diagnosis of CAD this is often recommended, depending upon how the CAD was diagnosed, and especially following interventions like angioplasty, stenting, or bypass surgery.

Cardiac rehab saves lives. It lowers risks of MI, stroke, and death. It improves overall physical wellbeing, and functional capacity. It is strongly recommended for subjects with CAD.

dingram: My dad had high blood pressure and died of COPD at 66, his dad, heart attack, at 55. His mom had a pace maker and high blood pressure and she died at 84. I run and cycle, trying to be proactive with my heart. I ran a marathon may 5 a week or so later got sick. Well June 14 I ended up in the ER diagnosed with pericarditis. Just had a stress echo and primary care Dr. said I was ok. Should I see a cardiologist too? Could running again cause damage to my heart? I miss being active.

Stanley_Hazen,_MD,_PhD_: You should let the pericarditis completely heal before taking on a marathon again. Adoption of a reasonable exercise program is an excellent way to improve overall cardiovascular health. Speak to your primary care doctor to find out when you are safe to begin exercising. Usually your body will also let you know when.

Andreea: What kind of exercises and how much physical effort are recommended for someone who had an aortic valve replacement?

Stanley_Hazen,_MD,_PhD_: First, you need to be cleared by your CT surgeon for exercising. An exercise program is an essential part of convalescence and overall improved cardiovascular health. Cardiac rehabilitation is recommended. This program would not only help teach you the appropriate amount of exercise and goals individually tailored to you, but would also be a supervised exercise program for the initial part (recommended initially).

Long term, a routine exercise regimen is strongly recommended for all subjects’ cardiovascular health, whether they have had surgery on the heart or not- but especially for those who have had surgery.

As a general rule, walking at a brisk pace, for 30-45 min, 3-5 days per week, is a general rule of thumb for exercise recommendations for someone without any health issues – but this really needs to be tailored to the individual.

BarbaraF: After 9 stents, my cardiologist sent me to cardiac rehab. After 5 years at the "gym", I am having back and knee problems. Been going to PT and doing exercises at home. When I skip the gym for a week, my back and knee return to normal. What should I do? Thank you, Barbara.

Stanley_Hazen,_MD,_PhD_: Keep up an exercise program, but find one that is gentler on the back and knees! Examples include water based exercise programs that are fantastic for cardiac conditioning, and better for those with orthopedic issues. Another option is a recumbent bike- which is easier on the knees and back as well. Most gyms have these as well. good luck - and keep up the excellent exercise efforts !!!!

Irish: I have read numerous articles from cardiology units across the country that state excessive running (over 20 miles per week, 4-5 miles per run) could be dangerous for your health. The articles talk about scar tissue forming and promoting arteriosclerosis. What are your thoughts on this?

Stanley_Hazen,_MD,_PhD_: Epidemiology studies do show a "J-shaped" curve with amount of running and cardiac risks. Too much is associated with increased risks. So the marathon enthusiasts- and super-marathoners especially beware ! Does anyone ever really see someone smile when running a marathon? If it is what gets you going, and makes you interested in exercise- then having that as a goal to run, as an infrequent event, is reasonable.

Diet and Cardiovascular Risk

GeorgeBMac: How many eggs do YOU typically eat in a week?

Stanley_Hazen,_MD,_PhD_: Funny - I don't eat many eggs. So less than 2 (within cooked foods). Last time I had a scrambled egg or omelet was probably a year ago or more...though I guess I did have a deviled egg, the worst kind, at my cousin's wedding....

Irish: I know many of the cardiologists at the Clinic recommend the Mediterranean diet, but advise against the Esselstyn (plant based diet). I have never received a reason on why the plant based diet is not recommended by the Clinic. Is there a reason you could provide?

Stanley_Hazen,_MD,_PhD_: Well - I recommend the diet if someone is committed to it and really wants to go that route. But it is also important to realize that a totally plant based diet has its own issues. Vitamin B12 needs to be supplemented (2500 micrograms via sublingual lozenges daily - an over the counter supplement). More critical, it is often hard to get enough protein. And many who follow this diet have problems with too many carbs, and worsening diabetes control, or prediabetes, or advancing prediabetes to diabetes. I advocate moderation. And also will work with whatever the patient wants to do, provided I don’t think they are causing themselves harm.

Peppy: If you already have the CAD diagnosis which diet should one follow: Ornish, Esselstyn's, Mediterranean, Fuhrman (vegan, vegetarian)? The recent Seventh Day Adventist study suggesting a longer, healthier life if you follow a vegan/vegetarian diet also showed that women did not fare as well on these diets having more strokes. Why? What should women eat then? The Mediterranean diet? Thank you.

Stanley_Hazen,_MD,_PhD_: I believe a choice of diet is a very personal thing - and most importantly has to be something the person feels they will enjoy and can sustain. Diets are not supposed to be temporary "fixes" but life long sustainable healthy choices. As for the data with the various trials - there is no comparison- the Mediterranean diet by far has the best data, hands down, in terms of reducing risks for heart attack, stroke, need for revascularization (CABG, MI, angioplasty or stent) ....the things that count. None of the other diets has this data. The Mediterranean diet was recently reported to reduce cardiac adverse outcomes, including stroke, in men and women alike, by 30% in an article in the New England J of Medicine a few months ago.

Peppy: There have been some studies suggesting Pomegranate might reduce carotid plaque. One study was completed in Israel. What do you think? Are there side effects especially if you are taking a statin?

Stanley_Hazen,_MD,_PhD_: I know these studies well. In a test tube, pomegranate juice functions as an "anti-oxidant" and therefore is hypothesized to help reduce some forms of inflammation and possibly help with cardiac disease. Unfortunately, the studies with the juice in humans are small, and have not shown with hard endpoints a reduction in heart attack, stroke, death, or need for revascularization (stenting, angioplasty, or CABG). I recommend eating the pomegranate itself - and not the juice- it takes so much work and time that you will burn more calories! If you like the juice - drink it - but realize it has calories, and use it as a fruit portion. In general, juices tend to have a lot of sugar, and are not the best idea for those with impaired fasting glucose (pre-diabetes) or diabetes.

Peppy: Yes, I read the study on-line for the med diet and it seems when nuts were added to the diet there was regression whereas olive oil caused the CAD to remain stable. Your thoughts?

Stanley_Hazen,_MD,_PhD_: That study looked at hard outcomes, not "regression" And both the olive oil arm, and the "nut" arm of the Mediterranean diet each showed a 30% reduction in risk of hard cardiac events.

Sleep and Cardiovascular Risk

Frank2995: How is sleep related to heart disease. I am trying to eat right and exercise but I really have difficulty sleeping. My dad died at 52 from a heart attack so worried this may have an impact. Do I need to get treatment for it to stop the risk - or will my other healthy habits make a better impact and I don't have to worry about the sleep?

Stanley_Hazen,_MD,_PhD_: Studies have shown that sleeping a good 8hr a day on a regular schedule is associated with overall lower CAD risks than someone who sleeps less than 6hr per night, or someone who sleeps excessively long on average (I don't recall the cutoff for long sleeping - which was somewhere in the 10h or longer range). The mechanism isn't known. Obstructive sleep apnea (OSA), associated with snoring and poor sleep, is a strong risk factor for sudden cardiac death, and heart disease. A sleep study may be in order if even when you make the time , you are having sleep issues. There are treatments for OSA that are helpful.

Calcium and Vitamin D

Jan: I was told that I need to take Calcium and Vitamin D supplement of about 1200 mgs. Calcium pd. and also Fosomax due to osteoporosis. I had a heart attack 2 years ago have a stent in the LAD and atherosclerosis and am on a lot of meds. I read somewhere that it is not recommended that heart patients take high doses of Calcium and Fosomax. What is your opinion??

Stanley_Hazen,_MD,_PhD_: It is understandable why you have questions about this - because some statisticians have gone wild and mucked up the field here....There have been many epidemiological studies that suggest perhaps that taking a calcium supplement might be associated with increased atherosclerotic heart disease, or coronary calcification. But taking calcium supplement is also associated with increased age, and it is not always that easy to statistically remove these associations through math....and see if the association is real or residual co-association. The best way to answer this question is not with statistics- but with a randomized placebo controlled trial- which has been done. Many studies have looked at whether taking calcium supplements are beneficial in women (and men) for reducing osteoporosis, or hip fractures. As part of these studies adverse events are always monitored, like heart attacks, and development of CAD. In these studies no significant signal is seen. So if you have thin bones, and are at increase risk for fractures, and your MD has recommended you take Vitamin D and Calcium supplements- I recommend following your doctors recommendations. A hip fracture, or compression fractures of the spine, are not fun things...and cause significant health issues.

SaraL: I have been taking Vitamin D Complex for about 4 yrs. There have been studies about taking vitamin D and not taking vitamin D - what do you recommend in relation to risk of heart disease?

Stanley_Hazen,_MD,_PhD_: This is another area where the field is murky. The truth is, there have NOT been many interventional outcome trials where bodies are counted- heart attack, stroke, death....the hard outcomes that really matter, and vitamin D. Such trials are ongoing - have been for a long time - we are waiting to hear on the results still. I recommend at present only taking vitamin D if you have osteoporosis (thin bones) and/or a low vitamin D level. And under the prescription/supervision of your doctor. One can "OD" on too much vitamin D, and have increased risk for kidney stones. For typical maintenance levels of supplemental Vitamin D (2000iU max per day) one does not get increased risk of kidney stones. So if you are self supplementing, don't go above 2000 per day without advice of your doctor.



Stanley_Hazen,_MD,_PhD_: The larger randomized clinical studies examining L-arginine supplementation showed increased, not decreased, risk. No large intervention studies with hard outcomes (MI, stroke or death) that I am aware of have looked at the Arg/citrulline combination. All studies I am aware of with this combination have been either done in animal models, or small clinical studies with no hard outcomes.

However, I do note that in a study of > a thousand subjects we observed that elevated plasma levels of citrulline were strikingly associated with INCREASED (not decreased) risk for MI, stroke or death over the ensuing 3 yr period.

For this reason, I strongly recommend to my patients NOT to take Arg or Cit as supplement.

I believe there will be a subset of subjects for whom Arg may benefit them. In large clinical studies (several thousands of subjects) a low global arginine bioavailability ratio [Arg/citrulline, or Arg/(Cit + Orn)], has been shown to predict increased risks quite well, whether the subject has CAD, or does not have CAD.

This is research only studies at present, and not ready for clinical use. No interventional studies have been performed as of yet looking at Arg supplementation in these subjects.

Research: Gut Flora, TMAO

GeorgeBMac: Hi. Thanks for your work on TMAO. I have two questions:
1). When will a test for TMAO be available at the Cleveland Clinic?
2). Do TMAO levels rise and fall on a daily or weekly basis due to things like diet and other lifestyle factors?

Stanley_Hazen,_MD,_PhD_: TMAO testing is not yet available at CC other than for research studies at present that are ongoing. You can contact 216.445.1174 to learn more about those studies. But at present, results are remaining blinded to both investigators and subjects until completion of the studies, and only aggregate results are being reported. CC licensed the TMAO testing to a company named Liposcience Inc., with whom we are working to develop the test for clinical use. That test, in research format, will be available soon (predicted to go live in August).

As for variability – TMAO looks to be like glucose, and can vary depending upon what was eaten over the preceding several days. The levels appear to have acute oscillations based on diet, superimposed upon longer larger overall more global changes based on chronic dietary patterns (again – similar to glucose).

On average though the value appears to be relatively stable, in as much as those whose levels tend to be low seem to stay low, and those who have high levels are more likely to show swings in the higher level range.

More studies on these very issues, and what dietary changes can help to reduce TMAO levels, are some of the studies that are ongoing and planned.

Nancy L23: Related to your research into gut flora and bacteria - do you think probiotics or foods such as yogurt with probiotics will be helpful in the future?

Stanley_Hazen,_MD,_PhD_: Yes - possibly - but not any we know of on the market at present. None are designed and tested yet for heart disease as a treatment. So for now, I would only eat yogurt if you like it, and it agrees with you...and realizing it has calories and counts as a food portion. Most probiotics don't even survive the acidity of the stomach.

Peppy: What is TMAO?

Stanley_Hazen,_MD,_PhD_: TMAO is Trimethylamine-N-oxide.

Coronary Artery Spasms

NEWYORKER: My dad died at 59 from a MI, I am 58 have 2 RCA stents, I am very compliant take all medicine ride stationary bicycle, still I suffer from artery spasms since stenting, take imdor but can't get the spasms under control, what can be done, I tried magnesium, I may try arganine, this is causing me great anxiety and stress and I would like get this under control. Thanks for any help.

Stanley_Hazen,_MD,_PhD_: I would avoid the arginine. Several randomized trials have thus far shown increased risks - not decreased. So Arginine = bad thing to try. As for spasms...I assume you are avoiding stimulants - like caffeinated drinks, coffee, tea, and of course, "recreational" drugs ....we wont go there. Have you had a Beck depression inventory or other form of anxiety or depression tool/questionnaire. Any chance stress is in your life, and might be somehow contributing? This may be an area to look into. A routine exercise program can also help. You mention biking - how often, how long. Any relation to spasms and days exercising, or not ? Any known inciting factors, etc...all of these are things to discuss with your doctor. There are other sorts of medications too that if needed can be tried. Really depends on how often, how severe, etc the symptoms are. Good luck.


lightning#: Hello. How do I differentiate between harmless and significant chest pain? Don't want to be running to the doctor or ER for every episode of chest pain. I'm 76 yo and have had symptoms of mild congestive heart failure (diagnosis by GP). This is the cause of death noted on my mother's death certificate. I had a full cardiology work-up a year ago. Since then I've stepped up using meditation and Heart Math to control symptoms with good results. I don't have much energy for exercise even though I know this would help. Non-smoker, rare alcohol, my doctor is satisfied with my cholesterol panel; father died with coronary thrombosis after a blood clot traveled from a broken leg. Sorry if I've given too much information. Thanks, Norma.

Stanley_Hazen,_MD,_PhD_: This is a hard question - but it is better to be safe than sorry. I recommend you discuss this with your primary care doctor. There are many things that need to be reviewed and it is difficult to address this in a website chat.


samata02: Hi. My name is Samantha & just got the Thyroid level test which TSH : 13.640mIu/ml. So does it mean that I have high thyroid problem?

Stanley_Hazen,_MD,_PhD_: Individual labs vary in terms of normal range – but that value is very likely higher than normal, indicating your thyroid is hypoactive (not producing enough thyroid hormone). You should follow-up with your physician who ordered the test, or your primary care physician.

Valve Disease and Heart Disease Risk

Andreea: My father had an aortic valve replacement. Does that mean I am at a higher risk of getting heart disease? What tests should I get done annually? I am now 31. Thank you.

Stanley_Hazen,_MD,_PhD_: There is only a modest increase in risk for aortic valve disease if a first degree relative has had such disease, particularly at a younger age and not associated with history of rheumatic fever. In the absence of symptoms, and a normal cardiac exam, no routine testing is needed.

More importantly, there is a stronger link for family history of heart and vascular disease (atherosclerosis, heart attack, stroke) between first degree relatives. Annual testing for blood pressure, cholesterol panel is recommended if any of these are abnormal, and if not, at least once in early 30s, and then possibly thereafter beyond 35 (though the precise age where annual vs. a little less frequent is debatable in young individuals in 30s if all else is normal).

fowens: Is there anything one can do to minimize the risk of heart valve, such as aorta, calcification such as diet considerations? Where does the calcium come from? Is there a calcium compound in the blood stream?

Stanley_Hazen,_MD,_PhD_: Aortic valve calcification is predominantly related to age. So one doesn’t want to avoid getting old to avoid this. Seriously, there are no real dietary efforts specifically for helping to retard progression of aortic valve calcification. In sharp contrast, dietary efforts are essential for retarding progression of heart disease (atherosclerosis- with low cholesterol, low fat), high blood pressure (with low salt/sodium), and diabetes (with low sugar/carbohydrate).

GeorgeBMac: I just wanted to say: "Thank You Dr Hazen!" I don't know for sure -- none of us do -- but my gut tells me that you are making a real difference and that this is a better, safer, healthier world because of you and your work. Thank you!

Stanley_Hazen,_MD,_PhD_: You're welcome. Thank you!

Reviewed: 07/13

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