Classification and external resources
Automated arm blood pressure meter showing arterial hypertension (shown a systolic blood pressure 158 mmHg, diastolic blood
pressure 99 mmHg and heart rate of 80 beats per minute).
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Hypertension (HTN) or high blood pressure is a chronic medical condition in which the systemic arterial blood
pressure is elevated. It is the opposite of hypotension. It is classified as either primary (essential) or secondary.
About 90–95% of cases are termed "primary hypertension", which refers to high blood pressure for which no
medical cause can be found. The remaining 5–10% of cases (Secondary hypertension) are caused by other
conditions that affect the kidneys, arteries, heart, or endocrine system.
Persistent hypertension is one of the risk factors for stroke, myocardial infarction, heart failure and arterial aneurysm,
and is a leading cause of chronic kidney failure. Moderate elevation of arterial blood pressure leads to shortened
life expectancy. Dietary and lifestyle changes can improve blood pressure control and decrease the risk of associated
health complications, although drug treatment may prove necessary in patients for whom lifestyle changes prove
ineffective or insufficient.
The variation in pressure in the left ventricle
(blue line) and the aorta (red line) over two
cardiac cycles ("heart beats"), showing the
definitions of systolic and diastolic pressure
Classification Systolic pressure Diastolic pressure
mmHg kPa mmHg kPa
Normal 90–119 12–15.9 60–79 8.0–10.5
Prehypertension 120–139 16.0–18.5 80–89 10.7–11.9
Stage 1 140–159 18.7–21.2 90–99 12.0–13.2
Stage 2 ≥160 ≥21.3 ≥100 ≥13.3
Isolated systolic ≥140 ≥18.7 <90 <12.0
Source: American Heart Association (2003).
Blood pressure is usually classified based on the systolic and diastolic blood pressures. Systolic blood pressure is the
blood pressure in vessels during a heart beat. Diastolic blood pressure is the pressure between heartbeats. A systolic
or the diastolic blood pressure measurement higher than the accepted normal values for the age of the individual is
classified as prehypertension or hypertension.
Hypertension has several sub-classifications including, hypertension stage I, hypertension stage II, and isolated
systolic hypertension. Isolated systolic hypertension refers to elevated systolic pressure with normal diastolic
pressure and is common in the elderly. These classifications are made after averaging a patient's resting blood
pressure readings taken on two or more office visits. Individuals older than 50 years are classified as having
hypertension if their blood pressure is consistently at least 140 mmHg systolic or 90 mmHg diastolic. Patients with
blood pressures higher than 130/80 mmHg with concomitant presence of diabetes mellitus or kidney disease require
Hypertension is also classified as resistant if medications do not reduce blood pressure to normal levels.
Exercise hypertension is an excessively high elevation in blood pressure during exercise.   The range
considered normal for systolic values during exercise is between 200 and 230 mm Hg. Exercise hypertension may
indicate that an individual is at risk for developing hypertension at rest. 
Signs and symptoms
Mild to moderate essential hypertension is usually asymptomatic.
Accelerated hypertension is associated with headache, drowsiness, confusion, vision disorders, nausea, and vomiting
symptoms which are collectively referred to as hypertensive encephalopathy. . Hypertensive encephalopathy is
caused by severe small blood vessel congestion and brain swelling, which is reversible if blood pressure is
Some signs and symptoms are especially important in newborns and infants such as failure to thrive, seizures,
irritability, lack of energy, and difficulty breathing. In children, hypertension can cause headache, fatigue, blurred
vision, nosebleeds, and facial paralysis.
Some additional signs and symptoms suggest that the hypertension is caused by disorders in hormone regulation.
Hypertension combined with obesity distributed on the trunk of the body, accumlated fat on the back of the neck
('buffalo hump'), wide purple marks on the abdomen (abdominal striae), or the recent on set of diabetes suggests that
an individual has a hormone disorder known as Cushing's syndrome. Hypertension caused by other hormone
disorders such as hyperthyroidism, hypothyroidism, or growth hormone excess will be accompanied by additional
symptoms specific to these disorders. For example, hyperthyrodism can cause weight loss, tremors, heart rate
abnormalities, reddening of the palms, and increased sweating. Signs and symptoms associated with growth
hormone excess include coarsening of facial features, protrusion of the lower jaw, enlargement of the tongue,
excessive hair growth, darkening of the skin color, and excessive sweating. :499. Other hormone disorders like
hyperaldosteronism may cause less specific symptoms such as numbness, excessive urination, excessive sweating,
electrolyte imbalances and dehydration, and elevated blood alkalinity. and also cause of mental pressure.
Hypertension in pregnant women is known as pre-eclampsia. Pre-eclampsia can progress to a life-threatening
condition called eclampsia, which is the development of protein in the urine, generalized swelling, and severe
seizures. Other symptoms indicating that brain function is becoming impaired may precede these seizures such as
nausea, vomiting, headaches, and vision loss.
Essential hypertension is the most prevalent hypertension type, affecting 90–95% of hypertensive patients.
Although no direct cause has identified itself, there are many factors such as sedentary lifestyle, stress, visceral
obesity, potassium deficiency (hypokalemia), obesity (more than 85% of cases occur in those with a body
mass index greater than 25), salt (sodium) sensitivity, alcohol intake, and vitamin D deficiency that
increase the risk of developing hypertension.  Risk also increases with aging, some inherited genetic
mutations, and having a family history of hypertension. An elevation of renin, a hormone secreted by the
kidney, is another risk factor, as is sympathetic nervous system overactivity. Insulin resistance which is a
component of syndrome X, or the metabolic syndrome is also thought to contribute to hypertension.  Recent
studies have implicated low birth weight as a risk factor for adult essential hypertension.
Secondary hypertension by definition results from an identifiable cause. This type is important to recognize since it's
treated differently than essential hypertension, by treating the underlying cause of the elevated blood pressure.
Hypertension results in the compromise or imbalance of the pathophysiological mechanisms, such as the
hormone-regulating endocrine system, that regulate blood plasma volume and heart function. Many conditions cause
hypertension, some are common and well recognized secondary causes such as Cushing's syndrome, which is a
condition where the adrenal glands overproduce the hormone cortisol. In addition, hypertension is caused by
other conditions that cause hormone changes such as hyperthyroidism, hypothyroidism (citation needed), and certain
tumors of the adrenal medulla (e.g., pheochromocytoma). Other common causes of secondary hypertension include
kidney disease, obesity/metabolic disorder, pre-eclampsia during pregnancy, the congenital defect known as
coarctation of the aorta, and certain prescription and illegal drugs.
Most of the mechanisms associated
with secondary hypertension are
generally fully understood. However,
those associated with essential
(primary) hypertension are far less
understood. What is known is that
cardiac output is raised early in the
disease course, with total peripheral
resistance (TPR) normal; over time A diagram explaining factors affecting arterial pressure
cardiac output drops to normal levels
but TPR is increased. Three theories have been proposed to explain this:
• Inability of the kidneys to excrete sodium, resulting in natriuretic factors such as Atrial Natriuretic Factor being
secreted to promote salt excretion with the side effect of raising total peripheral resistance.
• An overactive Renin-angiotensin system leads to vasoconstriction and retention of sodium and water. The
increase in blood volume leads to hypertension.
• An overactive sympathetic nervous system, leading to increased stress responses.
It is also known that hypertension is highly heritable and polygenic (caused by more than one gene) and a few
candidate genes have been postulated in the etiology of this condition.
Recently, work related to the association between essential hypertension and sustained endothelial damage has
gained popularity among hypertension scientists. It remains unclear however whether endothelial changes precede
the development of hypertension or whether such changes are mainly due to long standing elevated blood pressures.
Hypertension is generally diagnosed on the basis of a persistently high blood pressure. Usually this requires three
separate sphygmomanometer (see figure) measurements at least one week apart. Initial assessment of the
hypertensive patient should include a complete history and physical examination. Exceptionally, if the elevation is
extreme, or if symptoms of organ damage are present then the diagnosis may be given and treatment started
Once the diagnosis of hypertension has been made, physicians will attempt to identify the underlying cause based on
risk factors and other symptoms, if present. Secondary hypertension is more common in preadolescent children, with
most cases caused by renal disease. Primary or essential hypertension is more common in adolescents and has
multiple risk factors, including obesity and a family history of hypertension. Laboratory tests can also be
performed to identify possible causes of secondary hypertension, and determine if hypertension has caused damage
to the heart, eyes, and kidneys. Additional tests for Diabetes and high cholesterol levels are also usually performed
because they are additional risk factors for the development of heart disease require treatment. Tests typically
performed are classified as follows:
Renal Microscopic urinalysis, proteinuria, serum BUN (blood urea nitrogen) and/or creatinine
Endocrine Serum sodium, potassium, calcium, TSH (thyroid-stimulating hormone).
Metabolic Fasting blood glucose, total cholesterol, HDL and LDL cholesterol, triglycerides
Other Hematocrit, electrocardiogram, and chest radiograph
      
Sources: Harrison's principles of internal medicine others
Creatinine (renal function) testing is done to determine if kidney disease is present, which can be either the cause or
result of hypertension. In addition, it provides a baseline measurement of kidney function that can be used to monitor
for side-effects of certain antihypertensive drugs on kidney function. Additionally, testing of urine samples for
protein is used as a secondary indicator of kidney disease. Glucose testing is done to determine if diabetes mellitus is
present. Electrocardiogram (EKG/ECG) testing is done to check for evidence of the heart being under strain from
high blood pressure. It may also show if there is thickening of the heart muscle (left ventricular hypertrophy) or has
experienced a prior minor heart distubance such as a silent heart attack. A chest X-ray may be performed to look for
signs of heart enlargement or damage to heart tissue.
The degree to which hypertension can be prevented depends on a number of features including current blood
pressure level, sodium/potassium balance, detection and omission of environmental toxins, changes in end/target
organs (retina, kidney, heart, among others), risk factors for cardiovascular diseases and the age at diagnosis of
prehypertension or at risk for hypertension. A prolonged assessment in which repeated measurements of blood
pressure are taken provides the most accurate assessment of blood pressure levels. Following this, lifestyle changes
are recommended to lower blood pressure, before the initiation of prescription drug therapy. The process of
managing prehypertension according the guidelines of the British Hypertension Society suggest the following
• Weight reduction and regular aerobic exercise (e.g., walking): Regular exercise improves blood flow and helps to
reduce the resting heart rate and blood pressure.
• Reducing dietary sugar.
• Reducing sodium (salt) in the diet: This step decreases blood pressure in about 33% of people (see above). Many
people use a salt substitute to reduce their salt intake.
• Additional dietary changes beneficial to reducing blood pressure include the DASH diet (dietary approaches to
stop hypertension) which is rich in fruits and vegetables and low-fat or fat-free dairy products. This diet has been
shown to be effective based on research sponsored by the National Heart, Lung, and Blood Institute. In
addition, an increase in dietary potassium, which offsets the effect of sodium has been shown to be highly
effective in reducing blood pressure.
• Discontinuing tobacco use and alcohol consumption has been shown to lower blood pressure. The exact
mechanisms are not fully understood, but blood pressure (especially systolic) always transiently increases
following alcohol or nicotine consumption. Abstaining from cigarette smoking reduces the risk of stroke and heart
attack which are associated with hypertension.
• Reducing stress, for example with relaxation therapy, such as meditation and other mindbody relaxation
techniques, by reducing environmental stress such as high sound levels and over-illumination can also lower
blood pressure. Jacobson's Progressive Muscle Relaxation and biofeedback are also beneficial, such as
device-guided paced breathing,  although meta-analysis suggests it is not effective unless combined with
other relaxation techniques.
The first line of treatment for hypertension is the same as the recommended preventative lifestyle changes such as
the dietary changes, physical exercise, and weight loss, which have all been shown to significantly reduce blood
pressure in people with hypertension. If hypertension is high enough to justify immediate use of medications,
lifestyle changes are still recommended in conjunction with medication. Drug prescription should take into account
the patient's absolute cardiovascular risk (including risk of myocardial infarction and stroke) as well as blood
pressure readings, in order to gain a more accurate picture of the patient's cardiovascular profile. Different
programs aimed to reduce psychological stress such as biofeedback, relaxation or meditation are advertised to reduce
hypertension. However, in general claims of efficacy are not supported by scientific studies, which have been in
general of low quality.  
Regarding dietary changes, a low sodium diet is beneficial; A Cochrane review published in 2008 concluded that a
long term (more than 4 weeks) low sodium diet in Caucasians has a useful effect to reduce blood pressure, both in
people with hypertension and in people with normal blood pressure. Also, the DASH diet (Dietary Approaches to
Stop Hypertension) is a diet promoted by the National Heart, Lung, and Blood Institute (part of the NIH, a United
States government organization) to control hypertension. A major feature of the plan is limiting intake of sodium,
and it also generally encourages the consumption of nuts, whole grains, fish, poultry, fruits and vegetables while
lowering the consumption of red meats, sweets, and sugar. It is also "rich in potassium, magnesium, and calcium, as
well as protein".
Several classes of medications, collectively referred to as antihypertensive drugs, are currently available for treating
hypertension. Agents within a particular class generally share a similar pharmacologic mechanism of action, and in
many cases have an affinity for similar cellular receptors. An exception to this rule is the diuretics, which are
grouped together for the sake of simplicity but actually exert their effects by a number of different mechanisms.
Reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34%, of ischaemic heart disease by
21%, and reduce the likelihood of dementia, heart failure, and mortality from cardiovascular disease. The aim of
treatment should be reduce blood pressure to <140/90 mmHg for most individuals, and lower for individuals with
diabetes or kidney disease (some medical professionals recommend keeping levels below 120/80 mmHg).
Comorbidity also plays a role in determining target blood pressure, with lower BP targets applying to patients with
end-organ damage or proteinuria.
Often multiple drugs are combined to achieve the goal blood pressure. Commonly used prescription drugs
• ACE inhibitors (e.g., captopril)
• Alpha blockers (e.g., prazosin)
• Angiotensin II receptor antagonists (e.g., losartan)
• Beta blockers (e.g., propranolol)
• Calcium channel blockers (e.g., verapamil)
• Diuretics (e.g. hydrochlorothiazide)
• Direct renin inhibitors (e.g., aliskiren)
Some examples of common combined prescription drug treatments include:
• A fixed combination of an ACE inhibitor and a calcium channel blocker. One example of this is the combination
of perindopril and amlodipine, the efficacy of which has been demonstrated in individuals with glucose
intolerance or metabolic syndrome.
• A fixed combination of an ACE inhibitor and a calcium channel blocker.
• A fixed combination of a diuretic and an ARB.
Guidelines for treating resistant hypertension have been published in the UK and US.
Hypertension is the most important risk factor for death in
industrialized countries. It increases hardening of the arteries
thus predisposes individuals to heart disease, peripheral vascular
disease, and strokes. Types of heart disease that may occur
include: myocardial infarction, heart failure, and left ventricular
hypertrophy Other complications include:
• Hypertensive retinopathy
• Hypertensive nephropathy
• If blood pressure is very high hypertensive encephalopathy may
Diagram illustrating the main complications of
persistent high blood pressure.
In the year 2000 it is estimated that nearly one billion people or ~26% of the adult population have hypertension
worldwide. It was common in both developed (333 million ) and undeveloped (639 million) countries.
However rates vary markedly in different regions with rates as low as 3.4% (men) and 6.8% (women) in rural India
and as high as 68.9% (men) and 72.5% (women) in Poland.
In 1995 it is estimated that 43 million people in the United States had hypertension or were taking antihypertensive
medication, almost 24% of the adult population. The prevalence of hypertension in the United States is increasing
and reached 29% in 2004.  It is more common in blacks and less in whites and Mexican Americans, rates
increase with age, and is greater in the southeastern United States. Hypertension is more prevalent in men (though
menopause tends to decrease this difference) and those of low socioeconomic status.
Over 90–95% of adult hypertension is essential hypertension. The most common cause of secondary hypertension
is primary aldosteronism. The incidence of exercise hypertension is reported to range from 1–10%.
The prevalence of high blood pressure in the young is increasing. Most childhood hypertension, particularly in
preadolescents, is secondary to an underlying disorder. Kidney disease is the most common (60–70%) cause of
hypertension in children. Adolescents usually have primary or essential hypertension, which accounts for 85–95% of
Some cite the writings of Sushruta in the 6th century BC as being the
first mention of symptoms like those of hypertension. Others
propose even earlier descriptions dating as far as 2600 years before
Christ. Main treatment for what was called the "hard pulse disease"
consisted in reducing the quantity of blood in a subject by the
sectioning of veins or the application of leeches. Well known
individuals such as The Yellow Emperor of China, Cornelius Celsus,
Galen, and Hipocrates advocated such treatments.
Image of veins from Harvey's Exercitatio
Our modern understanding of hypertension began with the work of
Anatomica de Motu Cordis et Sanguinis in
physician William Harvey (1578–1657), who was the first to describe Animalibus
correctly the systemic circulation of blood being pumped around the
body by the heart in his book "De motu cordis". The basis for measuring blood pressure were established by Stephen
Hales in 1733. Initial descriptions of hypertension as a disease came among others from Thomas Young in 1808
and specially Richard Bright in 1836. The first ever elevated blood pressure in a patient without kidney disease
was reported by Frederick Mahomed (1849–1884). It was not until 1904 that sodium restriction was advocated
while a rice diet was popularized around 1940.
Studies in the 1920s demonstrated the public health impact of untreated high blood pressure; treatment options were
limited at the time, and deaths from malignant hypertension and its complications were common. A prominent
victim of severe hypertension leading to cerebral hemorrhage was Franklin D. Roosevelt (1882–1945). The
Framingham Heart Study added to the epidemiological understanding of hypertension and its relationship with
coronary artery disease. The National Institutes of Health also sponsored other population studies, which additionally
showed that African Americans had a higher burden of hypertension and its complications. Before
pharmacological treatment for hypertension became possible, three treatment modalities were used, all with
numerous side-effects: strict sodium restriction, sympathectomy (surgical ablation of parts of the sympathetic
nervous system), and pyrogen therapy (injection of substances that caused a fever, indirectly reducing blood
The first chemical for hypertension, sodium thiocyanate, was used in 1900 but had many side effects and was
unpopular. Several other agents were developed after the Second World War, the most popular and reasonably
effective of which were tetramethylammonium chloride and its derivative hexamethonium, hydralazine and reserpine
(derived from the medicinal plant Rauwolfia serpentina). A randomized controlled trial sponsored by the Veterans
Administration using these drugs had to be stopped early because those not receiving treatment were developing
more complications and it was deemed unethical to withhold treatment from them. These studies prompted public
health campaigns to increase public awareness of hypertension and the advice to get blood pressure measured and
treated. These measures appear to have contributed at least in part of the observed 50% fall in stroke and ischemic
heart disease beween 1972 and 1994.
A major breakthrough was achieved with the discovery of the first well-tolerated orally available agents. The first
was chlorothiazide, the first thiazide and developed from the antibiotic sulfanilamide, which became available in
1958;  it increased salt excretion while preventing fluid accumulation. In 1975, the Lasker Special Public
Health Award was awarded to the team that developed chlorothiazide. The British physician James W. Black
developed beta blockers in the early 1960s; these were initially used for angina, but turned out to lower blood
pressure. Black received the 1976 Lasker Award and in 1988 the Nobel Prize in Physiology or Medicine for his
discovery. The next class of antihypertensives to be discovered was that of the calcium channel blockers. The
first member was verapamil, a derivative of papaverine that was initially thought to be a beta blocker and used for
angina, but then turned out to have a different mode of action and was shown to lower blood pressure. ACE
inhibitors were developed through rational drug design; the renin-angiotensin system was known to play an
important role in blood pressure regulation, and snake venom from Bothrops jararaca could lower blood pressure
through inhibition of ACE. In 1977 captopril, an orally active agent, was described; this led to the development
of a number of other ACE inhibitors.
Society and culture
The National Heart, Lung, and Blood Institute (NHLBI) estimated in 2002 that hypertension cost the United States
High blood pressure is the most common chronic medical problem prompting visits to primary health care providers,
yet it is estimated that only 34% of the 50 million American adults with hypertension have their blood pressure
controlled to a level of <140/90 mm Hg . Thus, about two thirds of Americans with hypertension are at increased
risk for heart disease. The medical, economic, and human costs of untreated and inadequately controlled high blood
pressure are enormous. Adequate management of hypertension can be hampered by inadequacies in the diagnosis,
treatment, and/or control of high blood pressure. Health care providers face many obstacles to achieving blood
pressure control from their patients, including resistance to taking multiple medications to reach blood pressure
goals. Patients also face the challenges of adhering to medicine schedules and making lifestyle changes. Nonetheless,
the achievement of blood pressure goals is possible, and most importantly, lowering blood pressure significantly
reduces the risk of death due to heart disease, the development of other debilitating conditions, and the cost
associated with advanced medical care., 
The World Health Organization attributes hypertension, or high blood
pressure, as the leading cause of cardiovascular mortality. The World
Hypertension League (WHL), an umbrella organization of 85 national
hypertension societies and leagues, recognized that more than 50% of
the hypertensive population worldwide are unaware of their
condition. To address this problem, the WHL initiated a global
awareness campaign on hypertension in 2005 and dedicated May 17 of
each year as World Hypertension Day (WHD). Over the past three
Graph showing, prevalence of awareness,
years, more national societies have been engaging in WHD and have treatment and control of hypertension compared
been innovative in their activities to get the message to the public. In between the four studies of NHANES
2007, there was record participation from 47 member countries of the
WHL. During the week of WHD, all these countries – in partnership with their local governments, professional
societies, nongovernmental organizations and private industries – promoted hypertension awareness among the
public through several media and public rallies. Using mass media such as Internet and television, the message
reached more than 250 million people. As the momentum picks up year after year, the WHL is confident that almost
all the estimated 1.5 billion people affected by elevated blood pressure can be reached.
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• The American Journal of Hypertension (http://www.nature.com/ajh)
• The Framingham Heart Study (http://www.nhlbi.nih.gov/about/framingham/)
• Video showing how to measure blood pressure (http://www.medicalvideos.us/
• Hypertension (http://www.dmoz.org//Health/Conditions_and_Diseases/Cardiovascular_Disorders/
Vascular_Disorders/Hypertension//) at the Open Directory Project
• High Blood Pressure (http://ww2.heartandstroke.ca/Page.asp?PageID=1975&ArticleID=5211) from the Heart
and Stroke Foundation of Canada
• High Blood Pressure (http://medlineplus.nlm.nih.gov/medlineplus/highbloodpressure.html) from
• A guide to lowering high blood pressure (http://www.nhlbi.nih.gov/hbp/) from the National Heart, Lung, and
• High Blood Pressure (http://www.americanheart.org/presenter.jhtml?identifier=2114) (from the American
• Pulmonary Hypertension (http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/
nephrology/arterial-hypertension/) from Cleveland Clinic Online Medical Reference
Article Sources and Contributors 15
Article Sources and Contributors
Hypertension Source: http://en.wikipedia.org/w/index.php?oldid=389163158 Contributors: 1ForTheMoney, 207-203-156-105, 2D, 4wajzkd02, A. B., A930913, ABF, ARHAPSTF, AS,
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Falcon, Blenda, Blood Pressure Association Publications Officer, Blurpeace, BobKawanaka, Bobblewik, Bobo192, BradBeattie, Bradeos Graphon, BrettMontgomery, Brian Crawford, Brianga,
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Doomsayer, Doops, Dougofborg, Dr.Gangino, Draeco, Dreamyshade, Drevrengul, Drew R. Smith, Drfarhan99, Drflgd, Drjayakumar1999, Drmies, Dthomsen8, Duster.Cleaner, Dysepsion,
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HandThatFeeds, Hankwang, Hans Dunkelberg, HardworkinJudy, HarryHenryGebel, Hartz, Hbent, Headbomb, Hi878, Highbloodpressure, Holme053, House Centipede, Hu12, Ihuxley,
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Image Sources, Licenses and Contributors
File:Grade 1 hypertension.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Grade_1_hypertension.jpg License: Creative Commons Attribution 3.0 Contributors:
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