Hypertension Guidelines: Are We Overtreating Older Adults?
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Abstract
This paper evaluates contemporary hypertension treatment guidelines and their clinical application in older adults, with particular attention to the possibility that current practices may contribute to overtreatment in this population. Hypertension is highly prevalent among adults aged 65 and older, and blood pressure control plays a central role in reducing the risk of myocardial infarction, stroke, heart failure, and other cardiovascular complications. However, the application of uniform blood pressure targets across diverse older adult populations raises important questions about safety, appropriateness, and individualized care.
Through a review of recent clinical trials, large-scale observational studies, and major guideline updates, this paper examines the complex balance between cardiovascular risk reduction and the potential harms associated with intensive blood pressure lowering. Evidence from landmark trials demonstrates that lower blood pressure targets can reduce cardiovascular events in carefully selected older adults who are relatively robust and able to tolerate intensive therapy. Yet these benefits are not universal. Older adults frequently present with multimorbidity, polypharmacy, frailty, cognitive impairment, and varying degrees of functional independence. These factors meaningfully influence the risk-benefit ratio of antihypertensive treatment and can increase susceptibility to adverse outcomes such as orthostatic hypotension, syncope, acute kidney injury, electrolyte disturbances, and falls.
The literature increasingly supports an individualized approach to hypertension management in adults aged 65 and older. Clinical decisions should consider physiologic reserve, frailty status, comorbid conditions, medication burden, and estimated life expectancy. Patient preferences, goals of care, and quality-of-life considerations are also essential components of treatment planning. Rather than applying stringent blood pressure targets universally, clinicians may achieve better outcomes by tailoring therapy to the needs and capacities of each patient, with close monitoring for adverse effects and periodic reassessment of treatment goals.
This review synthesizes current evidence to support practical, patient-centered decision-making in the management of hypertension among older adults. It highlights the importance of moving beyond a one-size-fits-all framework and adopting a more nuanced, individualized approach that balances cardiovascular protection with safety and overall well-being.
Introduction
Hypertension affects nearly 80 percent of adults aged 65 years and older in the United States, making it one of the most prevalent chronic conditions in aging populations. Its management plays a critical role in the prevention of cardiovascular morbidity and mortality, as elevated blood pressure remains a major modifiable risk factor for stroke, myocardial infarction, heart failure, and chronic kidney disease. However, treating hypertension in older adults involves complexities that differ significantly from management strategies used in younger individuals. Age-related physiological changes, multimorbidity, frailty, and polypharmacy all influence both the risks and benefits of antihypertensive therapy in this demographic.
Over the past several decades, clinical guidelines have increasingly endorsed lower blood pressure targets. A major shift occurred in 2017 when the American College of Cardiology and American Heart Association redefined the threshold for hypertension from 140 over 90 mmHg to 130 over 80 mmHg. This change affected millions of older adults and encouraged a trend toward more intensive blood pressure management. While lower targets may benefit certain high-risk individuals, growing evidence suggests that applying these thresholds uniformly across all older adults may not be appropriate. Older adults exhibit substantial heterogeneity in health status, functional capacity, and life expectancy, and these factors strongly influence the potential advantages and harms of treatment.
The concept of overtreatment has therefore become increasingly relevant. Overtreatment refers to medical interventions that offer minimal clinical benefit while posing unnecessary or avoidable risks. In the context of hypertension, overtreatment may involve excessive blood pressure reduction that leads to adverse events such as orthostatic hypotension, falls, acute kidney injury, syncope, electrolyte disturbances, or worsening frailty. These risks are especially concerning in older adults who already face higher vulnerability due to age-related declines in autonomic regulation, reduced renal reserve, and the presence of multiple interacting medications.
This paper evaluates whether current hypertension guidelines sufficiently account for the clinical diversity of older adults and explores whether more individualized approaches to treatment are warranted. The discussion reviews evidence on cardiovascular outcomes, functional status, frailty assessment, and real-world risks associated with aggressive blood pressure lowering. It also examines the potential benefits of tailoring treatment goals based on biological rather than chronological age, incorporating geriatric principles such as shared decision-making, deprescribing considerations, and prioritization of quality-of-life outcomes.
Ultimately, the goal is to determine whether existing hypertension management strategies strike an appropriate balance between preventing cardiovascular events and avoiding harm in older adults. By analyzing emerging data and identifying gaps in present guidelines, this review aims to support clinicians in optimizing care for a population characterized by significant physiological complexity and diverse health needs.
Historical Perspective on Hypertension Treatment in Older Adults
The treatment of hypertension in older adults has evolved considerably over the past several decades. Early studies in the 1980s and 1990s, including the Systolic Hypertension in the Elderly Program (SHEP) and the Hypertension in the Very Elderly Trial (HYVET), established that treating hypertension in older adults reduces cardiovascular events and mortality. These landmark trials used relatively modest blood pressure targets, typically aiming for systolic pressures below 150 mmHg.
The SHEP trial, published in 1991, demonstrated that treating isolated systolic hypertension in adults over 60 reduced stroke risk by 36% and coronary events by 27%. Importantly, this trial used a systolic blood pressure target of less than 160 mmHg or a 20 mmHg reduction from baseline. The HYVET trial, focusing on adults over 80, showed benefits with targets below 150/80 mmHg.
However, the publication of the Systolic Blood Pressure Intervention Trial (SPRINT) in 2015 marked a turning point in hypertension management philosophy. SPRINT demonstrated that targeting systolic blood pressure below 120 mmHg reduced cardiovascular events by 25% and death by 27% compared to targeting below 140 mmHg in adults aged 50 and older. Notably, benefits were observed in participants over 75 years of age, leading to enthusiasm for more aggressive targets in older adults.
Following SPRINT, the 2017 ACC/AHA guidelines recommended blood pressure targets below 130/80 mmHg for most adults, including older adults, representing a substantial shift from previous recommendations. This change effectively reclassified millions of older adults as having hypertension requiring treatment.
Current Evidence on Blood Pressure Targets in Older Adults 
The SPRINT Trial and Its Implications
The SPRINT trial enrolled 9,361 adults aged 50 and older with systolic blood pressure between 130-180 mmHg and increased cardiovascular risk. The study excluded individuals with diabetes, prior stroke, or heart failure, limiting its generalizability to the broader older adult population. Among participants aged 75 and older, intensive treatment (systolic BP < 120 mmHg) reduced the primary composite outcome by 34% compared to standard treatment (systolic BP < 140 mmHg).
However, intensive treatment also increased rates of hypotension, syncope, electrolyte abnormalities, and acute kidney injury. In the subset of participants over 75, intensive treatment increased serious adverse events by 24%. These findings highlight the importance of considering both benefits and risks when applying SPRINT results to clinical practice.
Post-SPRINT Evidence and Real-World Studies
Several studies have examined the real-world implementation of intensive blood pressure targets following SPRINT. A large observational study using Veterans Affairs data found that among adults over 65, achieving systolic blood pressure below 120 mmHg was associated with increased emergency department visits and hospitalizations for hypotension, falls, and syncope compared to maintaining pressures between 120-139 mmHg.
The RESPECT-EPA trial, conducted in Japan, randomized adults over 65 to strict (< 120 mmHg) versus standard (< 140 mmHg) systolic blood pressure targets. While the strict target reduced cardiovascular events, it also increased treatment-related adverse events, including hypotension and kidney dysfunction. Importantly, the benefits of strict control were primarily observed in younger-old adults (65-74 years) rather than those over 75.
Observational Evidence on Blood Pressure and Outcomes
Large observational studies have provided additional insights into optimal blood pressure levels in older adults. A meta-analysis of individual patient data from over 1 million adults found that while lower blood pressure was generally associated with reduced cardiovascular risk across all age groups, the relative benefits diminished with advancing age.
The relationship between blood pressure and mortality in older adults appears to follow a J-shaped curve, where very low blood pressure levels are associated with increased mortality. This phenomenon may reflect reverse causation, where underlying illness leads to both low blood pressure and increased mortality risk. However, it also raises concerns about potential harms from excessive blood pressure lowering in vulnerable older adults.
Physiological Considerations in Older Adults
Age-Related Cardiovascular Changes
Normal aging is associated with several cardiovascular changes that affect blood pressure regulation and treatment response. Arterial stiffening leads to increased systolic blood pressure and pulse pressure, making older adults more susceptible to systolic hypertension. Reduced baroreceptor sensitivity impairs the ability to maintain blood pressure during position changes, increasing fall risk with aggressive blood pressure lowering.
Age-related changes in kidney function affect both blood pressure regulation and medication clearance. Declining glomerular filtration rate may increase sensitivity to blood pressure medications, particularly ACE inhibitors and diuretics. These physiological changes suggest that older adults may require different treatment approaches than younger individuals.
Frailty and Heterogeneity in Older Adults
Older adults represent a heterogeneous population with varying degrees of fitness, frailty, and life expectancy. Frail older adults may experience greater harm than benefit from intensive blood pressure lowering due to increased risk of falls, medication side effects, and limited life expectancy to realize cardiovascular benefits.
The concept of frailty encompasses multiple domains including physical weakness, cognitive impairment, and multiple comorbidities. Frail older adults were largely excluded from major hypertension trials, limiting evidence for treatment benefits in this population. Observational studies suggest that very frail older adults may have better survival with higher blood pressure levels, possibly reflecting the need to maintain perfusion pressure in the setting of decreased cardiovascular reserve.
Guidelines and Recommendations
Current Guideline Recommendations
The 2017 ACC/AHA guidelines recommend a blood pressure target of less than 130/80 mmHg for older adults, similar to younger adults. However, the guidelines acknowledge that treatment decisions should consider individual factors including life expectancy, comorbidities, and patient preferences. The guidelines suggest that older adults with limited life expectancy or multiple comorbidities may be appropriate for less stringent targets.
The European Society of Cardiology and European Society of Hypertension 2018 guidelines take a more conservative approach, recommending initial targets below 140/90 mmHg for adults over 65, with consideration of targets below 130/80 mmHg if tolerated. For adults over 80, the guidelines recommend targets between 130-139 mmHg systolic.
International Perspectives
Different international guidelines vary in their recommendations for older adults. The Canadian Hypertension Education Program recommends targets below 140/90 mmHg for most older adults, with consideration of lower targets in selected individuals. The Japanese Society of Hypertension guidelines recommend targets below 140/90 mmHg for adults over 65, with stricter targets for those with additional cardiovascular risk factors.
These variations in international recommendations reflect ongoing uncertainty about optimal blood pressure targets in older adults and the need to balance benefits and risks in this heterogeneous population.
Potential Harms of Overtreatment
Falls and Injury Risk
One of the most concerning potential harms of aggressive blood pressure treatment in older adults is increased fall risk. Falls are a leading cause of injury and death in older adults, and medications that lower blood pressure can increase fall risk through several mechanisms including orthostatic hypotension, dizziness, and sedation.
Several studies have examined the relationship between blood pressure medications and fall risk in older adults. A systematic review found that initiation of antihypertensive medications increased fall risk by approximately 30% in the first 15 days of treatment, with risks remaining elevated for several weeks. The risk was highest with loop diuretics and vasodilators.
Cognitive Effects
The relationship between blood pressure and cognitive function in older adults is complex. While hypertension is a risk factor for dementia and cognitive decline, excessive blood pressure lowering may also impair cognitive function through reduced cerebral perfusion. Several studies have reported associations between very low blood pressure and increased risk of cognitive impairment in older adults.
The SPRINT-MIND ancillary study found that intensive blood pressure treatment reduced the risk of mild cognitive impairment but did not reduce the risk of probable dementia. However, other studies have suggested that rapid or excessive blood pressure lowering may increase dementia risk, particularly in very old adults.
Medication Side Effects and Polypharmacy
Older adults are at increased risk for medication side effects due to age-related changes in drug metabolism, multiple comorbidities, and polypharmacy. Achieving intensive blood pressure targets often requires multiple medications, increasing the risk of drug interactions and adverse effects.
Common side effects of blood pressure medications in older adults include electrolyte abnormalities, kidney dysfunction, and sexual dysfunction. These side effects can impact quality of life and may lead to medication non-adherence. The burden of multiple medications can also increase healthcare costs and complexity of care.
Quality of Life Considerations
The impact of intensive blood pressure treatment on quality of life is an important but often overlooked consideration. Achieving very low blood pressure targets may require frequent medication adjustments, regular monitoring, and lifestyle modifications that can be burdensome for older adults.
Some older adults may prefer to accept higher cardiovascular risk in exchange for fewer medications and less intensive monitoring. These preferences should be incorporated into treatment decisions, particularly for adults with limited life expectancy or significant comorbidities.
Risk Stratification and Individualized Treatment
Identifying High-Risk vs. Low-Risk Older Adults
Not all older adults have the same risk-benefit profile for intensive blood pressure treatment. Several factors can help identify older adults most likely to benefit from more aggressive treatment:
Higher cardiovascular risk older adults who may benefit from intensive treatment include those with established cardiovascular disease, diabetes, chronic kidney disease, or multiple cardiovascular risk factors. These individuals have higher absolute risk for cardiovascular events and therefore greater potential for benefit from risk reduction interventions.
Lower cardiovascular risk older adults who may be at risk for overtreatment include those with limited life expectancy, significant frailty, multiple falls, cognitive impairment, or minimal cardiovascular risk factors. These individuals may experience harm from intensive treatment without proportional benefit.
Assessment Tools and Risk Calculators
Several tools have been developed to help clinicians assess cardiovascular risk and life expectancy in older adults. The ACC/AHA Pooled Cohort Equations estimate 10-year cardiovascular risk based on traditional risk factors. However, these calculators were developed primarily in younger populations and may not accurately predict risk in older adults.
Frailty assessment tools can help identify older adults at higher risk for treatment-related adverse events. The Clinical Frailty Scale is a validated tool that assesses frailty across multiple domains and can be completed during routine clinical encounters. Older adults with moderate to severe frailty may be candidates for less intensive blood pressure targets.
Life expectancy calculators can help identify older adults who may not live long enough to benefit from intensive cardiovascular risk reduction. Adults with life expectancy less than 5 years may be appropriate candidates for less aggressive blood pressure targets focused on symptom management rather than long-term risk reduction.
Personalized Treatment Approaches
Based on individual risk assessment, older adults can be categorized into different treatment approaches:
Fit older adults with high cardiovascular risk and good life expectancy may be appropriate for intensive blood pressure targets similar to younger adults, with careful monitoring for adverse effects.
Older adults with intermediate risk or frailty may benefit from moderate blood pressure targets (130-140 mmHg systolic) with emphasis on avoiding treatment-related adverse events.
Frail older adults with limited life expectancy may be appropriate for conservative blood pressure targets (140-150 mmHg systolic) focused on symptom management and avoiding treatment burden.
Alternative Approaches to Hypertension Management
Lifestyle Interventions
Lifestyle interventions remain important components of hypertension management in older adults and may be particularly appropriate for those at risk for medication-related adverse events. The DASH diet has been shown to reduce blood pressure in older adults and may be as effective as single-drug therapy for mild hypertension.
Regular physical activity can reduce blood pressure and improve overall health in older adults. However, exercise recommendations should be tailored to individual functional capacity and comorbidities. Resistance training may be particularly beneficial for older adults as it can improve both blood pressure and physical function.
Weight management can be challenging in older adults due to age-related changes in metabolism and physical activity. However, even modest weight loss can provide blood pressure benefits. Care must be taken to avoid excessive weight loss that could lead to frailty or malnutrition.
Device-Based Therapies
Several device-based therapies have been developed for hypertension management and may be appropriate for selected older adults. Renal denervation involves ablation of renal sympathetic nerves and has shown modest blood pressure lowering effects in clinical trials. This approach might be considered for older adults with resistant hypertension who cannot tolerate multiple medications.
Baroreflex activation therapy involves implantation of a device that stimulates carotid baroreceptors, leading to blood pressure reduction. While invasive, this approach might be appropriate for selected older adults with severe hypertension and multiple medication intolerances.
Medication Selection Considerations
When medications are needed, drug selection should consider age-related factors and comorbidities. ACE inhibitors and angiotensin receptor blockers are generally well-tolerated in older adults and provide cardiovascular protection beyond blood pressure lowering. However, these medications can cause hyperkalemia and kidney dysfunction, particularly in older adults with baseline kidney impairment.
Calcium channel blockers are effective blood pressure lowering agents in older adults but can cause ankle swelling and constipation. Diuretics are effective and inexpensive but can cause electrolyte abnormalities and may increase fall risk through volume depletion.
Clinical Applications and Practice Recommendations
Assessment and Monitoring
Clinical assessment of older adults with hypertension should include evaluation of cardiovascular risk, frailty, cognitive function, and life expectancy. Blood pressure measurement should follow standardized protocols, including assessment for orthostatic hypotension.
Regular monitoring should include assessment of treatment response, medication tolerance, and adverse effects. Home blood pressure monitoring can provide valuable information about blood pressure control and may help identify white coat hypertension or masked hypertension.
Laboratory monitoring should include assessment of kidney function and electrolytes, particularly in older adults receiving ACE inhibitors, ARBs, or diuretics. More frequent monitoring may be needed during medication initiation or dose adjustments.
Shared Decision-Making
Treatment decisions should involve shared decision-making that incorporates patient preferences, values, and goals of care. Older adults should be informed about potential benefits and risks of different blood pressure targets and medication regimens.
For older adults with limited life expectancy or significant comorbidities, treatment goals may focus on symptom management and quality of life rather than long-term cardiovascular risk reduction. These discussions should be documented and revisited regularly as health status changes.
Transitional Care Considerations
Transitions of care, such as hospital discharge or nursing home placement, represent high-risk periods for medication errors and adverse events. Blood pressure medications should be carefully reviewed during transitions, with consideration of whether intensive targets remain appropriate given changes in health status.
Medication reconciliation should include assessment of blood pressure control, medication adherence, and adverse effects. Temporary liberalization of blood pressure targets may be appropriate during acute illness or major health transitions.
Challenges and Limitations
Evidence Gaps
Despite decades of research on hypertension in older adults, important evidence gaps remain. Most clinical trials have excluded very old adults (over 85), adults with multiple comorbidities, and frail adults. This limits the generalizability of trial results to real-world older adult populations.
Long-term follow-up data on intensive blood pressure treatment in older adults are limited. Most trials have followed participants for 3-5 years, which may not capture all potential benefits and harms of long-term intensive treatment.
The optimal blood pressure targets for specific subgroups of older adults, such as those with dementia, diabetes, or chronic kidney disease, remain unclear. More research is needed to develop evidence-based recommendations for these populations.
Implementation Challenges
Implementing individualized blood pressure management in clinical practice can be challenging due to time constraints, competing priorities, and limited resources. Many healthcare systems are organized around standardized protocols and quality measures that may not accommodate individualized approaches.
Electronic health records and clinical decision support tools could help facilitate individualized care but require intensive investment and customization. Quality measures for hypertension management may need to be revised to account for appropriate variation in treatment approaches for different older adult populations.
Healthcare System Factors
Healthcare payment systems often reward achieving standardized targets rather than individualized care. This can create incentives for overtreatment of older adults to meet quality metrics. Payment reform may be needed to support more nuanced approaches to hypertension management in older adults.
Care coordination becomes increasingly important as treatment approaches become more individualized. Primary care providers, specialists, pharmacists, and other healthcare team members need to communicate effectively about treatment goals and monitoring plans.
Future Directions and Research Needs
Clinical Trial Design
Future clinical trials in older adults should use more inclusive eligibility criteria that better represent real-world older adult populations. Trials should specifically enroll frail older adults and those with multiple comorbidities to generate evidence for these high-risk populations.
Pragmatic trial designs that compare different blood pressure targets in routine clinical settings may provide more generalizable results than highly controlled efficacy trials. These trials should include patient-reported outcomes and quality of life measures in addition to traditional cardiovascular endpoints.
Adaptive trial designs that allow for modification of treatment targets based on individual response and risk factors may be particularly appropriate for heterogeneous older adult populations.
Biomarker Development
Research into biomarkers that can predict individual response to blood pressure treatment could help guide personalized treatment approaches. Potential biomarkers include measures of vascular stiffness, cardiac function, kidney function, and frailty.
Genetic markers associated with blood pressure response and medication metabolism may help identify older adults at higher risk for adverse effects or treatment resistance.
Technology Integration
Digital health technologies, including remote monitoring devices and smartphone applications, could facilitate more personalized and responsive hypertension management in older adults. These tools could enable real-time adjustment of treatment based on blood pressure patterns and symptoms.
Artificial intelligence and machine learning approaches could help analyze complex patient data to identify optimal treatment approaches for individual older adults. These tools could integrate multiple risk factors, comorbidities, and patient preferences to generate personalized treatment recommendations.
Health Services Research
Research is needed to understand the real-world implementation of individualized hypertension management approaches. Studies should examine the feasibility, acceptability, and effectiveness of different implementation strategies.
Economic analyses should evaluate the cost-effectiveness of different blood pressure targets and treatment approaches in older adults, considering both healthcare costs and quality-adjusted life years.
Conclusion
Key Takeaways
Current hypertension guidelines may not adequately address the heterogeneity of older adults, potentially leading to overtreatment in some populations. While intensive blood pressure treatment can reduce cardiovascular events in selected older adults, universal application of aggressive targets may cause harm in frail or high-risk individuals.
Individualized treatment approaches that consider cardiovascular risk, frailty, life expectancy, and patient preferences are more appropriate than one-size-fits-all targets. Fit older adults with high cardiovascular risk may benefit from intensive treatment, while frail older adults with limited life expectancy may be better served by conservative approaches.
Shared decision-making should be central to hypertension management in older adults, with honest discussions about potential benefits and risks of different treatment approaches. Quality measures and healthcare systems may need to evolve to support more individualized care.
Healthcare providers should regularly reassess treatment goals and appropriateness as older adults’ health status and preferences change over time. The goal should be to optimize both cardiovascular health and overall well-being rather than simply achieving numerical targets.
Additional research is needed to develop evidence-based approaches for managing hypertension in very old adults, frail individuals, and those with multiple comorbidities. Future guidelines should provide more specific recommendations for different subgroups of older adults rather than applying uniform targets across all individuals over 65.
The question of whether we are overtreating older adults with hypertension cannot be answered with a simple yes or no. Instead, it requires careful consideration of individual patient factors and a commitment to personalized care that balances benefits and risks for each person.
Frequently Asked Questions:
What blood pressure target should be used for adults over 80?
For adults over 80, blood pressure targets should be individualized based on frailty, comorbidities, and life expectancy. Generally fit adults over 80 may benefit from targets similar to younger adults (< 130/80 mmHg), while frail adults may be appropriate for more conservative targets (130-150 mmHg systolic). The key is avoiding both undertreating high-risk individuals and overtreating those likely to experience harm.
How can clinicians assess whether an older adult is at risk for overtreatment?
Risk factors for overtreatment include frailty, history of falls, cognitive impairment, multiple comorbidities, limited life expectancy (< 5 years), orthostatic hypotension, and medication intolerance. Clinical assessment tools such as the Clinical Frailty Scale and life expectancy calculators can help identify high-risk individuals.
What are the most concerning side effects of intensive blood pressure treatment in older adults?
The most concerning side effects include falls and injury related to hypotension, cognitive impairment from reduced cerebral perfusion, electrolyte abnormalities, kidney dysfunction, and medication interactions. These risks tend to be higher in frail older adults and those on multiple medications.
Should blood pressure medications be stopped in very frail older adults?
Medication discontinuation should be considered individually based on the balance of benefits and risks. Very frail adults with limited life expectancy and high fall risk may be candidates for medication reduction or discontinuation. However, this decision should involve careful monitoring and shared decision-making with patients and families.
How often should blood pressure targets be reassessed in older adults?
Blood pressure targets should be reassessed regularly, particularly during transitions of care, changes in health status, or development of new comorbidities. At minimum, annual reassessment is appropriate, with more frequent evaluation during periods of clinical instability.
What role do lifestyle interventions play in managing hypertension in older adults?
Lifestyle interventions remain important for older adults and may be particularly appropriate for those at risk for medication-related adverse events. Dietary approaches like the DASH diet, appropriate physical activity, and weight management can provide blood pressure benefits. However, recommendations should be tailored to individual functional capacity and health status.
How do current quality measures affect hypertension treatment in older adults?
Current quality measures often focus on achieving standardized blood pressure targets without considering individual patient factors. This can create incentives for overtreatment in older adults who might be better served by more conservative approaches. Healthcare systems and quality measures may need to evolve to support more individualized care.
What should be done for older adults with resistant hypertension?
Resistant hypertension in older adults requires careful evaluation for secondary causes, medication adherence issues, and appropriate medication selection. Before intensifying treatment, clinicians should assess whether current targets are appropriate given the individual’s overall health status. Alternative approaches such as device-based therapies may be considered in selected cases.
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