Cardiac Rehabilitation Programs for Heart Failure Patients

12 Cardiac Rehabilitation Programs for Heart Failure Patients

Table of Contents

Introduction

Cardiac rehabilitation is a special program that helps people with heart problems get better and stay healthy. It’s like having a team of doctors, nurses, and exercise experts working together to make your heart stronger. This program is not just for one type of heart problem – it can help people who have had heart attacks, those with heart failure, and even folks who’ve had heart surgery.

When you join a cardiac rehabilitation program, you get a plan that’s made just for you. This plan has three main parts:

  1. Exercise training: You’ll learn safe ways to move your body and make your heart stronger. The exercises are chosen carefully to match what you can do, and they get harder as you get stronger.

  2. Heart-healthy education: You’ll learn all about how to take care of your heart. This includes things like eating the right foods, understanding your medicines, and knowing the signs of heart problems.

  3. Stress reduction: The program teaches you ways to relax and handle stress better. This is important because stress can be bad for your heart.

For people with heart failure, cardiac rehabilitation is extra important. Heart failure means your heart isn’t pumping blood as well as it should. The program helps these patients in several ways:

  • It teaches them how to manage their symptoms, like feeling short of breath or tired.
  • It helps them do more everyday activities without getting too tired.
  • It shows them how to take care of themselves better, like watching what they eat and drink.
  • It helps them understand their condition and how to follow their doctor’s advice.

By doing all these things, cardiac rehabilitation helps heart failure patients feel better and live a fuller life. It also lowers the chance that they’ll have more heart problems in the future. This program is like a heart school that helps you learn to live your best life with a heart condition.

Understanding Heart Failure

Heart failure is a serious chronic condition that affects millions of people worldwide. It occurs when the heart is unable to pump blood efficiently enough to meet the body’s needs for oxygen and nutrients. This condition can develop gradually over time or appear suddenly, depending on the underlying cause.

There are three main types of heart failure:

  1. Left-sided heart failure: This is the most common type, where the left ventricle of the heart cannot pump blood effectively to the rest of the body.

  2. Right-sided heart failure: In this type, the right ventricle struggles to pump blood to the lungs for oxygenation.

  3. Biventricular heart failure: This occurs when both the left and right ventricles are affected, leading to overall heart dysfunction.

Several factors can contribute to the development of heart failure. Common causes include:

  • Coronary artery disease, which narrows the arteries supplying blood to the heart
  • High blood pressure, which forces the heart to work harder to pump blood
  • Diabetes, which can damage blood vessels and increase the risk of heart problems
  • Heart valve problems, which can disrupt normal blood flow through the heart

People with heart failure may experience a range of symptoms that can vary in severity. Some common signs include:

  • Shortness of breath, especially during physical activity or when lying down
  • Persistent fatigue and weakness
  • Swelling in the legs, ankles, and feet due to fluid buildup
  • Rapid or irregular heartbeat
  • Reduced ability to exercise or perform daily activities
  • Persistent coughing or wheezing, sometimes with white or pink-tinged mucus

Diagnosing heart failure typically involves a combination of methods. Healthcare providers usually start with a thorough physical examination and review of the patient’s medical history. They may listen to the heart and lungs for abnormal sounds and check for swelling in the legs and feet. Additional tests are often necessary to confirm the diagnosis and determine the severity of the condition. These may include:

  • Echocardiograms, which use sound waves to create images of the heart’s structure and function
  • Blood tests to check for specific markers that indicate heart stress or damage
  • Chest X-rays to examine the size and shape of the heart
  • Electrocardiograms (ECGs) to assess the heart’s electrical activity
  • Stress tests to evaluate how the heart performs during physical activity

Understanding heart failure is crucial for patients, caregivers, and healthcare providers alike. With proper diagnosis and management, many people with heart failure can improve their quality of life and reduce the risk of complications.

Benefits of Cardiac Rehabilitation Programs

Cardiac rehabilitation programs offer numerous benefits for heart failure patients. These programs are designed to improve overall health and well-being, helping patients recover and manage their condition more effectively.

Improved Physical Function and Exercise Capacity

Exercise training is a core component of cardiac rehabilitation. Patients participate in various types of exercises tailored to their individual needs and abilities. These exercises may include:

  • Aerobic activities such as walking, cycling, or swimming
  • Resistance training to build muscle strength
  • Flexibility exercises to improve range of motion

Regular exercise helps improve heart function by strengthening the heart muscle and improving its ability to pump blood efficiently. This leads to increased stamina and reduced fatigue, allowing patients to perform daily activities with greater ease. Additionally, physical activity helps manage weight, which is crucial for heart health. It also improves blood flow throughout the body and can help lower blood pressure, further reducing strain on the heart.

Enhanced Quality of Life

Cardiac rehabilitation programs focus on improving overall well-being by addressing both physical and emotional health. These programs help patients feel more energetic and capable of performing daily activities without undue strain. They often include:

  • Stress management techniques like deep breathing and meditation
  • Guidance on healthy lifestyle habits, such as proper sleep and relaxation
  • Social support through group activities and interactions with other patients

By incorporating these elements, cardiac rehabilitation programs help patients regain confidence in their abilities and enjoy a better quality of life despite their heart condition.

Reduced Symptoms and Hospitalizations

One of the most significant benefits of cardiac rehabilitation is the reduction in symptoms and hospitalizations. By improving heart function and reducing the risk of complications, patients often experience:

  • Fewer episodes of shortness of breath
  • Reduced swelling in the legs and ankles
  • Improved energy levels
  • Better sleep quality

These improvements lead to a more stable and manageable condition, reducing the need for emergency hospital visits or prolonged stays. Patients can enjoy more time at home and less time worrying about their health.

Increased Patient Compliance and Self-Care

Education is a key part of cardiac rehabilitation. Patients learn how to manage their condition effectively through various means:

  • Understanding how to monitor symptoms and recognize warning signs
  • Learning the correct way to take medications and why they are important
  • Gaining knowledge about heart-healthy nutrition and meal planning
  • Developing strategies for stress management and emotional well-being

This comprehensive education empowers patients to take an active role in their care. As a result, patients are more likely to follow their treatment plans, take medications as prescribed, and make necessary lifestyle changes. This increased compliance and self-care lead to better overall health outcomes and a reduced risk of future heart problems.

Improved Mental Health and Reduced Depression

Heart failure can have a significant impact on mental health, often leading to anxiety and depression. Cardiac rehabilitation programs address these issues by including:

  • Psychological support and counseling
  • Group therapy sessions
  • Stress reduction techniques
  • Education on the mind-body connection in heart health

By addressing mental health concerns, these programs help patients develop coping strategies and improve their overall emotional well-being. This can lead to a more positive outlook, reduced symptoms of depression, and a better ability to manage stress related to their heart condition.

Enhanced Patient Education and Awareness

Patients in cardiac rehabilitation programs receive extensive education on heart-healthy living. This includes:

  • Information on nutritious diets and how to prepare heart-healthy meals
  • Guidance on reading food labels and making smart food choices
  • Stress management techniques for everyday life
  • The importance of regular exercise and how to incorporate it safely into daily routines
  • Understanding risk factors for heart disease and how to manage them

By gaining a deeper understanding of their condition, patients can make informed decisions about their health and lifestyle. This knowledge empowers them to take control of their heart health and make lasting positive changes that can improve their long-term prognosis.

Components of Cardiac Rehabilitation Programs

Cardiac rehabilitation programs are comprehensive and multifaceted, designed to address various aspects of a patient’s health and well-being. These programs incorporate several key components to ensure holistic care for heart failure patients.

Exercise Training

Exercise training forms the foundation of cardiac rehabilitation. This component includes a variety of physical activities tailored to each patient’s specific needs and abilities. Aerobic exercises, such as walking, cycling, or swimming, help improve cardiovascular health by strengthening the heart and lungs. Resistance training, which may involve using weights or resistance bands, helps build muscle strength and endurance. Flexibility exercises, like stretching or yoga, improve range of motion and reduce stiffness in joints and muscles. All these exercises are carefully planned and supervised by trained professionals to ensure they are safe and effective for each individual patient.

Education on Heart Healthy Lifestyle

Education plays a crucial role in cardiac rehabilitation. Patients receive comprehensive information about maintaining a heart-healthy lifestyle. This includes learning about nutritious diets that are low in saturated fats, cholesterol, and sodium. Patients are taught how to read food labels, plan balanced meals, and make healthier food choices. Stress management techniques, such as deep breathing exercises, meditation, or progressive muscle relaxation, are also covered. The importance of getting enough quality sleep is emphasized, as good sleep habits can significantly impact heart health. Patients also learn how to monitor their vital signs, including blood pressure, blood sugar, and cholesterol levels. They are taught to understand what these numbers mean and how to take action if they fall outside the normal range.

Medication Management and Adherence

Proper medication management is crucial for heart failure patients. Cardiac rehabilitation programs provide detailed education about prescribed medications, including their purposes, proper dosages, and potential side effects. Patients learn strategies to remember to take their medications regularly, such as using pill organizers or setting reminders on their phones. The importance of not skipping doses or stopping medications without consulting a doctor is stressed. Patients are also taught how to recognize and report any adverse reactions to their medications.

Monitoring and Management of Risk Factors

Cardiac rehabilitation programs place a strong emphasis on managing risk factors that can worsen heart failure. Patients learn how to monitor their blood pressure, blood sugar, and cholesterol levels at home. They are taught to recognize warning signs that indicate their condition may be worsening, such as sudden weight gain or increased shortness of breath. The program also covers lifestyle changes that can help manage these risk factors, such as quitting smoking, limiting alcohol intake, and maintaining a healthy weight. Patients learn how these factors impact their heart health and are given practical tools to make positive changes in their daily lives.

Psychological Support and Counseling

The emotional impact of heart failure can be significant, and psychological support is a vital component of cardiac rehabilitation. Patients have access to counseling services to help them cope with stress, anxiety, and depression, which are common among heart failure patients. These sessions may be one-on-one or in group settings, allowing patients to share experiences and support each other. Counselors help patients develop coping strategies for dealing with the emotional challenges of their condition. They also work on building self-confidence and motivation, which are crucial for maintaining a heart-healthy lifestyle long-term. Family members may also be included in counseling sessions to help them understand and support the patient’s journey.

Phases of Cardiac Rehabilitation

Cardiac rehabilitation is typically divided into three phases, each designed to meet the patient’s evolving needs as they recover from heart failure. These phases are carefully structured to provide the right level of care and support at each stage of recovery.

Phase 1: Inpatient Rehabilitation

Phase 1 begins immediately after hospitalization and focuses on stabilizing the patient’s condition. During this phase, healthcare professionals closely monitor the patient’s heart function and overall health. Patients undergo initial assessments to determine their current physical capabilities and limitations. Medical checkups are frequent to ensure the patient is responding well to treatment. Basic exercises are introduced to improve mobility and strength, which may include gentle stretching and supervised walking. Patients also receive education about their condition and guidance on lifestyle changes they’ll need to make. This phase typically lasts for the duration of the hospital stay, which can range from a few days to a couple of weeks, depending on the patient’s condition.

Phase 2: Outpatient Rehabilitation

Phase 2 starts after discharge from the hospital and is more intensive. This phase usually lasts for several weeks to a few months. Patients attend regular sessions at a rehabilitation center, often three times a week. During these sessions, they engage in supervised exercise training tailored to their specific needs and abilities. The exercises may include walking on a treadmill, cycling, or using light weights to build strength. Patients also receive comprehensive education on heart-healthy living, covering topics such as nutrition, stress management, and medication adherence. Frequent medical checkups are conducted to monitor progress and adjust the rehabilitation plan as needed. This phase aims to help patients regain confidence in their physical abilities and learn how to manage their heart condition effectively.

Phase 3: Maintenance and Long-Term Management

Phase 3 is the long-term maintenance phase where patients continue to exercise regularly and manage their condition independently. This phase can last indefinitely, becoming a part of the patient’s new lifestyle. Patients are encouraged to continue their exercise routines at home or in community settings, such as gyms or fitness centers. They apply the knowledge gained in earlier phases to make heart-healthy choices in their daily lives. While direct supervision is reduced, ongoing support is still available. Patients may have periodic check-ins with their healthcare team to ensure they’re maintaining their progress. Many rehabilitation programs offer support groups or follow-up classes to help patients stay motivated and connected. The goal of this phase is to empower patients to take control of their heart health and prevent future complications.

Creating a Personalized Cardiac Rehabilitation Plan

Creating a personalized cardiac rehabilitation plan is essential for effective care. This process involves several steps that help tailor the program to each patient’s unique needs and goals.

Assessing Individual Needs and Goals

The first step in creating a personalized cardiac rehabilitation plan is to assess the patient’s individual needs and goals. This assessment begins with a thorough medical evaluation conducted by a team of healthcare professionals. They review the patient’s medical history, current health status, and any ongoing treatments. The team also talks with the patient to understand their personal goals for recovery and what they hope to achieve through cardiac rehabilitation. This might include improving their ability to perform daily activities, returning to work, or engaging in specific hobbies or sports.

Setting Realistic and Achievable Objectives

Once the assessment is complete, the next step is to set realistic and achievable objectives. These objectives are carefully tailored to the patient’s current fitness level and medical history. The healthcare team works closely with the patient to create goals that are challenging enough to promote improvement but not so difficult that they become discouraging. For example, a patient might start with a goal of walking for 10 minutes a day and gradually increase the duration and intensity over time. These objectives are regularly reviewed and updated as the patient progresses through their rehabilitation program.

Developing a Tailored Exercise Program

A key component of the personalized cardiac rehabilitation plan is a tailored exercise program. This program is designed to improve cardiovascular health and overall fitness while taking into account the patient’s specific needs and limitations. The exercise plan typically includes a mix of different types of activities:

  • Aerobic exercises: These help strengthen the heart and improve circulation. Examples include walking, cycling, or swimming.
  • Resistance exercises: These help build muscle strength and endurance. They might include light weightlifting or using resistance bands.
  • Flexibility exercises: These improve range of motion and reduce stiffness. Gentle stretching exercises are often included.

The intensity, duration, and frequency of these exercises are carefully planned to ensure safety and effectiveness for each individual patient.

Incorporating Lifestyle Modifications and Education

Lifestyle modifications and education are crucial parts of a personalized cardiac rehabilitation plan. Patients learn how to make heart-healthy choices in their daily lives. This includes:

  • Dietary changes: Patients learn about heart-healthy eating habits, including how to read food labels, plan balanced meals, and choose foods that support cardiovascular health.
  • Stress management techniques: The plan includes strategies to help patients manage stress, such as deep breathing exercises, meditation, or yoga.
  • Regular sleep habits: Patients are educated on the importance of good sleep hygiene and how to establish healthy sleep patterns.
  • Smoking cessation: For patients who smoke, the plan includes support and resources to help them quit.

These lifestyle modifications are tailored to each patient’s specific needs and preferences, making them more likely to be adopted and maintained long-term.

Regular Monitoring and Adjustments to the Plan

Regular monitoring is a vital part of the personalized cardiac rehabilitation plan. The healthcare team closely tracks the patient’s progress through regular check-ups and assessments. These might include:

  • Physical examinations
  • Exercise stress tests
  • Blood pressure and heart rate monitoring
  • Surveys about symptoms and quality of life

Based on these assessments, the plan is adjusted as needed. If a patient is progressing faster than expected, their exercise program might be intensified. If they’re struggling with certain aspects, the plan can be modified to provide additional support or alternative approaches. This ongoing monitoring and adjustment ensure that the rehabilitation plan remains effective and appropriate for the patient’s changing needs throughout their recovery journey.

Overcoming Barriers to Cardiac Rehabilitation

Common Barriers

Cardiac rehabilitation programs offer numerous benefits for heart failure patients, but several obstacles can hinder participation. Cost is a major concern for many individuals, as these programs can be expensive and not all insurance plans provide full coverage. Some patients may have to pay out-of-pocket expenses, which can be a significant financial burden. Accessibility is another common barrier, particularly for those living in rural areas or far from rehabilitation centers. Transportation issues and long travel times can make it challenging for patients to attend regular sessions. Motivation can also be a stumbling block, as some individuals may feel discouraged by their condition or lack the willpower to commit to a rehabilitation program. Fear of exercise, lack of understanding about the benefits, and low self-confidence can contribute to this motivational barrier.

Strategies to Overcome Barriers

Fortunately, there are several strategies to help patients overcome these obstacles and access the care they need. Home-based programs have become increasingly popular, allowing patients to complete rehabilitation exercises in the comfort of their own homes. These programs often use technology like smartphones or tablets to guide patients through exercises and track their progress. Telehealth services have also emerged as a valuable tool, enabling patients to connect with healthcare providers remotely for consultations, education, and monitoring. This approach can significantly reduce travel time and costs associated with in-person visits.

To address financial concerns, some healthcare providers offer sliding scale fees or payment plans to make rehabilitation more affordable. Additionally, community health centers and non-profit organizations may provide low-cost or free cardiac rehabilitation services to eligible patients. Support groups, both in-person and online, can play a crucial role in overcoming motivational barriers. These groups offer a space for patients to share experiences, exchange tips, and provide encouragement to one another.

Importance of Patient Engagement and Motivation

Patient engagement and motivation are key factors in the success of cardiac rehabilitation programs. When patients are actively involved in their care, they are more likely to stick to their rehabilitation plan and achieve better outcomes. Healthcare providers can foster engagement by involving patients in setting realistic goals and creating personalized treatment plans. Regular check-ins and progress tracking can help patients see their improvements over time, boosting their motivation to continue.

Education is another vital component of patient engagement. By helping patients understand the benefits of cardiac rehabilitation and how it can improve their quality of life, healthcare providers can increase motivation and commitment. Involving family members or caregivers in the rehabilitation process can also provide additional support and encouragement for the patient.

Celebrating small victories and milestones throughout the rehabilitation journey can help maintain motivation. This could include recognizing improvements in exercise capacity, reductions in symptoms, or achievements of personal goals. By focusing on these positive outcomes, patients are more likely to stay engaged and committed to their rehabilitation program.

The Role of Healthcare Professionals in Cardiac Rehabilitation

Multidisciplinary Team Approach

A multidisciplinary team approach is essential for effective cardiac rehabilitation. This means that different types of healthcare professionals work together to help heart failure patients get better. The team includes doctors who specialize in heart health, nurses, experts who help with exercise, nutrition specialists, and mental health professionals. Each of these team members has a special job to do in helping patients recover and live healthier lives.

Roles and Responsibilities of Each Healthcare Professional

Cardiologists are heart doctors who lead the medical care for patients. They check how well the heart is working and make sure any medicines are helping. Nurses are like helpers who teach patients about their heart condition and how to take care of themselves at home. They also answer questions and give support when patients feel worried.

Physical therapists are exercise experts who create safe workout plans for patients. They teach patients how to exercise without putting too much stress on their hearts. These experts also show patients how to use exercise equipment and help them feel more confident about being active.

Dietitians are food experts who teach patients about eating heart-healthy foods. They help patients understand which foods are good for their hearts and which ones to avoid. Dietitians also give tips on how to cook healthy meals and make smart choices when eating out.

Mental health providers, like psychologists or counselors, help patients deal with feelings of sadness or worry that can come with having heart problems. They teach patients ways to relax and feel better about their health situation.

Importance of Communication and Collaboration

It’s very important for all these healthcare professionals to talk to each other and work together. They have meetings to share information about how patients are doing. This helps make sure everyone knows what’s happening with each patient’s health. When the team works well together, patients get the best care possible.

The team also talks to the patient and their family often. They explain things in simple ways so everyone understands what’s happening and what needs to be done. This helps patients feel more in control of their health and more likely to follow their treatment plan.

By working together, the healthcare team can spot problems early and make changes to the patient’s care plan if needed. This teamwork helps patients recover faster and learn how to take good care of their hearts for a long time.

Future Directions and Emerging Trends in Cardiac Rehabilitation

Advances in Technology

Cardiac rehabilitation programs are embracing new technologies to improve patient care and outcomes. Telehealth services are becoming more common, allowing patients to participate in rehabilitation sessions from the comfort of their homes. This is especially helpful for those who live far from medical facilities or have difficulty traveling. Video consultations, smartphone apps, and online education tools are making it easier for patients to stay connected with their healthcare team.

Wearable devices, such as fitness trackers and smartwatches, are playing a bigger role in cardiac rehabilitation. These devices can monitor a patient’s heart rate, physical activity, and even detect irregular heart rhythms. The data collected by these devices helps healthcare professionals track a patient’s progress and make adjustments to their treatment plan as needed. Some wearable devices can also send alerts to medical staff if they detect any concerning changes in a patient’s health.

Virtual reality (VR) technology is being explored as a way to make exercise more engaging and enjoyable for cardiac rehabilitation patients. VR programs can simulate outdoor environments or create fun, interactive games that encourage patients to stay active and motivated during their recovery.

Personalized Medicine and Genomics

The field of cardiac rehabilitation is moving towards more personalized treatment approaches. By studying a patient’s genetic makeup, doctors can better understand how they might respond to different medications and lifestyle changes. This information helps healthcare professionals create tailored treatment plans that are more likely to be effective for each individual patient.

Genetic testing can also help identify patients who may be at higher risk for certain heart-related complications. This allows doctors to take preventive measures and closely monitor these patients during their rehabilitation. As our understanding of genetics and heart disease grows, personalized medicine will likely play an even bigger role in cardiac rehabilitation programs.

Expanding Cardiac Rehabilitation to Underserved Populations

Efforts are being made to make cardiac rehabilitation more accessible to people who have traditionally had limited access to these services. This includes developing programs that can be done at home, which is especially helpful for people living in rural areas or those who have transportation difficulties.

Community-based rehabilitation programs are being created to reach underserved populations. These programs often take place in community centers, churches, or other local gathering places, making them more convenient and culturally appropriate for different groups of people.

Mobile cardiac rehabilitation units are another innovative approach to reaching underserved populations. These specially equipped vehicles can travel to different communities, bringing rehabilitation services directly to patients who might otherwise not have access to them.

Technology is also being used to make cardiac rehabilitation more affordable and accessible. Smartphone apps and online platforms can provide education, exercise guidance, and support at a lower cost than traditional in-person programs. These digital tools can be especially helpful for people who can’t afford or don’t have insurance coverage for traditional cardiac rehabilitation services.

Focus on Mental Health

There is a growing recognition of the importance of mental health in cardiac rehabilitation. Many patients experience anxiety, depression, or stress after a heart-related event. Future cardiac rehabilitation programs are likely to include more mental health support, such as counseling services, stress management techniques, and mindfulness training.

Integration of Nutrition and Lifestyle Counseling

Cardiac rehabilitation programs are increasingly focusing on comprehensive lifestyle changes. This includes more emphasis on nutrition education and counseling. Patients may work with dietitians to develop heart-healthy eating plans tailored to their individual needs and preferences. Programs may also include cooking classes or grocery store tours to help patients make practical changes to their diets.

Conclusion

Cardiac rehabilitation programs play a vital role in helping heart failure patients improve their overall health and reduce the chances of future heart problems. These programs offer many benefits that can make a big difference in a patient’s life. For example, they help patients get stronger and move better, which can make daily activities easier. They also help patients feel happier and more positive about their lives. Many patients who take part in these programs find that their heart failure symptoms get better, and they don’t need to go to the hospital as often.

Another great thing about cardiac rehabilitation is that it teaches patients how to take better care of themselves. This includes learning about healthy eating, exercise, and how to take medications correctly. When patients understand their condition better and know how to manage it, they’re more likely to follow their treatment plans and stay healthy.

Cardiac rehabilitation also helps with mental health. Many heart failure patients feel scared or sad about their condition, but these programs can help them feel more confident and less stressed. They often get to meet other patients who are going through similar experiences, which can be very comforting.

It’s important to remember that each patient is different, so cardiac rehabilitation programs should be tailored to fit each person’s needs. This means looking at things like how severe their heart failure is, what other health problems they might have, and what their personal goals are.

Sometimes, patients face challenges that make it hard for them to take part in cardiac rehabilitation. These might include transportation issues, busy schedules, or not understanding how important the program is. Healthcare professionals play a big role in helping patients overcome these obstacles. They can explain the benefits of the program, help patients find ways to fit it into their lives, and provide support throughout the process.

As time goes on and technology gets better, cardiac rehabilitation programs will keep improving. New tools and methods are being developed all the time to make these programs even more effective and easier for patients to use. This means that in the future, heart failure patients will have even better options for getting the care and support they need to live healthier, happier lives.

References

  1. Cardiac Rehabilitation Programs (CAG-00089R) – Decision Memo. CMS.gov.
  2. Cardiac rehabilitation – Mayo Clinic. Mayo Clinic.
  3. What is Cardiac Rehabilitation? | American Heart Association. American Heart Association.
  4. Cardiac Rehabilitation – StatPearls – NCBI Bookshelf. NCBI.
  5. The role of cardiac rehabilitation in improving cardiovascular … – NCBI. NCBI.

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