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MANAJEMEN HIPERTENSI

PADA PENYAKIT JANTUNG

Germany 6.6-13.1%
Bulgary 1,1%
England 21%

Japan 20%

Canada 13%

Greece 27%

USA 25-29%

Korea 4,7%

Mexico 2,3%

France 16,1-18,5%

Taiwan 2-5%

Spain 25.7-35%

China 1.2-4.1%
South Africa 14,8%

Brazil 21.7%

Prevalence of hypertension: Asia

Gu DF, et al. Hypertension 2002;40:920-927; Singh RB, et al. J Hum Hypertens 2000;14:749-763; Janus ED. Clin Exp Pharmacol Physiol
1997;24:987-988; National Health Survey 1998, Singapore. Epidemiology and Disease Department, Ministry of Health, Singapore.; Lim TO, et al.
Singapore Med J 2004;45:20-27; Tatsanavivat P, et al. Int J Epidemiol 1998;27:405-409; Muhilal H. Asia Pacific J Clin Nutr 1996;5:132-134;
Gupta R. J Hum Hypertens 2004;18:73-78; Asai Y, et al. Nippon Koshu Eisei Zasshi 2001;48:827-836 [in Japanese]

Hypertension in INDONESIA
Based on Survey of Household Health
(SKRT 1995) is 8,3 % per 100 population
Women > men
Based on bordeline hypertension criteria
(140/90-159/94 mmHg), the prevalence is
4,8-18,8%.

prevalence of hypertension (%)

Prevalence of Hypertension
70
60

SBP > 140 mm Hg


DBP > 90 mm Hg

65

70-79

80+

54

50

44

40
30
20

64

21
4

11

18-29

30-39

10
0
age (yrs)

40-49

50-59

60-69

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36

Update in hypertension
Global mortality 2000: impact of hypertension
and other health risk factors
High blood pressure (BP)
Tobacco
High cholesterol
Underweight
Unsafe sex
High BMI
Physical inactivity

High-mortality, developing region

Alcohol

Low-mortality, developing region

Indoor smoke from fuels

Developed region

Iron deficiency
0

1000

2000

3000

4000

5000

6000

Attributable mortality
(In thousands; total 55,861,000)

Adapted from Ezzati et al, Lancet, 2002.

7000

8000

Heart failure development:


Population-attributable risk
Prevalence Attributable
(%)
risk (%)
60
39
62
59
10
34
3
13
11
5
9
6
8
6
5
12
4
4
3
5
5
7
8
8

Hypertension
MI
Angina pectoris
Diabetes
LVH
Valvular disease
male
female

1.5

3.0 4.5
Hazard Ratio

7.5
Levy et al JAMA 1996

RULE OF HALF
Hypertensive patients
who are treated
but uncontrolled

Patients who are aware


but remain untreated
and uncontrolled

25%

12.5%
12.5%

50%

Hypertensive patients
who are unaware

Source : Joffres et al. (1997) Am. J. Hypertension 10: 1097-1102

Hypertensive patients
who are treated
and controlled

CONTROLLED HYPERTENSION
< 140/90 mmHg
USA
27

England
6

Canada
16

France
24

< 160/95 mmHg


Finland

Spain

20.5

20

Germany
22.5

Scotland

Australia
19

India

17.5

> 65 years

USA: JNC VI. Arch Intern Med 1997


Marques-Vidal P et al. J Hum Hypertens 1997
Canada: Joffres et al. Am J Hypertens 1997
England: Colhoun et al. J Hypertens 1998
France: Chamontin et al. Am J Hypertens 1998
Adapted from G. Mancia / L. Ruilope

A Result of Hypertensive Study in Harapan


Kita
Within 6 month follow up:
Only 29% of registered hypertensive patients
visit outpatient clinic regularly
25.81% of sample taken medicine regularly
87.10 % of examined hypertensive patient
had a diastolic dysfunction
20.97% of sample had both the diastolic and
systolic dysfunction

Nani et al. 2008 In press

8x

4x
2x

Impact of High-Normal BP on CV
Disease Risk in Women
12
10
Highnormal

8
Cumulative
Incidence
(%)

6
4

Normal

Optimal

0
0

6
Time (y)

10

12

Optimal: <120/80 mm Hg; normal: 120-129/80-84 mm Hg; high-normal: 130-139/85-89 mm Hg.


Vasan RS. N Engl J Med. 2001;345:1291-1297.

Impact of High-Normal BP on CV
Disease Risk in Men
16
14

Cumulative
Incidence
(%)

12

Highnormal

10

Normal

8
6

Optimal

4
2
0
0

6
Time (y)

10

12

Optimal: <120/80 mm Hg; normal: 120-129/80-84 mm Hg; high-normal: 130-139/85-89 mm Hg.


Vasan RS. N Engl J Med. 2001;345:1291-1297.

Risiko Infark Miokard dan Stroke

15

5-year risk (%)

10

5
MI
MI

Stroke
Stroke

0
0

100

200

300

Systolic blood pressure (mm Hg)


Brown, M.J., Lancet 2000;355:653-4

CUMULATIVE INCIDENCE OF HF
IN HYPERTENSIVE PATIENTS
20
Stage 2+ hypertension

15
CHF
Cumulative
Incidence
(%)

10

Stage 1+ hypertension

5
Normal BP

5
10
Years From Baseline Exam

15

Lenfant C, Roccella EJ. J Hypertens Suppl. 1999;17:S3-S7.


Data from Levy D et al. JAMA. 1996;275:1557-1562.

Total Mortality and Continuous Ambulatory Blood


Pressure
Systolic
Systolic Blood
Blood Pressure
Pressure
events/100 pt/yrs

Diastolic
Diastolic Blood
Blood Pressure
Pressure
5

5
4

2
1
< 140

mm Hg

mm Hg
140-159 160-179 180-199 200+

< 80

80-89

90-99

100-109

110+

Assessment of the 24-hour blood pressure load is


a good clinical method to identify high-risk patients
Khattar, R.S. et al. Circulation 1999; 100:1071-4

Hypertension Treatment Significantly Reduced


Mortality and Morbidity
Estimated Cumulative Incidence of All Morbid Events Over 5 Years

VA Cooperative
Study Group

Control - Placebo

Active Treatment Groups Diuretic-based regimen


and hydralazine

Veterans Administration Cooperative Study Group on antihypertensive agents JAMA 1970;213(7):1143-1152.

META-ANALYSIS
(LANCET 2000)
35 40 % mean reduction in stroke
20 25 % decrease in MI incidence
> 50 % reduction in CHF

BENEFITS OF BP LOWERING

Adapted from THE JNC7 REPORT 2003

Stage I Hypertensive Patients with CVD Risk Factors


Sustained 12-mmHg decrease in systolic BP for 10
years prevents 1 death for every 11 patients
treated
Stage I Hypertensive Patients with CVD
Sustained 12-mmHg decrease in systolic BP for 10
years prevents 1 death for every 9 patients treated

BENEFITS OF BP LOWERING
Adapted from THE JNC7 REPORT 2003

Implications of small reductions in DBP


for primary prevention
DBP reduction

Risk reduction (%)

7.5 mmHg

5-6 mmHg

2 mmHg

-6

-10

-15

-16

-20
-21
-30
-40
-50

-38

CHD
Stroke

-46

DBP, diastolic blood pressure; CHD, coronary heart disease

Cook NR, et al. Arch Intern Med 1995;155:701-709

12
12 to
to 13
13 mm
mm Hg
Hg Drop
Drop in
in Systolic BP Reduces
4-Year
4-Year Risk
Risk of
of CAD,
CAD, Stroke,
Stroke, Mortality
Mortality

Reduction in risk (%)

0%

-10%
-13%
P=0.005

-20%

-30%

-40%

-21%
P<0.0001

-25%
P<0.001

-37%
P<0.001

Meta-analysis of 10 randomized trials. He and Whelton, J Hypertens, 1999.

THE PROGRESSION FROM


HYPERTENSION TO HEART FAILURE
LVH

Diastolic
dysfunction
CHF

Hypertension
MI

Death

Systolic
dysfunction

LV
Subclinical
Overt
Normal LV
Structure & Function remodeling LV dysfunction Heart Failure
Time
(decades)

Time
(months)
Vasan RS, Levy D. 1996. Arch Intern Med 156 : 1759-1796

Health Status/QOL
Lower
Higher

The Cardiovascular Continuum:


HBP to Heart Failure
Normotensive
Elevated Blood
Pressure
Left Ventricular
Dysfunction
Heart
Failure
Death
Time (years)
(Adapted from Dzau V, Braunwald E. Am Heart J. 1991)

Left ventricular hypertrophy


Diastolic
dysfunction

Impaired
coronary
reserve

Cardiac
arrhythmia

Myocardial
infarction

Sudden
death

Systolic
dysfunction

Congestive
heart failure

Hypertension to Heart Failure

Hypertension to Heart Failure

Concentric Hypertrophy

Normal

Dilatation

Reduction in LVM with antihypertensive agents

% Change

-Bloq
-5
Diuretics
-8
CCB
-11

Schmieder et al. Nephrol Dial Transplant 1998; 15: 564.


* B Dahlof. AJH 2001.

ACEi
-12

ARBs
-12 *

THE CARDIOVASCULAR CONTINUUM

Coronary
thrombosis

Myocardial
infarction

Myocardial
ischaemia
CAD
STROKE
Atherosclerosis
LVH

Risk factors
smoking, HYPERTENSION,
cholesterol, diabetes

Sudden Death
Arrhythmia &
loss of muscle
Remodelling
Ventricular
dilatation
Congestive
heart failure

Death

Possible Mechanism Leading from Hypertension to


Atherosclerosis

Hypertension
Shear forces
vessel wall thickness

Endothelial injury

Change in gene
expression, cytokines,
growth factors, adhesion
mollecules

Change in lipid
metabolism

Atherosclerosis

Change in Redox
status/
free radicals

CARA MENGUKUR TEKANAN DARAH


Ukuran cuff harus sesuai
dan setinggi jantung

Tangan ditopang dimeja

ALat pengukur harus ditera


Kolom merkuri tegak lurus
Pompa sampai pulsasi
nadi hilang,lalu deflasi
2-3 mmHg per detik.
Sistole bunyi pertama
terdengar
Diastole, saat bunyi hilang
Catat sampai 2 mmHg
yg terdekat.
Duduk santai/ setelah istirahat
bbrp menit
Tidak minum kopi, alkohol,
obat-obatan ( pseudoefedrin)

Kaki menapak dilantai

British Hypertension Society

ESH 2003 & JNC VII


ESH-ESC
BP Classification

BP

BP

Optimal

<120 / <80

<120/<80

Normal

120-129 / 80-84

120-129 /80-84

Prehypertension

High normal

130-139 / 85-89

130-139 / 85-89

Prehypertension

Grade 1 Hypertension
(mild)

140-159 / 90-99

140-159 / 90-99

Stage 1
Hypertension

Grade 2 Hypertension
(moderate)

160-179 /100-109

Grade 3 Hypertension
(severe)

> 180 / >110

Isolated Systolic
Hypertension

>160 / >100

>140

<90

JNC VII
Bp Classification
Normal

Stage 2
Hypertension

Isolated Systolic
Hypertension

Goals of Therapy
Reduce CVD and renal morbidity and
mortality

Treat to BP < 140 / 90 mmHg


or BP < 130 / 80 mmHg in patients with
diabetes.

Achieve SBP goal especially in persons


>50 years of age.

Minimal BP Goal of Therapy


Recommendations (SBP/DBP mmHg)
Patient Type

JNC VII

Uncomplicated HTN

< 140/90

Hypertension with
diabetes mellitus

< 130/85
< 130/80*
< 130/85
< 125/75

Heart failure
Hypertension with
renal impairment

*National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group.

Proteinuria > 1 g/24h.


(Bakris GL, et al for the National Kidney Foundation Hypertension and Diabetes Executive
Committees Working Group. Am J Kidney Dis. 2000) (JNC VI. Arch Intern Med. 1997)

Cardiovascular Risk Stratification


Blood pressure (mm Hg)
Other risk factor,
organ damage, or
disease

Normal

High
normal

No other risk
factors

Average
risk

Average
risk

1-2 risk factors

Low
added
risk

3 risk factors,
mets, organ
damage, or
diabetes
Established CV or
renal disease

Grade 1
HT

Grade 2
HT

Grade 3
HT

Low
added
risk

Low
added
risk
Moderate
added
risk

Moderate
added
risk
Moderate
added
risk

Moderate
added
risk

High
added
risk

High
added
risk

High
added
risk

Very high
added risk

Very high
added
risk

Very high
added
risk

Very high
added
risk

Very high
added
risk

Very high
added risk

High
added risk
Very high
added risk

HT: hypertension; mets: metabolic syndrome; CV: cardiovascular


Mancia G, et al. 2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007;25:1105-1187

Treatment
Treatment initiation: ESH/ESC 2003
Blood pressure
Other risk factors
and disease
history

Normal

High normal

Grade 1

Grade 2

Grade 3

No other risk
factors

No BP
intervention

No BP
intervention

Lifestyle changes
for several
months, then
drug treatment if
preferred by the
patient and
resources
available

Lifestyle changes
for several
months, then
drug treatment

Immediate drug
treatment and
lifestyle changes

1-2 risk factors

Lifestyle
changes

Lifestyle
changes

Lifestyle changes
for several
months, then
drug treatment

Lifestyle changes
for several
months, then
drug treatment

Immediate drug
treatment and
lifestyle changes

3 or more risk
factors, target
organ damage, or
diabetes

Lifestyle
changes

Drug treatment
and lifestyle
changes

Drug treatment
and lifestyle
changes

Drug treatment
and lifestyle
changes

Immediate drug
treatment and
lifestyle changes

Associated clinical
conditions

Drug
treatment and
lifestyle
changes

Immediate drug
treatment and
lifestyle
changes

Immediate drug
treatment and
lifestyle changes

Immediate drug
treatment and
lifestyle changes

Immediate drug
treatment and
lifestyle changes

Assessment of the Overall


Cardiovascular Risk Factors
Presence of Risk Factors
Increasing age
Male gender
Smoking
Family history of premature cardiovascular disease ( age< 55 in man and < 65 in women )
Dyslipidemia
Sedentary lifestyle
Unhealthy eating
Abdominal obesity
Dysglicemia ( diabetes, impaired glucosa tolerance, impaired fasting glucosa )

Presence of Target Organ Damage


Microalbuminuria or proteinuria
Left ventriculer hypertrophy
Chronic kidney disease

Presence of Atherosclerotic Vascular Disease


Previous stroke or TIA
Coronary heart disease
Periphheral arterial disease
2000 chep recomendation

Management of Hypertension for adult


Initial drug therapy
BP
classification
Normal

SBP*
mmHg

DBP*
mmHg

Lifestyle
modification

<120

and <80

Encourage

Without compelling
indication

Prehypertensio 120139 or 8089


n

Yes

No antihypertensive drug
indicated.

Stage 1
Hypertension

Yes

Thiazide-type diuretics for


most. May consider ACEI,
ARB, BB, CCB, or
combination.

Stage 2
Hypertension

140159 or 9099

>160

or >100

Yes

With compelling
indications

Drug(s) for
compelling
indications.

Drug(s) for the


compelling
indications.
Other
antihypertensive
Two-drug combination for
most (usually thiazide-type drugs (diuretics,
diuretic and ACEI or ARB or ACEI, ARB, BB,
CCB) as needed.
BB or CCB).

Management of Hypertension for Adult


LIFESTYLE MODIFICATIONS
Not Goal BP

INITIAL DRUG CHOICES


Without Compelling Indications
Stage 1
Hypertension (SBP
140-159 or DBP 90-99
mmHg)
Thiazide-Type
diuretics for most. May
consider ACEI, ARB,
BB, CCB, or
combination

With Compelling Indications

Stage 2
HTN (SBP >=160 or DBP
>=100 mmHg)
Two Drug combination
for most (usually thiazidetype diuretic and ACEI, or
ARB, or BB, or CCB

Drug (s) for the


compelling
indications.
Other anti HTN
Drugs (Diuretics,
ACEI, ARB, BB,
CCB) as needed
US-JNC VII Report, 2003

Lifestyle Modifications to
Prevent and Manage Hypertension
Reduce weight

Moderate consumption
of:
alcohol
sodium
saturated fat
cholesterol

Increa
se
physic
al
activity
(JNC VI. Arch Intern Med. 1997)

Maintain adequate intake of


dietary:
potassium
calcium
magnesium

Avoid
tobacco

Development of Antihypertensive Drugs


Reserpin (1949)
1950
HCT (1958)
1960

Diuretics

Verapamil (1963)
Furosemide (1964)

Beta blockers

Propanolol (1965)
1970
Nifedipin (1975)

CCBs
1-blockers

Prazosin (1977) Diltiazem (1980)


1980
Captopril (1981) Amlodipine (1987)

ACE-inhibitors

Bisoprolol (1988)
Losartan (1995)
1990

AT-antagonists/ARB

Valsartan

2000 ?

Clinical Trial and Guideline Basis for Compelling Indications for


Individual Drug Classes
BP
Classification

BB

ACEI

ACB

CCB

Heart failure

Ald Ant

Clinical Trial Basis


ACC/AHA Heart failure Guideline,
MERIT-HF, COPERNICUS, CIBIS,
SOLVD, AIRE,TRACE, ValHEFT, RALES

Post-MI

ACC/AHA Post-Mi Guideline,


BHAT, SAVE, Capricorn,
EPHESUS

High coronary
disease risk

ALLHAT, HOPE, ANBP2, LIFE,


CONVINCE

Diabetes

NKF-ADA Guideline, UKPDS, ALLHAT

Chronic kidney
disease

NKF Guideline, Captopril Trial,


RENAAL, idnt, REIN, AASK

JNC VII 2003

Indications and Contraindications for the major classes of AHD

Class

Coditions
favouring the use

Contraindications
Compelling

Diurretics
(thiazides)

Congestive HF
Elderly hypertensive
ISH
Hypertensive African

Gout

Diuretics (loop)

Renal Insufficiency
Congestive HF

Diuretics (anti aldosteron)

Congestive HF
Post-MI

Renal failure
Hyperkalemia

Beta - blocker

Angina pectooris
Post-MI
Congestive HF (up
titration)
Active patients
Tachyarrythmias

Asthma
COPD
A-V block (grade 2
or 3)

Possible
Pregnancy

Peripheral Vascular D
Glucose intolerance
Athletes and
physically
Dyslipidemia

Indications and Contraindications for the major classes of AHD


Class

Coditions favouring
the use

Contraindications
Compelling

Calcium antagonist
(dihydropyridines)

Elderly patients
Isolated SH
Angina pectoris
Peripheral vascular D
Carotid atherosclerosis
Pregnancy

Calcium antagonist
(verapamil, diltiazem)

Angina pectoris
Carotid atherosclerosis
Supraventricular
tachycardia

A-V block (grade 2 or


3)
Congestive HF

ACEI

Congestive HF
LV dysfunction
Post-MI
Non-diabetic nephropathy
Type-1 diabetic
nephropathy
Proteinuria

Pregnancy
Hyperkalemia
Bilateral renal artery
stenosis

Possible

Tachyarrythmias
Congestive HF

Indications and Contraindications for the major classes of AHD


Class

Coditions favouring
the use

Contraindications
Compelling

ACEI

Congestive HF
LV dysfunction
Post-MI
Non-diabetic nephropathy
Type-1 diabetic nephropathy
Proteinuria

Pregnancy
Hyperkalemia
Bilateral renal artery
stenosis

ARB

Type-2 diabetic nephropathy


Diabetic microalbuminuria
Proteinuria
LVH
ACEI cough

Pregnancy
Hyperkalemia
Bilateral renal artery
stenosis

Alfa-blocker

BPH
Hyperlipidemia

Orthostatic
hypotension

Possible

Congestive HF

Conditions favouring the use of some


antihypertensive drugs (1)

Subclinical organ damage


LVH
Asympromatic
atherosclerosis
Microalbuminuria
Renal Dysfunction

ACEI, CA, ARB


CA, ACEI
ACEI, ARB
ACEI, ARB

Conditions favouring the use of some antihypertensive


drugs versus other (2)

Clinical event
Previous stroke

any BP lowering agent

Previous MI

BB, ACEI, ARB

Angina pectoris

BB, CA

Heart failure

diuretics, BB, ACEI, ARB,


Anti-aldosterone agents

Atrial fibrillation
Recurrent
Permanent

ARB, ACEI
BB, non-dihydropiridine
CA

Tachyarrhythmias

BB

ESRD/proteinuria

ACEI, ARB, loop diuretics

Peripheral artery disease

CA

LV dysfunction

ACEI

Conditions favouring the use of some


antihypertensive drugs (2)
Condition
ISH (elderly)

diuretics, CA

Metabolic syndrome

ACEI, ARB, CA

Diabetes mellitus

ACEI, ARB

Pregnancy

CA, Methyldopa, BB

Black People

diuretic, CA

Glaucoma

BB

ACEI induced cough

ARB

Why combination therapy


Multiple mechanisms involved in the pathogenesis of
hypertension
Effectiveness of monotherapy limited by stimulation
of counter-regulatory mechanisms
Effective BP control seen in only 50% of patients on
monotherapy; combination therapy results in a much
higher responder rate (>80%)
BP goals difficult to attain with monotherapy in
patients with diabetes or target organ damage

Patients with systolic BP 20 mm


Hg and diastolic BP 20 mm Hg
above BP goal are candidates for
combination therapy

The JNC VII Report. JAMA 2003;289:2560-2572

Monotherapy versus combination therapy strategies


Choose between
Mild BP elevation
Low/moderate CV risk
Conventional BP target

Marked BP elevation
high/very high CV risk
Lover BP target

Single agent at
low dose

Two-drug combination
at low dose
If goal BP not
achieved

Previous agent
at full dose

Switch to
different agent
at low dose

Previous
combination at
full dose

Add a third
drug at low
dose

If goal BP
not
achieved
Two-to three-drug
combination at
full dose

Full dose
monotherapy

Two-three drug
combination at full dose

ESH Guideline 2007

2003 ESH/ESC Guidelines 2007 ESH/ESC Guidelines


Diuretics

Diuretics

-blockers

AT1-receptor
blockers

-blockers

AT1-receptor
blockers

1-blockers

Calcium
antagonists

1-blockers

Calcium
antagonists

ACE inhibitors

ACE inhibitors

The BHS recommendations for combining blood


pressure-lowering drugs
55 years or black
patients at any age

<55 years

Step 1

Step 2

Step 3

Step 4

C or D
A

or

Add: further diuretic therapy or alpha-blocker or beta-blocker


Consider seeking specialist advice

A: ACE inhibitor or ARB, if ACE inhibitor intolerant C:


Calcium-channel blocker
D: Diuretic (thiazide)
BHS, British Hypertension Society; ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker

2006 update

National Collaborating Centre for Chronic Conditions. Hypertension: management in


adults in primary care: partial update. London: Royal College of Physicians, 2006

Advantages of a long-acting antihypertensive


agent
May protect against heightened risk of cardiovascular
events coincident with the early morning rise in blood
pressure
More consistent blood pressure control
- reduces mean 24-hour blood pressure
- reduces blood pressure variability
Nocturnal blood pressure control
Improved compliance with once-daily dosing

Are two drugs Combination Enough ?


No less than 15-20% of the patients need more
than two anti hypertensive drugs to achieve an
effective BP reduction. The combination of a
blocker of renin-angiotensin system, a CCB and a
thiazide diuretic may be a rational combination.
B-blocker or alpha blocker, maybe included in a
multiple approach, depending on clinical
circumstance
Mancia G, et all. Reappraisal of European Guidelines on Hypertension
management: a European Society of Hypertension Task Force Document, J
Hypertens 2009, 27:000-000

Adverse Effects of Commonly Used


Antihypertensive Agents
Diuretics
Muscle cramps
Impotence
Gout
Glucose
intolerance
Hypokalemia
Hyperuricemia
Hypomagnesemia
Hypercalcemia

BBs
Depression
Sleep
disorders
Exercise
intolerance
Dyslipidemia
Glucose
intolerance
Impotence

CCB

ACEIs

Edema
Flushing
Headache
Dizziness
GI
disorders
Changes
in heart
rate

Cough
Hyperkalemia
Rash
Angioedema
Hyperkalemia (rare)
Angioedema

ARBs

(Adapted from Hollenberg NK, Higginbotham MB. Therapeutic Options to Preserve Target
Organs. Parsippany, NJ: Applied Clinical Communications; Case 3 of 5)

Thank You