A brief review of the cardiovascular complication of COVID-19 – what is the pathophysiology of arrhythmia during infection?
DOI:
https://doi.org/10.15584/ejcem.2025.3.1Keywords:
arrhythmias, cardiovascular diseases, coronavirus, COVID-19, pathophysiologyAbstract
Introduction and aim. COVID-19, caused by SARS-CoV-2, significantly affects the cardiovascular system beyond its respiratory manifestations. This review examines the intricate relationship between COVID-19 and cardiovascular complications, focusing on cardiac arrhythmias and their underlying pathophysiology.
Material and methods. A comprehensive literature search was conducted in PubMed and Google Scholar from its inception to December 2024, including peer-reviewed articles published in English.
Analysis of literature. In COVID-19, a spectrum of cardiovascular complications is observed, including acute myocardial infarction, arrhythmias, myocarditis, venous thromboembolism, and heart failure/cardiac shock. The pathophysiology of cardiovascular damage in COVID-19 involves multiple mechanisms, primarily including direct viral cardiotoxicity, systemic inflammation, and hypercoagulability. Arrhythmias are a common cardiac complication in COVID-19, encompassing a range of disturbances, from bradycardia to ventricular fibrillation. The mechanisms underlying arrhythmias in COVID-19 are multifaceted, including direct viral injury to cardiomyocytes, hypoxia, systemic inflammation, hyperthermia, autonomic imbalance, electrolyte imbalances, side effects of medications, and drug-drug interactions.
Conclusion. Understanding the complex interplay of these factors is crucial for the early diagnosis and appropriate management of cardiac complications in patients with COVID-19. To mitigate cardiovascular morbidity and mortality in individuals with COVID-19, cardiovascular monitoring and the development of targeted therapeutic strategies are highly recommended.
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References
Lai CC, Shih TP, Ko WC, Tang HJ, Hsueh PR. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): The epidemic and the challenges. Int J Antimicrob Agents. 2020;55(3):105924. doi: 10.1016/j.ijantimicag.2020.105924
Terzic CM, Medina-Inojosa BJ. Cardiovascular Complications of Coronavirus Disease-2019. Physical Medicine and Rehabilitation Clinics of North America. 2023;34(3):551-561. doi: https://doi.org/10.1016/j.pmr.2023.03.003
Long B, Brady WJ, Koyfman A, Gottlieb M. Cardiovascular complications in COVID-19. Am J Emerg Med. 2020;38(7):1504-1507. doi: 10.1016/j.ajem.2020.04.048
Shao HH, Yin RX. Pathogenic mechanisms of cardiovascular damage in COVID-19. Mol Med. 2024;30(1):92. doi: 10.1186/s10020-024-00855-2
Kang Y, Chen T, Mui D, et al. Cardiovascular manifestations and treatment considerations in COVID-19. Heart. 2020;106(15):1132-1141. doi: 10.1136/heartjnl-2020-317056
Farshidfar F, Koleini N, Ardehali H. Cardiovascular complications of COVID-19. JCI Insight. 2021;6(13):e148980. doi: 10.1172/jci.insight.148980
Vasbinder A, Meloche C, Azam TU, et al. Relationship Between Preexisting Cardiovascular Disease and Death and Cardiovascular Outcomes in Critically Ill Patients With COVID-19. Circ Cardiovasc Qual Outcomes. 2022;15(10): e008942. doi: 10.1161/circoutcomes.122.008942
Shafi AMA, Shaikh SA, Shirke MM, Iddawela S, Harky A. Cardiac manifestations in COVID-19 patients-A systematic review. J Card Surg. 2020;35(8):1988-2008. doi: 10.1111/jocs.14808
Magadum A, Kishore R. Cardiovascular Manifestations of COVID-19 Infection. Cells. 2020;9(11):2508. doi: 10.3390/cells9112508
Goha A, Mezue K, Edwards P, Nunura F, Baugh D, Madu E. COVID-19 and the heart: An update for clinicians. Clin Cardiol. 2020;43(11):1216-1222. doi: 10.1002/clc.23406
Mojón-Álvarez D, Giralt T, Carreras-Mora J, et al. Baseline NT-proBNP levels as a predictor of short-and long-term prognosis in COVID-19 patients: a prospective observational study. BMC Infect Dis. 2024;24(1):58. doi: 10.1186/s12879-024-08980-3
Al-Aly Z, Bowe B, Xie Y. Long COVID after breakthrough SARS-CoV-2 infection. Nat Med. 2022;28(7):1461-1467. doi: 10.1038/s41591-022-01840-0
Dherange P, Lang J, Qian P, et al. Arrhythmias and COVID-19: A Review. JACC Clin Electrophysiol. 2020;6(9): 1193-1204. doi: 10.1016/j.jacep.2020.08.002
Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020;323(11): 1061-1069. doi: 10.1001/jama.2020.1585
Babapoor-Farrokhran S, Rasekhi RT, Gill D, Babapoor S, Amanullah A. Arrhythmia in COVID-19. SN Compr Clin Med. 2020;2(9):1430-1435. doi: 10.1007/s42399-020-00454-2
Sritharan HP, Bhatia KS, van Gaal W, Kritharides L, Chow CK, Bhindi R. Association between pre-existing cardiovascular disease, mortality and cardiovascular outcomes in hospitalised patients with COVID-19. Front Cardiovasc Med. 2023;10:1224886. doi: 10.3389/fcvm.2023.1224886
Rastogi A, Tewari P. Covid 19 and its cardiovascular effects. Ann Card Anaesth. 2020;23(4):401-408. doi: 10.4103/aca.aca_237_20
Pranata R, Huang I, Lukito AA, Raharjo SB. Elevated N-terminal pro-brain natriuretic peptide is associated with increased mortality in patients with COVID-19: systematic review and meta-analysis. Postgrad Med J. 2020;96(1137):387-391. doi: 10.1136/postgradmedj-2020-137884
Ozen M, Yilmaz A, Cakmak V, et al. D-Dimer as a potential biomarker for disease severity in COVID-19. Am J Emerg Med. 2021;40:55-59. doi: 10.1016/j.ajem.2020.12.023
Shah S, Shah K, Patel SB, et al. Elevated D-Dimer Levels Are Associated With Increased Risk of Mortality in Coronavirus Disease 2019: A Systematic Review and Meta-Analysis. Cardiol Rev. 2020;28(6):295-302. doi: 10.1097/crd.0000000000000330
Mouhat B, Besutti M, Bouiller K, et al. Elevated D-dimers and lack of anticoagulation predict PE in severe COVID-19 patients. Eur Respir J. 2020;56(4):2001811. doi: 10.1183/13993003.01811-2020
Task Force for the management of COVID-19 of the European Society of Cardiology. European Society of Cardiology guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 1-epidemiology, pathophysiology, and diagnosis. Eur Heart J. 2022;43(11):1033-1058. doi: 10.1093/eurheartj/ehab696
El-Menyar A, Ramzee AF, Asim M, et al. COVID-19 Increases the Risk of New Myocardial Infarction in Patients with Old Myocardial Infarction: A Retrospective Observational Study. Clin Med Insights Cardiol. 2024;18:11795468241301133. doi: 10.1177/11795468241301133
Poredos P, Spirkoska A, Lezaic L, Mijovski MB, Jezovnik MK. Patients with an Inflamed Atherosclerotic Plaque have Increased Levels of Circulating Inflammatory Markers. J Atheroscler Thromb. 2017;24(1):39-46. doi: 10.5551/jat.34884
Abou-Ismail MY, Diamond A, Kapoor S, Arafah Y, Nayak L. The hypercoagulable state in COVID-19: Incidence, pathophysiology, and management. Thromb Res. 2020;194:101-115. doi: 10.1016/j.thromres.2020.06.029
Jain V, Gupta K, Bhatia K, et al. Management of STEMI during the COVID-19 pandemic: Lessons learned in 2020 to prepare for 2021. Trends Cardiovasc Med. 2021;31(3):135-140. doi: 10.1016/j.tcm.2020.12.003
Seligman H, Sen S, Nijjer S, et al. Management of Acute Coronary Syndromes During the Coronavirus Disease 2019 Pandemic: Deviations from Guidelines and Pragmatic Considerations for Patients and Healthcare Workers. Interv Cardiol. 2020;15:e16. doi: 10.15420/icr.2020.21
Altamimi H, Abid AR, Othman F, Patel A. Cardiovascular Manifestations of COVID-19. Heart Views. Jul-Sep 2020;21(3):171-186. doi: 10.4103/heartviews.Heartviews_150_20
Varney JA, Dong VS, Tsao T, et al. COVID-19 and arrhythmia: An overview. J Cardiol. 2022;79(4):468-475. doi: 10.1016/j.jjcc.2021.11.019
Hooks M, Bart B, Vardeny O, Westanmo A, Adabag S. Effects of hydroxychloroquine treatment on QT interval. Heart Rhythm. 2020;17(11):1930-1935. doi: 10.1016/j.hrthm.2020.06.029
Loungani RS, Rehorn MR, Newby LK, et al. A care pathway for the cardiovascular complications of COVID-19: Insights from an institutional response. Am Heart J. 2020;225:3-9. doi: 10.1016/j.ahj.2020.04.024
Lovell JP, Čiháková D, Gilotra NA. COVID-19 and Myocarditis: Review of Clinical Presentations, Pathogenesis and Management. Heart Int. 2022;16(1):20-27. doi: 10.17925/hi.2022.16.1.20
Rezkalla SH, Kloner RA. Viral myocarditis: 1917-2020: From the Influenza A to the COVID-19 pandemics. Trends Cardiovasc Med. 2021;31(3):163-169. doi: 10.1016/j.tcm.2020.12.007
Davis MG, Bobba A, Chourasia P, et al. COVID-19 Associated Myocarditis Clinical Outcomes among Hospitalized Patients in the United States: A Propensity Matched Analysis of National Inpatient Sample. Viruses. 2022;14(12):2791. doi: 10.3390/v14122791
Ali J, Khan FR, Ullah R, et al. Cardiac Troponin I Levels in Hospitalized COVID-19 Patients as a Predictor of Severity and Outcome: A Retrospective Cohort Study. Cureus. 2021;13(3):e14061. doi: 10.7759/cureus.14061
Malas MB, Naazie IN, Elsayed N, Mathlouthi A, Marmor R, Clary B. Thromboembolism risk of COVID-19 is high and associated with a higher risk of mortality: A systematic review and meta-analysis. EclinicalMedicine. 2020;29:100639. doi: 10.1016/j.eclinm.2020.100639
Angelini DE, Kaatz S, Rosovsky Rachel P, et al. COVID-19 and venous thromboembolism: A narrative review. Res Pract Thromb Haemost. 2022;6(2):e12666. doi: 10.1002/rth2.12666
Esmaeel HM, Ahmed HA, Elbadry MI, et al. Coagulation parameters abnormalities and their relation to clinical outcomes in hospitalized and severe COVID-19 patients: prospective study. Sci Rep. 2022;12(1):13155. doi: 10.1038/s41598-022-16915-8
Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020;18(4):844-847. doi: 10.1111/jth.14768
Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-1062. doi: 10.1016/s0140-6736(20)30566-3
Lawler PR, Goligher EC, Berger JS, et al. Therapeutic Anticoagulation with Heparin in Noncritically Ill Patients with Covid-19. N Engl J Med. 2021;385(9):790-802. doi: 10.1056/NEJMoa2105911
Tang N, Bai H, Chen X, Gong J, Li D, Sun Z. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost. 2020;18(5):1094-1099. doi: 10.1111/jth.14817
Spyropoulos AC, Levy JH, Ageno W, et al. Scientific and Standardization Committee communication: Clinical guidance on the diagnosis, prevention, and treatment of venous thromboembolism in hospitalized patients with COVID-19. Journal of Thrombosis and Haemostasis. 2020;18(8):1859-1865. doi: 10.1111/jth.14929
Murthy S, Gomersall CD, Fowler RA. Care for Critically Ill Patients With COVID-19. JAMA. 2020;323(15):1499-1500. doi: 10.1001/jama.2020.3633
Arentz M, Yim E, Klaff L, et al. Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA. 2020;323(16):1612-1614. doi: 10.1001/jama.2020.4326
Zhu Y, Zhang X, Peng Z. Consequences of COVID-19 on the cardiovascular and renal systems. Sleep Med. 2022;100:31-38. doi: 10.1016/j.sleep.2022.07.011
Patel AB, Verma A. COVID-19 and Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers: What Is the Evidence? JAMA. 2020;323(18):1769-1770. doi: 10.1001/jama.2020.4812
MacLaren G, Fisher D, Brodie D. Preparing for the Most Critically Ill Patients With COVID-19: The Potential Role of Extracorporeal Membrane Oxygenation. JAMA. 2020;323(13):1245-1246. doi: 10.1001/jama.2020.2342
Bartlett RH, Ogino MT, Brodie D, et al. Initial ELSO Guidance Document: ECMO for COVID-19 Patients with Severe Cardiopulmonary Failure. ASAIO J. 2020;66(5):472-474. doi: 10.1097/mat.0000000000001173
Kuck KH. Arrhythmias and sudden cardiac death in the COVID-19 pandemic. Herz. 2020;45(4):325-326. doi: 10.1007/s00059-020-04924-0
Shi S, Qin M, Shen B, et al. Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China. JAMA Cardiol. 2020;5(7):802-810. doi: 10.1001/jamacardio.2020.0950
Zakynthinos GE, Tsolaki V, Oikonomou E, Vavouranakis M, Siasos G, Zakynthinos E. New-Onset Atrial Fibrillation in the Critically Ill COVID-19 Patients Hospitalized in the Intensive Care Unit. J Clin Med. 2023;12(22):6989. doi: 10.3390/jcm12226989
Gawałko M, Kapłon-Cieślicka A, Hohl M, Dobrev D, Linz D. COVID-19 associated atrial fibrillation: Incidence, putative mechanisms and potential clinical implications. Int J Cardiol Heart Vasc. 2020;30:100631. doi: 10.1016/j.ijcha.2020.100631
Mohammad M, Emin M, Bhutta A, Gul EH, Voorhees E, Afzal MR. Cardiac arrhythmias associa-
ted with COVID-19 infection: state of the art review. Expert Rev Cardiovasc Ther. 2021;19(10):881-889. doi: 10.1080/14779072.2021.1997589
Gheblawi M, Wang K, Viveiros A, et al. Angiotensin-Converting Enzyme 2: SARS-CoV-2 Receptor and Regulator of the Renin-Angiotensin System: Celebrating the 20th Anniversary of the Discovery of ACE2. Circ Res. 2020;126(10):1456-1474. doi: 10.1161/circresaha.120.317015
Wang Y, Wang Z, Tse G, et al. Cardiac arrhythmias in patients with COVID-19. J Arrhythm. 2020;36(5):827-836. doi: 10.1002/joa3.12405
Tian S, Xiong Y, Liu H, et al. Pathological study of the 2019 novel coronavirus disease (COVID-19) through postmortem core biopsies. Mod Pathol. 2020;33(6):1007-1014. doi: 10.1038/s41379-020-0536-x
Swenson KE, Hardin CC. Pathophysiology of Hypoxemia in COVID-19 Lung Disease. Clin Chest Med. 2023;44(2):239-248. doi: 10.1016/j.ccm.2022.11.007
Plant LD, Xiong D, Romero J, Dai H, Goldstein SAN. Hypoxia Produces Pro-arrhythmic Late Sodium Current in Cardiac Myocytes by SUMOylation of Na(V)1.5 Channels. Cell Rep. 2020;30(7):2225-2236.e4. doi: 10.1016/j.celrep.2020.01.025
Hawerkamp HC, Dyer AH, Patil ND, et al. Characterisation of the pro-inflammatory cytokine signature in severe COVID-19. Front Immunol. 2023;14:1170012. doi: 10.3389/fimmu.2023.1170012
Li Y-S, Ren H-C, Cao J-H. Roles of Interleukin-6-mediated immunometabolic reprogramming in COVID-19 and other viral infection-associated diseases. Int Immunopharmacol. 2022;110:109005. doi: https://doi.org/10.1016/j.intimp.2022.109005
Roterberg G, El-Battrawy I, Veith M, et al. Arrhythmic events in Brugada syndrome patients induced by fever. Ann Noninvasive Electrocardiol. 2020;25(3):e12723. Doi: 10.1111/anec.12723
D’Aloia A, Faggiano P, Brentana L, et al. Recurrent ventricular fibrillation during a febrile illness and hyperthermia in a patient with dilated cardiomyopathy and automatic implantable cardioverter defibrillator. An example of reversible electrical storm. Int J Cardiol. 2005;103(2):207-208. doi: 10.1016/j.ijcard.2004.06.027
Ma JF, Zhou Y, Fu HX. Ventricular fibrillation induced by fever in structurally normal hearts. Front Cardiovasc Med. 2023;10:1230295. doi: 10.3389/fcvm.2023.1230295
El-Battrawy I, Lang S, Zhao Z, et al. Hyperthermia Influences the Effects of Sodium Channel Blocking Drugs in Human-Induced Pluripotent Stem Cell-Derived Cardiomyocytes. PLoS One. 2016;11(11):e0166143. doi: 10.1371/journal.pone.0166143
Naksuk N, Lazar S, Peeraphatdit TB. Cardiac safety of off-label COVID-19 drug therapy: a review and proposed monitoring protocol. Eur Heart J Acute Cardiovasc Care. 2020;9(3):215-221. doi: 10.1177/2048872620922784
Manolis AS, Manolis AA, Manolis TA, Apostolopoulos EJ, Papatheou D, Melita H. COVID-19 infection and cardiac arrhythmias. Trends Cardiovasc Med. 2020;30(8):451-460. doi: 10.1016/j.tcm.2020.08.002
Amaratunga EA, Corwin DS, Moran L, Snyder R. Bradycardia in Patients With COVID-19: A Calm Before the Storm? Cureus. 2020;12(6):e8599. doi: 10.7759/cureus.8599
Arnold AC, Ng J, Raj SR. Postural tachycardia syndrome - Diagnosis, physiology, and prognosis. Auton Neurosci. 2018;215:3-11. doi: 10.1016/j.autneu.2018.02.005
Ormiston CK, Świątkiewicz I, Taub PR. Postural orthostatic tachycardia syndrome as a sequela of COVID-19. Heart Rhythm. 2022;19(11):1880-1889. doi: 10.1016/j.hrthm.2022.07.014
Desai AD, Boursiquot BC, Melki L, Wan EY. Management of Arrhythmias Associated with COVID-19. Curr Cardiol Rep. 2020;23(1):2. doi: 10.1007/s11886-020-01434-7
Romiti GF, Corica B, Lip GYH, Proietti M. Prevalence and Impact of Atrial Fibrillation in Hospitalized Patients with COVID-19: A Systematic Review and Meta-Analysis. J Clin Med. 2021;10(11):2490. doi: 10.3390/jcm10112490
Beri A, Kotak K. Cardiac injury, arrhythmia, and sudden death in a COVID-19 patient. HeartRhythm Case Rep. 2020;6(7):367-369. doi: 10.1016/j.hrcr.2020.05.001
Bakhshi H, Donthi N, Ekanem E, et al. The clinical spectrum of myocardial injury associated with COVID-19 infection. J Community Hosp Intern Med Perspect. 2020;10(6):521-522. doi: 10.1080/20009666.2020.1809910
Giustino G, Pinney SP, Lala A, et al. Coronavirus and Cardiovascular Disease, Myocardial Injury, and Arrhythmia: JACC Focus Seminar. J Am Coll Cardiol. 2020;76(17):2011-2023. doi: 10.1016/j.jacc.2020.08.059
Izquierdo-Marquisá A, Cubero-Gallego H, Aparisi Á, Vaquerizo B, Ribas-Barquet N. Myocardial Injury in COVID-19 and Its Implications in Short- and Long-Term Outcomes. Front Cardiovasc Med. 2022;9:901245. doi: 10.3389/fcvm.2022.901245
Taghdiri A. Inflammation and arrhythmogenesis: a narrative review of the complex relationship. Int J Arrhythmia. 2024;25(1):4. doi: 10.1186/s42444-024-00110-z
Zequn Z, Yujia W, Dingding Q, Jiangfang L. Off-label use of chloroquine, hydroxychloroquine, azithromycin and lopinavir/ritonavir in COVID-19 risks prolonging the QT interval by targeting the hERG channel. Eur J Pharmacol. 2021;893:173813. doi: 10.1016/j.ejphar.2020.173813
Chen CY, Wang FL, Lin CC. Chronic hydroxychloroquine use associated with QT prolongation and refractory ventricular arrhythmia. Clin Toxicol (Phila). 2006;44(2):173-175. doi: 10.1080/15563650500514558
Roden DM, Harrington RA, Poppas A, Russo AM. Considerations for Drug Interactions on QTc in Exploratory COVID-19 Treatment. Circulation. 2020;141(24):e906-e907. doi: 10.1161/circulationaha.120.047521
Watson OJ, Barnsley G, Toor J, Hogan AB, Winskill P, Ghani AC. Global impact of the first year of COVID-19 vaccination: a mathematical modelling study. Lancet Infect Dis. 2022;22(9):1293-1302. doi: 10.1016/s1473-3099(22)00320-6
Polack FP, Thomas SJ, Kitchin N, et al. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. N Engl J Med. 2020;383(27):2603-2615. doi: 10.1056/NEJMoa2034577
Kuodi P, Gorelik Y, Zayyad H, et al. Association between BNT162b2 vaccination and reported incidence of post-COVID-19 symptoms: cross-sectional study 2020-21, Israel. NPJ Vaccines. 2022;7(1):101. doi: 10.1038/s41541-022-00526-5
Krishna BA, Metaxaki M, Wills MR, Sithole N. Reduced Incidence of Long Coronavirus Disease Referrals to the Cambridge University Teaching Hospital Long Coronavirus Disease Clinic. Clin Infect Dis. 2023;76(4):738-740. doi: 10.1093/cid/ciac630
Ayoubkhani D, Bosworth ML, King S, et al. Risk of Long COVID in People Infected With Severe Acute Respiratory Syndrome Coronavirus 2 After 2 Doses of a Coronavirus Disease 2019 Vaccine: Community-Based, Matched Cohort Study. Open Forum Infect Dis. 2022;9(9):ofac464. Doi: 10.1093/ofid/ofac464
Mercadé-Besora N, Li X, Kolde R, et al. The role of COVID-19 vaccines in preventing post-COVID-19 thromboembolic and cardiovascular complications. Heart. 2024;110(9):635-643. doi: 10.1136/heartjnl-2023-323483
Pillay J, Gaudet L, Wingert A, et al. Incidence, risk factors, natural history, and hypothesised mechanisms of myocarditis and pericarditis following covid-19 vaccination: living evidence syntheses and review. BMJ. 2022;378:e069445. doi: 10.1136/bmj-2021-069445
Klein NP, Lewis N, Goddard K, et al. Surveillance for Adverse Events After COVID-19 mRNA Vaccination. JAMA. 2021;326(14):1390-1399. doi: 10.1001/jama.2021.15072
Gao J, Feng L, Li Y, et al. A Systematic Review and Meta-analysis of the Association Between SARS-CoV-2 Vaccination and Myocarditis or Pericarditis. Am J Prev Med. 2023;64(2):275-284. doi: 10.1016/j.amepre.2022.09.002
Krishna BA, Metaxaki M, Sithole N, Landín P, Martín P, Salinas-Botrán A. Cardiovascular disease and covid-19: A systematic review. Int J Cardiol Heart Vasc. 2024;54:101482. doi: 10.1016/j.ijcha.2024.101482
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