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European Heart Journal Advance Access originally published online on February 1, 2008
European Heart Journal 2008 29(5):602-608; doi:10.1093/eurheartj/ehn012
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org

Is vigorous physical activity contraindicated in subjects with coronary heart disease? Evidence from the Caerphilly study

Shicheng Yu1, Christopher C. Patterson2 and John W.G. Yarnell2,*

1 OHSAH in British Columbia, Ministry of Health Services, Vancouver, Canada
2 Department of Epidemiology and Public Health, Queen's University Belfast, Mulhouse Building, Royal Victoria Hospital Site, Grosvenor Road, Belfast BT12 6BJ, UK

Received 4 September 2007; revised 6 December 2007; accepted 7 January 2008; online publish-ahead-of-print 1 February 2008.

* Corresponding author. Tel: +44 28 9063 2746, Fax: +44 28 9023 1907, Email: h.porter{at}qub.ac.uk or j.yarnell{at}qub.ac.uk


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Funding
 Acknowledgements
 References
 
Aims: A large study of British civil servants reported that, in men with electrocardiogram ischaemia but no symptoms, vigorous habitual leisure activity might be associated with increased subsequent risk of myocardial infarction (MI). We examine this for MI and stroke in a general population of British men.

Methods and results: Between 1984 and 1988, 2398 middle-aged men were recruited into the cohort in Caerphilly, South Wales, UK. Physical activities during leisure and at work were assessed by validated questionnaires. Follow-up was for 12 years, and both fatal and non-fatal cardiovascular events (MI, stroke or MI, and stroke) were recorded. After adjustment for age and other confounders, men in the highest third of vigorous physical activity experienced decreased risk of MI, relative to men in the lowest third; hazard ratios (HR) (95% CI) were 0.71 (0.50, 1.03), 0.42 (0.19, 0.92), and 0.60 (0.38, 0.94) in men with symptomatic, asymptomatic coronary heart disease (CHD), and no evidence of CHD at baseline, respectively. HRs for stroke were non-significantly raised for subjects with asymptomatic CHD (1.36 (0.47, 3.91).

Conclusion: Habitual vigorous activity was not associated with increased risk of subsequent MI in subjects with established CHD, but additional data for stroke would be useful.

Key Words: Vigorous exercise • Risk • Coronary heart disease • Stroke • Asymptomatic coronary disease • Longitudinal study


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Funding
 Acknowledgements
 References
 
Many reports suggest that a sedentary lifestyle is associated with increased risk of cardiovascular disease (CVD),1–4 but the required intensity and type of physical activity has been controversial.5 A recent update from the American College of Sports Medicine and the American Heart Association for the general public includes an alternative recommendation based on vigorous intensity, aerobic physical activity for a minimum of three days each week.6 Some studies suggest that vigorous or high-intensity exercise is necessary for cardioprotection.7–10 A recent meta-analysis of cohort studies on stroke suggest that both vigorous and moderate exercise confer significant protection against subsequent risk of stroke, although the reductions in risk are modest [RR 0.75 (95% CI 0.69, 0.82) for vigorous, and RR 0.83 (95% CI 0.76, 0.89) for moderate intensity exercise].11

The majority of cohort studies exclude subjects with evidence of CVD at baseline and therefore few studies have been reported which compare risk prediction in those with and without CVD at recruitment. One study, in British civil servants, suggested that subjects with asymptomatic evidence of coronary heart disease (CHD) [based on the electrocardiogram (ECG) at baseline] had an increased risk of a coronary event if moderately or vigorously active.12 In the present report, we examine the risk of subsequent cardiovascular events in middle-aged British men, with and without epidemiological evidence of CVD at recruitment, according to their level of habitual physical activity.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Funding
 Acknowledgements
 References
 
Study design
The Caerphilly Collaborative Heart Disease Study began in 1979 and, during the initial recruitment phase (1979–1983), 2512 men aged 45–59 years were examined, representing 90% of the population of men in this age group from the town of Caerphilly and its surrounding villages (total population 40 000).13 Since then the men have been examined at 5-year intervals. At the first re-examination between 1984 and 1988, when the men were 49–64 years of age, men of the same age who had moved into the defined geographical area were also deemed to be eligible for the study. A total of 2398 men were recruited into the reconstructed cohort between 1984 and 1988. All men gave informed consent to participate in the study, which received ethical approval from the South Glamorgan Ethics Committee.

At the baseline survey for the reconstructed cohort men were invited to attend an afternoon or evening clinic. A detailed questionnaire derived from the Minnesota leisure time physical activity (LTPA) measurement14 was used to estimate energy expenditure in leisure time in kilocalories per day from a record of leisure activity during the preceding 12 months. A trained interviewer asked subjects about the type, frequency, and duration of their leisure activities. Light intensity activity was defined by summing those activities having intensity codes of 2.0, 2.5, 3.0, 3.5, and 4.0 (for example, walking, bowling, and sailing); moderate intensity activity was obtained by summing activities with intensity codes of 4.5, 5.0, and 5.5 (for example, golfing, digging, and dancing); and heavy intensity activity was defined by summing all activities having intensity codes ≥ 6.0 (for example, climbing stairs, swimming, tennis, and jogging). Four intensity scores characterized each subject, one for each class of intensity and one for their sum. Because the intensity code for each specific activity was based predominantly on the experience of middle-aged American men, some minor modifications were made to adapt for the leisure activity of British men in this study. The intensity codes represent metabolic equivalent tasks (METs) and were used to weigh each deviation of a particular intensity of activity. An intensity code of one is equivalent to an energy expenditure of 1 kcal/kg of body weight per hour. Total energy expenditure was derived from the summed total of individual activities.

The Health Insurance Plan (HIP) questionnaire,15 slightly modified, was used to assess physical activity at work, or previous work if unemployed or retired, by self-administration. A score from 1 (low) to 20 (high) was assigned to each subject. Job physical activity level was divided into four equally sized groups graded from low to high occupational physical activity. Individuals failing to answer one or more components of the job physical activity questionnaire were not classified (25 subjects, 1% of study sample).

A detailed medical and lifestyle history were obtained, and London School of Hygiene and Tropical Medicine (LSHTM) chest pain questionnaire16 was administered. A full 12-lead ECG was recorded, and height, weight, and blood pressure were measured.

Subjects with epidemiological evidence of CHD or stroke at recruitment included the following categories: (1) subjects with a clinical history of myocardial infarction (MI); (2) subjects with evidence of exertional angina from the LSHTM chest pain questionnaire; (3) subjects with ECG evidence of ischaemia as defined elsewhere from selected Minnesota codes16 (major and minor Q waves, ST and T wave changes, and left bundle-branch block); (4) subjects with a history of stroke. Subjects were classified as symptomatic if there had been a clinical history of MI, exertional angina, or a history of stroke, and asymptomatic if there was ECG evidence of ischaemia, but no clinical history of MI or exertional angina.

Outcome variables
The core outcome measures in this study were CHD (fatal and non-fatal), stroke (fatal and non-fatal), or both CHD and stroke. Fatal events: all men were flagged with the National Health Service Central Registry and we used death certificates coded to the ninth revision of the International Classification of Diseases (ICD-9 codes 410–414 for CHD; ICD-9 codes 430–438 for stroke) as our definition of fatal CHD or stroke. Non-fatal events: The LSHTM chest pain questionnaire16 was extended to include questions about hospitalization for severe chest pain. This, together with Hospital Activity Analysis notification of admissions coded to ICD-9 codes 410–414 for CHD, and ICD-9 codes 430–438 for stroke were used as the basis for a detailed search of hospital notes. Patient records were searched for events which met the standard World Health Organization criteria for definite acute MI17 (serial ECG changes, chest pain, or enzyme elevation) and were also used to obtain clinical validation of non-fatal stroke events, as described elsewhere.13 In this paper, we have used the term ‘incident event’ to describe cardiovascular events during the follow-up period. While this is equivalent to a first clinical event in subjects without evidence of CHD or prior stroke at baseline or in subjects with asymptomatic CHD, in subjects with symptomatic history of CHD or prior stroke incident events may be either the first clinical or recurrent events.

Statistical methods
Total, light, moderate, and heavy leisure activity showed positive skew in their distributions and so were summarized using median and inter-quartile range and compared between groups using the non-parametric Kruskal–Wallis test. For subsequent analysis, these variables were each divided by tertiles into equal-sized thirds. Other group characteristics were compared using one-way analysis of variance, the Kruskal–Wallis test or the chi-squared test, as appropriate. The analysis of endpoints was performed using survival analysis techniques with time to occurrence of MI, stroke, or the first of either event as the dependent variable. Follow-up ended on 31 December 2000 at which time follow-up on any patient not having an event was censored. Follow-up for MI ceased if a subject had a stroke and vice versa. Initially, rates were calculated by dividing number of events by person-years. Kaplan–Meier plots were also used to illustrate cumulative event rates by subgroup. The Cox proportional hazards model using time to first event was then fitted to the data assuming that each step up the three-point activity scale was associated with the same increase in the logarithm of the hazard rate, and resulting tests for linear trend over increasing thirds of activity are reported. Results are presented as the hazard ratio in each third of leisure time activity relative to the lowest third. Other patient characteristics were included in the Cox model as covariates. Tests for departure from linear trend and for failure of the hazard proportionality assumption were also performed. All statistical analysis was conducted using SPSS version 14 (SPSS Inc., Chicago, IL, USA) and Stata release 8 (StataCorp., College Station, TX, USA).


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Funding
 Acknowledgements
 References
 
A total of 2398 subjects aged 49–64 years were recruited into the cohort between 1984 and 1988. Of the total cohort at the baseline examination, 736 men were considered to have evidence of CHD as defined in the methods section, 39 men gave a history of having had a stroke, and 25 men had suffered from both CHD and stroke. By an average of 12 years follow-up, 398 (16.6%) subjects had one or more MI, 181 (7.5%) had one or more stroke, and 39 (1.6%) sustained both MI and stroke. All non-fatal cardiovascular events were validated from hospital records and fatal events obtained from death certification, with additional information from post-mortem examination, when available. The majority of non-fatal strokes were ischaemic in nature, but 13 haemorrhagic strokes were included in the totals. Baseline characteristics of the study subjects according to thirds of energy expenditure on total leisure activity are shown in Table 1.


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  		Table 1 Baseline characteristics of study subjects by thirds of total leisure physical activity

 
In this population, the average age was 57 years, 67% men were (or had been) employed in manual occupations (the study population was from a region formerly associated with coal mining and heavy industry), and 44% of men reported that they were smoking at the baseline examination. Lipid and classical risk factor levels were typical of British populations of the 1980s.

Table 2 shows the distribution of energy expenditure on LTPA by the category of CVD at baseline.


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  		Table 2 Distribution and quantity of energy expenditure of physical activity during leisure by activity intensity category in subjects without any evidence of coronary heart disease (CHD) or prior stroke at baseline and in those with and without symptomatic evidence of CHD or prior stroke at baseline (kcal/day)

 
For all four levels of activity intensity (light, moderate, heavy, and total), distributions and energy expenditure were skewed. When median values were considered subjects without evidence of CHD had the highest energy expenditure, and subjects with symptomatic CHD or prior stroke had the lowest energy expenditure. Subjects with ECG evidence of ischaemia at rest, but without symptoms had intermediate levels.

The rates of incident MI, incident stroke, and MI or stroke for subjects divided into thirds of total energy expenditure on leisure time activity are shown in Table 3. For each endpoint, men in the lowest third of energy expenditure had the highest incidence rate across the tertiles. Men in the most active group had the lowest incidence rate for MI and the test for trend obtained from a Cox model including age as a confounder is statistically significant (P = 0.006). Men in the middle group had the lowest incidence rates for stroke and both MI and stroke, but the test for trend was significant only for MI or stroke combined together.


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  		Table 3 Incident MI, incident stroke, and MI or stroke during 12 years of follow-up by total energy expenditure of physical activity

 
The data were next examined by the level of activity intensity (light, moderate, and heavy); Kaplan–Meier plots of time to first event (MI or stroke) for thirds of light, moderate, and heavy intensity activity are shown in Figure 1. Tests for trend in Cox models, which included age as a confounder, demonstrated that only for moderate and heavy intensity exercise were there significant differences in the combined event rate between thirds of the distributions.


Figure 1
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  		Figure 1 Cardiovascular event rate by thirds of light, moderate, and heavy intensity leisure-time activity

 
For thirds of heavy intensity exercise, the rate of the combined MI or stroke event was examined in subgroups of cardiovascular status at baseline (free of CHD or prior stroke, asymptomatic CHD, symptomatic CHD or prior stroke), and the results are shown in Figure 2. The age-adjusted test for trend across thirds of heavy intensity exercise was significant for all but the asymptomatic subgroup. In each subgroup, those in the lowest third of heavy intensity exercise had the highest MI or stroke event rate.


Figure 2
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  		Figure 2 Cardiovascular event rate by thirds of heavy-intensity exercise in subgroups defined by cardiovascular disease status at entry

 
As expected, subjects with symptoms of clinical CVD at baseline showed the highest cardiovascular event rates and those free of CHD or prior stroke at entry the lowest. Asymptomatic individuals showed intermediate rates. In Table 4, we have examined the incidence of the separate cardiovascular endpoints according to ascending thirds of heavy intensity activity in the same subgroups of CVD status at entry.


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  		Table 4 Incident MI, incident stroke, and combined MI or stroke during 12 years of follow-up by third of heavy energy expenditure of physical activity during leisure time in subgroups of pre-existent evidence of CHD or prior stroke at baseline

 
In all three subgroups, there was evidence of a gradient in the incidence of MI according to the amount of heavy intensity activity, but this was not present for stroke.

Previous analyses have not been adjusted for potential confounders other than age, and Table 5 shows the hazard ratios for highest compared with the lowest third of energy expenditure for both heavy and moderate intensity exercise after adjustment for age and other relevant confounders, those unlikely to be themselves modified by physical activity. A reduced risk of MI is evident for heavy intensity exercise in each of the three subgroups defined by cardiovascular status at entry. The results for the stroke endpoint are less consistent and the 95% confidence intervals reflect the smaller number of stroke events.


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  		Table 5 Risk (95% CI) of cardiovascular event by third of energy expenditure on heavy physical activity during leisure activity adjusted for age and relevant risk factorsa

 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Funding
 Acknowledgements
 References
 
The findings of this study suggest that among middle-aged men, total LTPA was associated with a reduction in the risk of incident MI after age adjustment. Moreover, heavy intensity activity is inversely associated with incident MI even after adjustment for potential confounders and stratification for evidence of CHD or prior stroke at baseline. There was evidence of an inverse trend for both asymptomatic CHD and for symptomatic CHD or prior stroke at baseline, although the trend was significant only for incident MI and not for incident stroke. In the present study, therefore, we found no evidence for the suggestion reported elsewhere12 that men with asymptomatic evidence of CHD were at greater risk of subsequent CHD if engaged in habitual vigorous physical activity. However, the data for stroke suggest that further research would be helpful in this area. Clinical experience suggests, however, that non-habitual vigorous activity is commonly a trigger for MI, and the UK public health recommendation, for middle-aged men and women therefore advises that increases in levels of intensity of exercise (from moderate to vigorous) should be undertaken gradually.18 In this study, however, subjects free of CVD at entry performed a larger amount of high-intensity activity than was the case for those with symptoms of CVD, who may have been limited by such symptoms. Those with asymptomatic disease had intermediate levels of vigorous physical activity but may have been restricted by non-cardiovascular morbidity, which we could not examine in this study.

The majority of epidemiological studies on the association of physical activity on subsequent CHD and stroke have been conducted among healthy men and women,7,19,20 and these have characteristically shown an attenuation of the effect following adjustment for potential confounders. In this present report, we have adjusted only for confounders known or suspected to be directly linked with cardiovascular risk independently of physical activity. In contrast, few studies have examined population that include subjects with asymptomatic or established CVD, but such studies have also shown considerable attenuation of the contribution of physical activity following adjustment for potential confounders.12 Standardization of potential confounders would be helpful in future epidemiological studies or systematic reviews.

In the present report, asymptomatic individuals with evidence of CVD may not be under routine medical supervision, but symptomatic individuals are likely to be under routine care at least from a primary-care physician. The findings in this study support the recommendations from Europe21 and from USA,22 and from systematic reviews23 of exercise programmes for patients with established CVD. However, the data may suggest that further research on the risk of stroke in relation to physical activity should be conducted in subjects with established or asymptomatic CVD.


   Funding
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Funding
Acknowledgements
 References
 
We thank the British Heart Foundation and the Medical Research Council for financial support.


   Acknowledgements
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Funding
 Acknowledgements
References
 
We thank Peter Sweetnam, formerly chief statistician to the Medical Research Council Epidemiological Unit for providing the data and generous advice. The Caerphilly database is held at the Department of Social Medicine, the University of Bristol, under the terms of the project grant from the Medical Research Council.

Conflict of interest: none declared.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Funding
 Acknowledgements
 References
 

  1. Berlin JA, Colditz GA. A meta-analysis of physical activity in the prevention of CHD. Am J Epidemiol (1990) 132:612–628.[Abstract/Free Full Text]
  2. Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C. Physical activity and public health. A recommendation from the Centres for Disease Control and Prevention and American College of Sports Medicine. JAMA (1995) 273:402–407.[Abstract/Free Full Text]
  3. Pearson TA, Blair SN, Daniels SR, Eckel RH, Fair JM, Fortmann SP, Franklin BA, Goldstein LB, Greenland P, Grundy SM, Hong Y, Miller NH, Lauer RM, Ockene IS, Sacco RL, Sallis JF Jr, Smith SC Jr, Stone NH, Taubert KA. AHA guidelines for primary prevention of cardiovascular disease and stroke (2002 update): consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases. Circulation (2002) 106:388–391.[Free Full Text]
  4. Myers J. Exercise and cardiovascular health. Circulation (2003) 107:2–5.[Free Full Text]
  5. Tanasescu M, Leitzmann MF, Rimm EB, Willett WC, Stampfer MJ, Hu FB. Exercise type and intensity in relation to coronary heart disease in men. JAMA (2002) 288:1994–2000.[Abstract/Free Full Text]
  6. Haskell WL, Lee I-M, Pate RR, Powell KE, Blair SN, Franklin BA, Macera CA, Heath GW, Thompson PD, Bauman A. Physical activity and public health. Updated Recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation (2007) 116:000–000.
  7. Folsom AR, Arnett D K, Hutchinson R G, Liao F, Clegg LX, Cooper LS. Physical activity and incidence of coronary heart disease in middle-aged women and men. Med Sci Sports Exerc (1997) 29:901–909.
  8. Morris JN, Clayton DG, Everitt MG, Semmence AM, Burgess EH. Exercise in leisure time: coronary attack and death rates. Br Heart J (1990) 63:325–334.[Abstract/Free Full Text]
  9. Sasso MD, Pattenbarger RS, Lee I-M. Physical activity and coronary heart disease in men: the Harvard alumni health study. Circulation (2000) 102:975–980.[Abstract/Free Full Text]
  10. Yu S, Yarnell JWG, Sweetnam PM, Murray L. What level of physical activity protects against premature cardiovascular death? The Caerphilly study. Heart (2003) 89:502–506.[Abstract/Free Full Text]
  11. Lee C-D, Folsom AR, Blair SN. Physical activity and stroke risk: a meta-analysis. Stroke (2003) 34:2475–2482.[Abstract/Free Full Text]
  12. Batty GD, Shipley MJ, Marmot M, Davey Smith G. Leisure time physical activity and coronary heart disease mortality in men symptomatic or asymptomatic for ischaemia: evidence from the Whitehall study. J Publ Health Med (2003) 25:190–196.[Abstract/Free Full Text]
  13. Baker IA, Pickering J, Elwood PC, Bayer A, Ebrahim S. Fibrinogen, viscosity and white blood cell count predict myocardial, but not cerebral infarction: evidence from the Caerphilly and Speedwell cohort. Thromb Haemost (2002) 87:421–425.[Web of Science][Medline]
  14. Taylor HL, Jacobs DR Jr, Schucker B, Knudsen J, Leon AS, DeBacker G. A questionnaire for the assessment of leisure time physical activities. J Chronic Dis (1978) 31:741–755.[CrossRef][Web of Science][Medline]
  15. Shapiro S, Weinblatt E, Frank CW, Sager RV. The H.I.P. study of incidence and prognosis of coronary heart disease. Preliminary findings on incidence of myocardial infarction and angina. J Chronic Dis (1965) 18:527–558.[CrossRef][Web of Science][Medline]
  16. Rose GA, Blackburn H, Gillum RF, Prineas RJ. Cardiovascular Survey Methods (1982) 2nd ed. Geneva: World Health Organization.
  17. Luepker RV, Evans A, McKeigue P, Reddy S. Cardiovascular Survey Methods (2004) 3rd ed. Geneva: World Health Organization. 114.
  18. Department of Health, Physical Activity, Health Improvement and Prevention. Evidence of the impact of physical activity and its relationship to heal. A report from the Chief Medical Officer. (2004) London: Department of Health. 29.
  19. Haapanen N, Miilunpalo S, Vuori I, Oja P, Pasanen M. A Association of leisure time physical activity with the risk of coronary heart disease, hypertension and diabetes in middle-aged men and women. Int J Epidemiol (1997) 26:739–747.[Abstract/Free Full Text]
  20. Schnohr P, Lange P, Scharling H, Jensen JS. Long-term physical activity in leisure time and mortality from coronary heart disease, stroke, respiratory diseases, and cancer. The Copenhagen City Heart Study. Eur J Cardiovasc Prev Rehabil (2006) 13:173–179.[CrossRef][Web of Science][Medline]
  21. Börjesson M, Assanelli D, Carré F, Dugmore D, Panhuyzen-Goedkoop NM. ESC Study Group of Sports Cardiology: recommendations for participation in leisure-time physical activity and competitive sports for patients with ischaemic heart disease. Eur J Cardiovasc Prev Rehabil (2006) 13:137–149.[CrossRef][Web of Science][Medline]
  22. Leon AS, Franklin BA, Costa F, Balady GJ, Berra KA, Stewart KJ, Thompson PD, Williams MA, Lauer MS. Cardiac Rehabilitation and Secondary Prevention of Coronary Heart Disease. An American Heart Association Scientific Statement from the Council on Clinical Cardiology (subcommittee on Exercise, Cardiac Rehabilitation and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (subcommittee on Physical Activity), in Collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation (2005) 111:369–376.[Abstract/Free Full Text]
  23. Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, Skidmore B, Stone JA, Thompson DR, Oldridge N. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med (2004) 116:682–692.[CrossRef][Web of Science][Medline]

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