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Myocardial Infarction (Heart Attack)
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NIH - Heart attack (Medical Encyclopedia) “Causes: Most heart attacks are caused by a blood clot that blocks one of the coronary arteries. The coronary arteries bring blood and oxygen to the heart. If the blood flow is blocked, the heart starves for oxygen and heart cells die. A clot most often forms in a coronary artery that has become narrow because of the build-up of a substance called plaque along the artery walls. (See: atherosclerosis) Sometimes, the plaque cracks and triggers a blood clot to form. Occasionally, sudden overwhelming stress can trigger a heart attack. ... Risk factors for heart attack and coronary artery disease include: • Bad genes (hereditary factors) • Being male • Diabetes • Getting older • High blood pressure • Smoking • Too much fat in your diet • Unhealthy cholesterol levels, especially high LDL ("bad") cholesterol and low HDL ("good") cholesterol Higher-than-normal levels of homocysteine, C-reactive protein, and fibrinogen may also increase your risk for a heart attack. Homocysteine is an amino acid. C-reactive protein and fibrinogen are linked to inflammation. Fibrinogen is also involved in blood clotting. Symptoms: Chest pain is a major symptom of heart attack. However, some people may have little or no chest pain, especially the elderly and those with diabetes. This is called a silent heart attack. The pain may be felt in only one part of the body or move from your chest to your arms, shoulder, neck, teeth, jaw, belly area, or back. The pain can be severe or mild. It can feel like: • Squeezing or heavy pressure • A tight band around the chest • Something heavy sitting on your chest • Bad indigestion Pain usually lasts longer than 20 minutes. Rest and a medicine called nitroglycerine do not completely relieve the pain of a heart attack. Other symptoms of a heart attack include: • Shortness of breath • Nausea or vomiting • Anxiety • Cough • Fainting • Lightheadedness - dizziness • Palpitations (feeling like your heart is beating too fast) • Sweating, which may be extreme “
NHS – Heart attack (includes video) “Some people do not feel any pain during a heart attack. This is known as a 'silent' heart attack and tends to affect people with diabetes, or those who are over 75 years of age. Some evidence suggests that up to 20% of mild heart attacks go undiagnosed. This means that some people, because of previous undiagnosed attacks, may be suffering progressive damage to the heart muscle. ... Diagnosing a heart attack: If you are having a suspected heart attack, you will usually be taken to hospital so that tests can be carried out to confirm the diagnosis. Some of these tests are outlined below. Electrocardiograph (ECG) An electrocardiograph (ECG) helps to trace the electrical activity of the heart. Every time your heart beats, it produces tiny electrical signals. An ECG machine records these signals on to paper, allowing your doctor to see how well your heart is functioning. An ECG can detect damage to your heart muscle, or problems with your heart rhythm. It can also show if you have had a heart attack, either recently, or some time ago. The test takes about five minutes and is painless. During the test, electrodes (flat metal discs) are attached to your arms, legs, and chest. Wires from the electrodes are connected to the ECG machine, which records the electrical impulses. Cardiac enzyme tests When your heart has been damaged by a heart attack, it causes certain enzymes to slowly leak into your blood. Enzymes are special proteins which help regulate the chemical reactions that take place in your body. If you have had a suspected heart attack, a sample of your blood will be taken so that it can be tested for these heart enzymes. Your enzyme levels will be measured through a series of blood samples taken over a few days. A chest X-ray may also be taken to look for any enlargement (swelling) of your heart.”Highlighted Articles
Hospitals Slow in Heart Cases, Research Finds (2008)"Delays were more likely in patients whose hearts stopped at night or on the weekend, who were admitted for noncardiac illnesses, in hospitals with fewer than 250 beds and in units without heart monitors."
Hospitals slow to defibrillate heart patients (2008) "Just because you're in the hospital doesn't mean you'll quickly get treated if your heart stops beating. About one-third of patients don't get a potentially live-saving shock within the recommended two minutes, a new study found. Those who don't get prompt defibrillation are more likely to die or end up brain damaged or disabled, the study showed. For every minute of delay, the chances of survival worsens, researchers reported in Thursday's New England Journal of Medicine. "It is probably fair to say that most patients assume - unfortunately, incorrectly - that a hospital would be the best place to survive a cardiac arrest ." "
What initial dose of aspirin is right for STEMI patients? (2008)"An initial dose of 162-mg aspirin may be as effective as and perhaps safer than 325 mg for the acute treatment of ST-elevation MI (STEMI), a new study suggests ."
High-Dose Folic Acid Pretreatment Blunts Cardiac Dysfunction During Ischemia Coupled to Maintenance of High-Energy Phosphates and Reduces Postreperfusion Injury (Circulation 2008) "Background-The B vitamin folic acid (FA) is important to mitochondrial protein and nucleic acid synthesis, is an antioxidant, and enhances nitric oxide synthase activity. Here, we tested whether FA reduces myocardial ischemic dysfunction and postreperfusion injury. . Conclusions-FA pretreatment blunts myocardial dysfunction during ischemia and ameliorates postreperfusion injury. This is coupled to preservation of high-energy phosphates, reducing subsequent reactive oxygen species generation, eNOS-uncoupling, and postreperfusion cell death."
Eating your greens could prove life-saving if a heart attack strikes (2007) "A diet rich in leafy vegetables may minimize the tissue damage caused by heart attacks, according to researchers at the Albert Einstein College of Medicine of Yeshiva University. Their findings, published in the November 12 Proceedings of the National Academy of Sciences, suggest that the chemical nitrite, found in many vegetables, could be the secret ingredient in the heart-healthy Mediterranean diet. … Researchers now have good evidence that hearts undergoing heart attacks have a “backup” pathway for making nitric oxide. Triggered by falling oxygen levels, enzymes in heart muscle convert nitrite stored there into nitric acid that can then help minimize tissue damage. Nitrite in the diet comes mainly from vegetables—celery, beets, and spinach, lettuce and other leafy types. Once consumed, nitrite exits the bloodstream and then accumulates and become stored in organs such as the heart, kidney and brain. … Dr. Lefer says that the nitrite levels found cardioprotective in his study can easily be achieved by consuming more vegetables containing the chemical. That dietary change, he says, might be especially helpful for people at increased heart-attack risk—those who’ve already suffered a heart attack, have been diagnosed with cardiovascular disease or have a family history of it."
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Myocardial Infarction (Heart Attack) Warning Signs
General Information 2000 - 2010 (News, Articles, Journal Articles, Guidelines, Internet Sites)
Heart Attack Symptoms in Women — Are they Different? "Chest pain is still the most common sign of a heart attack for most women, although studies have shown that women are more likely than men to have symptoms other than chest pain or discomfort when experiencing a heart attack or other form of acute coronary syndrome (ACS) … The authors also report that women are more likely than men to experience other forms of cardiac chest pain syndromes, such as unstable angina, and they appear to report a wider range of symptoms associated with ACS. For example, women are more likely to report pain in the middle or upper back, neck, or jaw; shortness of breath; nausea or vomiting; indigestion; loss of appetite; weakness or fatigue; cough; dizziness; and palpitations."
Heart Attacks Often Go Unrecognized: Some estimates run as high as 43 percent; women frequently under-diagnosed "On one point all agree: Both women and men need to know the warning signs of a heart attack and to seek immediate help if they suspect one. The worst that can happen if you're wrong? You'll be sent home from the emergency room, secure in the knowledge it was a false alarm."
Heartburn or Heart Attack? Know the Symptoms "The most common symptom of coronary heart disease is chest pain (angina) or discomfort, which can also occur in the shoulders, arms, neck, jaw or back. People may mistake this pain for indigestion, which can be dangerous. … Unfortunately, many people may not be aware they are having a heart attack."
Hospitals Slow in Heart Cases, Research Finds “Delays were more likely in patients whose hearts stopped at night or on the weekend, who were admitted for noncardiac illnesses, in hospitals with fewer than 250 beds and in units without heart monitors.”
Hospitals slow to defibrillate heart patients “Just because you’re in the hospital doesn’t mean you’ll quickly get treated if your heart stops beating. About one-third of patients don’t get a potentially live-saving shock within the recommended two minutes, a new study found. Those who don’t get prompt defibrillation are more likely to die or end up brain damaged or disabled, the study showed. For every minute of delay, the chances of survival worsens, researchers reported in Thursday’s New England Journal of Medicine. “It is probably fair to say that most patients assume — unfortunately, incorrectly — that a hospital would be the best place to survive a cardiac arrest …” “
Over 40 pct of mild heart attacks undetected - study "Heart attack is a leading cause of death in industrialized nations. Chest pain is the most common but by no means the only sign that sufferers notice. 'They may sense shoulder pain instead of chest pain, they may think they have severe flu that is taking a long time to recover from,' he told Reuters."
The Claim: You Can Keep Yourself Alive by Coughing During a Heart Attack " … experts say the "cough CPR" claim is largely untrue. It may have started because patients having angiograms are sometimes asked to cough forcefully when they have sudden abnormal heartbeats. Coughing deeply can help a person on the verge of passing out — a sign of cardiac arrest — until treatment can be given. But for someone having a heart attack that does not result in cardiac arrest, coughing can be extremely dangerous. And since most people are not able to tell the difference, coughing during a heart attack is almost always a bad idea, according to the American Heart Association. … THE BOTTOM LINE Coughing during a heart attack can be dangerous."
When Chest Pain Requires Quick Action in ER “The study included 3,031 people with acute coronary syndrome. Half were randomly assigned to get early assessment of coronary artery blockage followed by an artery-opening procedure if necessary -- on average, within 14 hours -- and the other half waited an average of 50 hours for such treatment. After six months, the incidence of death, heart attacks or stroke wasn't that different in the two groups -- 9.6 percent of those who had early intervention, 11.3 percent among those who waited. But analysis of the results showed that the benefit was concentrated among those people who were graded as being at highest risk on a scale that included such factors as age, blood pressure and presence of biomarkers of heart injury. So the bottom line, Mehta said, is that "it is OK to wait unless you are at high risk." The finding is useful in several practical ways, he said. For one, it helps settle a debate about whether early intervention might be harmful in some cases. "The study showed that early intervention does not increase the risk," Mehta said.”
With Heart Attacks, Fast Treatment Matters “People having a heart attack should be given balloon angioplasty without delay once they reach a hospital to reduce their risk of dying, a new study concludes. Balloon angioplasty, or primary percutaneous intervention, is used to open blocked coronary arteries.“
Younger Women Fail to Heed Heart Attack's Warning Signs "Women under the age of 55 often fail to recognize the symptoms of a heart attack until it's too late, a new study warns. Ignoring those signs -- which can include anything from chest pain to nausea -- can delay medical care and increase risks for disability and even death. … Less typical symptoms included pain in the jaw/shoulder area (experienced by 58 percent of the women); sweating (38 percent); nausea (29 percent); shortness of breath (29 percent); indigestion (21 percent) and weakness/fatigue (8 percent). … Focusing only on chest pain could cost lives, Goldberg warned. Other studies have shown that women often have symptoms other than chest pain."
AHA - Heart Attack Symptoms & Warning Signs "If you think you're having a heart attack, call 9-1-1 or your emergency medical system immediately. Some heart attacks are sudden and intense — the "movie heart attack," where no one doubts what's happening. But most heart attacks start slowly, with mild pain or discomfort. Often people affected aren't sure what's wrong and wait too long before getting help. Here are signs that can mean a heart attack is happening: Chest discomfort. Most heart attacks involve discomfort in the center of the chest that lasts more than a few minutes, or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain. Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw or stomach. Shortness of breath. May occur with or without chest discomfort. Other signs: These may include breaking out in a cold sweat, nausea or lightheadedness As with men, women's most common heart attack symptom is chest pain or discomfort. But women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, nausea/vomiting, and back or jaw pain."
Are heart attack symptoms in women different than in men? "Symptoms of a heart attack in women may be similar to men (mid chest pain), but may more likely be "atypical" (shortness of breath, sweatiness, arm or jaw pain only, etc). One must remember that either sex may have an "atypical" presentation, but it is more common in women."
Diagnosing the Cause of Chest Pain (Am Fam Physician 2005) "Chest pain presents a diagnostic challenge in outpatient family medicine. Noncardiac causes are common, but it is important not to overlook serious conditions such as an acute coronary syndrome, pulmonary embolism, or pneumonia. In addition to a thorough history and physical examination, most patients should have a chest radiograph and an electrocardiogram. Patients with chest pain that is predictably exertional, with electrocardiogram abnormalities, or with cardiac risk factors should be evaluated further with measurement of troponin levels and cardiac stress testing. … Although some patients with chest pain have heart failure, this is unlikely in the absence of dyspnea; a brain natriuretic peptide level measurement can clarify the diagnosis. Pain reproducible by palpation is more likely to be musculoskeletal than ischemic. Chest pain also may be associated with panic disorder … Chest pain is the chief complaint in about 1 to 2 percent of outpatient visits, and although the cause is often noncardiac, heart disease remains the leading cause of death in the United States.2 Thus, distinguishing between serious and benign causes of chest pain is imperative, and diagnostic and prognostic questions are important in making this determination."
Do You Know Which Symptoms Signal a Heart Attack in Women? ““It’s very typical for people to make a fist when they’re describing their symptoms,” she says. “Some people describe it as feeling like a vise encasing their whole chest area.” But in women, symptoms are more likely to be atypical: Although most women experience chest pain or discomfort, many don’t. In a 2003 Circulation study of female heart attack patients, scientists found that during an attack, 43% of the 515 women studied had no “acute chest pain, a ‘hallmark symptom in men.’” The study noted some common female heart attack symptoms: • shortness of breath (57.9%) • weakness (54.8%) • unusual fatigue (42.9%) Women had other atypical heart attack symptoms, too: nausea, dizziness, lower chest discomfort, upper abdominal pressure or discomfort that feels like indigestion, and upper back pain. Often, women are unfamiliar with these atypical symptoms and blame them on heartburn or indigestion, arthritis, or stress, experts say. If they become short of breath with little exertion, they tell themselves they are out of shape, overworked, or fatigued. Pay attention to heart attack symptoms But experts urge women to learn the various heart attack symptoms and to call 911 promptly at the appearance of these signs. While every woman feels indigestion once in a while, experiencing a cluster of unusual symptoms or a sensation in the chest or stomach never felt before is reason to seek emergency care. Park has seen too many patients wait too long. Because women have lots of competing demands -- jobs, families, and sometimes caregiving duties -- “taking care of themselves, even if they don’t feel well, usually doesn’t make it to the top of the list,” she says. “
Health Tip: Angina Is Chest Pain "Angina occurs when the heart does not receive enough blood. Angina may feel like pain or discomfort in the chest, including pressure, tightness, indigestion or heartburn. Pain from angina may also be felt in the neck, shoulders, jaw, back and arms. Since angina often is a symptom of coronary artery disease or heart attack, the National Heart, Lung, and Blood Institute recommends that you see your doctor any time you have angina."
Heart Attack Symptoms and Early Warning Signs "Although chest pain or pressure is the most common symptom of a heart attack, heart attack victims may experience a diversity of symptoms that include: • Pain, fullness, and/or squeezing sensation of the chest • Jaw pain, toothache, headache • Shortness of breath • Nausea, vomiting, and/or general epigastric (upper middle abdomen) discomfort • Sweating • Heartburn and/or indigestion • Arm pain (more commonly the left arm, but may be either arm) • Upper back pain • General malaise (vague feeling of illness) • No symptoms (Approximately one quarter of all heart attacks are silent, without chest pain or new symptoms. Silent heart attacks are especially common among patients with diabetes mellitus) Even though the symptoms of a heart attack at times can be vague and mild, it is important to remember that heart attacks producing no symptoms or only mild symptoms can be just as serious and life-threatening as heart attacks that cause severe chest pain. … Even if you’re not sure if something is really wrong, you should call 9-1-1 if you experience heart attack symptoms. "
Heart attack symptoms: Know what signals a medical emergency "Heart attack symptoms vary widely but often include chest pain or pressure, shortness of breath, nausea, or anxiety. See how women's symptoms may be different from men's symptoms. … Getting treatment quickly improves your chance of survival and minimizes damage from a heart attack. Don't "tough out" these symptoms for more than five minutes. Call 911 or other emergency medical services for help. If you don't have access to emergency medical services, have someone drive you to the nearest hospital. Drive yourself only as a last resort, if there are absolutely no other options."
More compressions, fewer interruptions lead to higher cardiac arrest survival “Study highlights: • Survival rates for sudden cardiac arrest patients increased when professional rescuers focused on minimizing interruptions to chest compressions during CPR. • Compression rate was increased to 50 compressions followed by two breaths. • Rescuers delayed other interventions, such as intubation and IVs, until enough compressions had been given."
10 Steps Before you Refer for: Chest Pain (Br J Cardiol. 2009)
A clinical prediction rule for early discharge of patients with chest pain. (Ann Emerg Med. 2006) "RESULTS: Of 769 patients studied, 77 (10.0%) had acute myocardial infarction and 88 (11.4%) definite unstable angina. We derived a clinical prediction rule that was 98.8% sensitive and 32.5% specific. Patients have very low risk of acute coronary syndrome if they have a normal initial ECG, no previous ischemic chest pain, and age younger than 40 years. In addition, patients at least 40 years old and with a normal ECG result, no previous ischemic chest pain, and low-risk pain characteristics have very low risk if they have an initial creatine kinase-MB (CK-MB) less than 3.0 microg/L or an initial CK-MB greater than or equal to 3.0 microg/L but no ECG or serum-marker increase at 2 hours."
A Community Intervention by Firefighters to Increase 911 Calls and Aspirin Use for Chest Pain. (Acad Emerg Med. 2006) "Firefighters delivered a heart attack survival kit (that included an aspirin) and counseled participants on the importance of aspirin and 911 use for chest pain. Main outcome measures were 911 calls for chest pain and aspirin ingestion for a chest pain event…"
A critical pathway for patients with acute chest pain and low risk for short-term adverse cardiac events: role of outpatient stress testing. (Ann Emerg Med. 2006) "CONCLUSION: For patients with chest pain and low risk for short-term cardiac events, outpatient stress testing is feasible, safe, and associated with decreased hospital admission rates. With an evidence-based protocol, physicians efficiently identify patients at low risk for clinically significant coronary artery disease and short-term adverse cardiac outcomes."
A review of symptoms of coronary artery disease in women. (J Adv Nurs. 2002)
[Acute chest pain.] (Med Klin (Munich). 2005)
Acute risk factors for myocardial infarction. (Int J Cardiol. 2006) "External triggers, such as heavy physical activity, emotional stress, eating, cold or heat exposure, coffee or alcohol consumption, cocaine or marijuana use and sexual intercourse are recognized as most important acute risk factors. … Lifestyle modifications, regular physical activity and adequate drug regimens may at least prove able to defer the occurrence of coronary thrombosis, thereby providing time for the development of collateral vessels, plaque stabilization or invasive/surgical treatment."
Anxiety disorder in patients with non-specific chest pain in the emergency setting. (Emerg Med J. 2006) "CONCLUSIONS: Physicians should always consider AD in patients presenting to the ED with chest pain after ruling out organic aetiology. Patients' definition of atypical pain, recurrent admissions to ED, and presence of associated symptoms such as dizziness, chills or hot flushes, and fear of dying could aid in considering AD."
Are there gender differences related to symptoms of acute myocardial infarction? A norwegian perspective. (Prog Cardiovasc Nurs. 2006) "The findings demonstrated that the most commonly reported symptom in both genders was chest pain. More than 90% of women and men experienced chest pain, with no difference between the genders. More women than men had nausea as well as pain located in their arms, back, jaw, and throat. More men than women attributed their symptoms to be cardiac in origin. Experiencing pain in the shoulders, attributing symptoms to be noncardiac, consulting a family member, and contacting several medical practitioners increased prehospital delay."
Chest pain in general practice: incidence, comorbidity and mortality. (Fam Pract. 2006)
[Complications of an unrecognized myocardial infarction] (Ned Tijdschr Geneeskd. 2005) "Patients with an untreated myocardial infarction may present with serious late complications. … Around one-third of patients who have a myocardial infarction do not have chest pain but experience shortness of breath, autonomic nervous symptoms (sweating, nausea, vomiting), extreme and inexplicable tiredness and fainting. These atypical symptoms should suggest myocardial infarction. In order to avoid high morbidity and death from complications such as arrhythmias, heart failure, rupture and aneurysm formation it is important that a patient who has had a myocardial infarction should be treated as soon as possible, preferably by reperfusion therapy."
Diagnosing the Cause of Chest Pain (Am Fam Physician 2005)
Heartburn or angina? Differentiating gastrointestinal disease in primary care patients presenting with chest pain: a cross sectional diagnostic study. (Arch Med. 2009) “Among patients presenting with chest pain in general practice, GI disease is with 5.8% (including 3.5% GERD) the fifth common aetiology. Pain worse with food intake and retrosternal pain radiation were associated positively with both GI disease and GERD; retrosternal pain localisation, vomiting, burning pain, epigastric pain and an average pain episode < 1 hour were associated positively only with GI disease.”
How do we define non-cardiac chest pain? (J Gastroenterol Hepatol. 2005)
How Sudden Is Sudden Cardiac Death? (Circulation 2006) "Typical angina was present for a median of 120 minutes in 25% of the 274 patients with witnessed arrest and in 33% with a symptom duration of less than 1 hour. … 'Our data show that 'sudden cardiac death' is not nearly as sudden in most cases as the term may suggest," and symptoms are present for 'a surprisingly long time in many patients' … "
Incidence of recognized and unrecognized myocardial infarction in men and women aged 55 and older: the Rotterdam Study. (Eur Heart J. 2006) "CONCLUSION: A high proportion of incident MIs remains clinically unrecognized. As a history of MI is associated with an increased risk of repeat cardiovascular complications, our data suggest a need for periodical electrocardiographic screening to recognize (prevalent) infarctions and to install effective preventive treatment in those aged 55 and older."
Manual Chest Compression vs Use of an Automated Chest Compression Device During Resuscitation Following Out-of-Hospital Cardiac Arrest: A Randomized Trial (JAMA 2006) "Conclusions Use of an automated LDB-CPR device as implemented in this study was associated with worse neurological outcomes and a trend toward worse survival than manual CPR."
Non-Cardiac Chest Pain: The Long-Term Natural History and Comparison With Gastroesophageal Reflux Disease. (Am J Gastroenterol. 2009) “OBJECTIVES:The source of most cases of non-cardiac chest pain (NCCP) is thought to be the esophagus. We reasoned that if the origin of NCCP is truly esophageal and not cardiac, the characteristics and survival of individuals with NCCP should be similar to those of individuals with benign esophageal disease, such as gastroesophageal reflux disease (GERD). … CONCLUSIONS:NCCP in most patients seems to be a short-lived event requiring extensive medical evaluation and having clinical characteristics significantly different from those associated with GERD. Patients with NCCP, confirmed by the absence of angiogram-documented coronary artery disease, who are referred for diagnostic endoscopy, have an excellent long-term benign prognosis, similar to patients with GERD.”
Risk factors for non-cardiac chest pain in the community. (Aliment Pharmacol Ther. 2005)
Symptom presentation and time to seek care in women and men with acute myocardial infarction. (Heart Lung. 2007) "The majority of women and men reported that their symptoms were different from what they expected an AMI would be like. Most stated that their pain was less than expected, whereas some reported either the location of discomfort or associated symptoms as different then expected. There was no gender difference in time to seek care."
The influence of age on acute myocardial infarction symptoms and patient delay in seeking treatment. (Prog Cardiovasc Nurs. 2006) "Older patients were significantly less likely to report classic pain in the center of the chest and other associated symptoms such as sweating and nausea; they also used fewer words to describe their discomfort compared with younger patients. Independent predictors of longer delay were: contacted physician, lacked similarity between experienced and expected symptoms, did not use 911 (older adults), lived alone, and contacted physician (younger adults). Primary care providers need to be aware that elderly persons are more likely to have mild or ambiguous acute myocardial infarction symptoms and education is needed for elderly persons regarding not only acute myocardial infarction symptoms but also rapid, action-centered decisions to attribute symptoms to heart problems and initiate ambulance use."
Treatment of noncardiac chest pain of psychological origin. (Curr Treat Options Gastroenterol. 2006)
Warning Signs of a Heart Attack (Circulation. 2001)
Women's Early Warning Symptoms of Acute Myocardial Infarction (Circulation. 2003)
NGC - Myocardial infarction. (2006)
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