Myocardial Infarction
   

Myocardial Infarction
Also Listed As:  Heart Attack
 
Signs and Symptoms
Causes
Risk Factors
Diagnosis
Preventive Care
Treatment Approach
Lifestyle
Medications
Nutrition and Dietary Supplements
Herbs
Homeopathy
Acupuncture
Massage and Physical Therapy
Mind/Body Medicine
Other Considerations
Prognosis and Complications
Supporting Research

The technical name for heart attack is myocaridal infarction (MI). The heart is a large muscle responsible for pumping blood, which carries oxygen, to every organ in the body including the heart itself. A heart attack occurs when an artery leading to an area of the heart becomes completely blocked. This blockage leads to the death of heart muscle cells in that area.

A heart attack is a medical emergency. Seek immediate medical attention if you or someone you are with is having the symptoms listed in the section below. .

If treatment is sought promptly, lives can be saved and threatened heart muscle can be salvaged. This prevents as much damage to the heart and preserves as much function as possible.


Signs and Symptoms
  • Pain, heaviness, tightness, burning—in chest, back, left arm, jaw, neck
  • Difficulty breathing
  • Dizziness, weakness
  • Nausea, vomiting
  • Irregular heartbeat

Causes

Atherosclerosis is plaque that builds up in arteries throughout the body, including coronary (heart) blood vessels, over time. Many factors, such as high LDL ("bad") chyolesterol contribute to the development of plaque. Most heart attacks are caused by a combination of the following:

  • A blood clot that blocks one of the coronary arteries (the blood vessels that bring blood and oxygen to the heart muscle)
  • Rupture of unstable plaque (atherosclerosis)
  • "Endothelial dysfunction"

Endothelial cells line the inner wall of coronary blood vessels. When these cells become disturbed (from, for example, eating a high fat meal, sudden stress, or high blood pressure), a piece of atherosclerotic plaque can dislodge and land in a narrow section of a coronary artery. When this happens, blood flow is blocked and can cause severe chest pain or even a heart attack. Atherosclerosis, plaque rupture, and endothelial dysfunction can also stimulate the formation of a blood clot which, in turn, interrupts blood flow and leads to a heart attack.

When a coronary artery is blocked the lack of blood and oxygen to the heart muscle leads to the death of heart cells in that area. The damaged heart muscle loses its ability to contract, and the remaining intact heart muscle needs to compensate for that area of weakness.

Endothelial dysfunction seems to be related to reduced levels of a substance called nitric oxide. Normal levels and function of nitric oxide help the coronary blood vessels relax and dilate (widen). When these vessels are relaxed, there is more blood flow to the heart. Oxidative stress (a normal but damaging metabolic process in the body exacerbated by environmental factors such as exposure to cigarette smoke and pollutants) reduces the availability and function of nitric oxide, thereby reducing the ability of the coronary blood vessels to relax. In theory, therefore, antioxidants (like carotenoids and vitamins C and E) in the diet or possibly from supplements may improve amounts and function of nitric oxide. This, in turn, improves blood flow and reduces the chances of a heart attack. (See Nutrition and Dietary Supplements.)


Risk Factors

Occasionally, sudden overwhelming stress can trigger a heart attack. Other common risk factors include:

  • Smoking
  • High-fat diet
  • Poor blood cholesterol levels, especially high LDL ("bad") cholesterol and low HDL ("good") cholesterol as well as elevated triglycerides
  • Family history of early MI
  • Diabetes
  • High blood pressure
  • Being male, or a female who has gone through menopause
  • Being overweight/obese (which also increases your risk for having high cholesterol, diabetes, and high blood pressure)
  • Sedentary lifestyle

Additional risk factors for coronary artery disease include elevated homocysteine, C-reactive protein (CRP), lipoprotein (a), and fibrinogen levels. CRP and fibrinogen are markers of inflammation. There is some thought that chronic infection may be involved in the development of atherosclerosis and the risk of having a heart attack. Lots of research in these areas is currently underway.

If you have had a heart attack and you have a high homocysteine level, the likelihood of a bad outcome (like another heart attack or even death) is greather than for those with a normal or low homocysteine level. High homocysteine can be treated with folic acid (see ).

Use of birth control pills, cocaine, or amphetamines may also increase your chances for a heart attack. And, certain psychological factors, listed below, have been linked to heart attacks and a worse outcome from a heart attack:

  • Depression
  • Anger and hostility
  • Social isolation and lack of social support
  • Chronic (ongoing) stress

It is now known whether treatment of these conditions and change of such situations will lessen your chances for a first time or repeat heart attack. However, it certainly seems reasonable to work on addressing these feelings and circumstances.


Diagnosis

If you think that you are having a heart attack, call for medical assistance immediately. Treating a heart attack within 90 minutes can save your life. In the emergency room, a health care provider will ask you about your symptoms and perform a physical examination.

The following tests may reveal a heart attack and the extent of heart damage:

  • Electrocardiogram (ECG) -- single or repeated over several hours
  • Echocardiography
  • Nuclear ventriculography (MUGA or RNV)

The following tests may show the by-products of heart damage from a heart attack:

  • Troponin I and troponin T
  • CK and CK-MB

Coronary angiography (a procedure to look at your coronary blood vessels) may be necessary to assess and treat the blocked coronary vessels.


Preventive Care

You may reduce your risk of heart attack by:

  • Avoiding known risk factors like cigarette smoking or exposure to secondhand smoke.
  • Getting aerobic exercise (such as walking, biking, or swimming) for at least 3 hours per week (for example, 30 minutes 6 days per week). If you haven't exercised much in the past, walking is a great way to start.
  • Reducing stress and learning stress-reduction techniques such as deep breathing and meditation. Yoga and tai chi, two forms of exercise that emphasize stretching, breathing, and meditating, can also help you reduce your stress level.
  • Eating a low-fat diet rich in antioxidants (like carotenoids, flavonoids, vitamins C and E) as well as fiber and stay at the proper weight for your height and age.

If you have high cholesterol, diabetes, or high blood pressure, follow your health care provider's instructions to keep these risk factors under control. Often, medications are necessary in addition to lifestyle changes. If you don't have heart disease yet or have not had a heart attack despite these risk factors, aggressive control can help prevent a problem from developing. And, if you already have heart disease, aggressive control of these risk factors can prevent further heart attacks or other problems related to heart disease.

Some studies have shown that healthy individuals who consume higher amounts of folic acid (vitamin B9) and vitamin B6 are less likely to develop atherosclerosis than those who consume lower amounts of these vitamins. The American Heart Association (AHA) believes, however, that there is not yet sufficient evidence to suggest that supplementation with B vitamins reduces the risk of atheroscerlosis or that taking these supplements prevents the development or recurrence of heart disease. The AHA does not currently recommend population-wide homocysteine screening, and suggests that folic acid, as well as vitamins B6, B12, and betaine requirements be met through diet alone. Individuals at high risk for developing atherosclerosis, however, should be screened for blood levels of homocysteine. If elevated levels are detected, a healthcare practitioner may recommend supplementation (see ).


Treatment Approach

The goal when treating a heart attack is to resume blood flow to the affected area of the heart immediately. When done promptly, heart muscle tissue and function can be preserved as much as possible. Three methods for doing this are drug therapy, angioplasty (using one of several methods to clear the blocked blood vessel, such as inflating a balloon inside it or holding it open with a device called a stent), and surgery.

Once treated acutely for a heart attack, changing lifestyle factors (including making important nutritional changes) and taking medications as prescribed as well as, possibly, supplements is very important for avoiding recurrent heart attacks and even death. Certain herbal remedies as well as relaxation techniques may also be considered.


Lifestyle

Attending cardiac rehabilitation following a heart attack can significantly improve many of your risk factors for heart disease, including high cholesterol, high blood pressure, extra weight, high homocysteine, and elevated C-reactive protein. This improvement, in turn, lowers your chances for repeat heart attacks. Cardiac rehabilitation programs generally involve comprehensive education on diet, physical activity, and relaxation with participation in a supervised exercise and stress reduction program.

To maintain the positive effects on both your risk factors and your heart, you must continue to follow the healthy habits taught in cardiac rehab, like exercise and eating properly, beyond the structured program (which usually lasts 3 months).

The AHA recommends that you eat the following to prevent the occurrence (or recurrence) of a heart attack:

  • A variety of fruits and vegetables (5 to 9 servings/day)
  • A variety of grain products, with an emphasis on whole grains (6 or more servings/day)
  • At least 2 servings of fish per week
  • Limited total fat intake to <30% and saturated fat to <7% of energy. Replace dietary saturated fats and trans fatty acids (for example, hydrogenated oils and fried foods) with monounsaturated and polyunsaturated fats (including foods rich in omega-3 fatty acids). Food sources of omega-3 fatty acids include fatty fish (such as salmon), flaxseed and flaxseed oil, soybean oil, canola oil, and nuts.
  • Limited amounts of dairy products to low-fat or fat free items (2 to 4 servings/day)
  • Limited sodium intake to 6 grams per day
  • Limited alcohol intake to 2 drinks/day for men and 1 drink/day for women
  • Maintain a healthy body weight by matching calorie intake to energy needs; this includes a moderate level of regular physical activity (30 to 60 minutes within your target heart range most days per week)

Medications

Aspirin and nitroglycerin are essential for improving blood flow. Nitroglycerin does so by widening the blocked artery, while aspirin does so by thinning the blood and preventing the formation of blood clots. Your health care provider may also prescribe one of several blood thinners listed below to improve blood flow in the blocked artery.

  • Streptokinase (SK)
  • Tissue plasminogen activator
  • Anisoylated plasminogens streptokinase activator complex—more expensive but longer anti-clotting activity than streptokinase
  • Heparin

Additional medications needed during acute treatment of a heart attack include:

  • Beta blockers—reduce cardiac rupture, new heart attacks, irregular heart beat; various side effects
  • Angiotensin-converting enzyme (ACE) inhibitors—reduce high blood pressure
  • Pain control—morphine sulfate, intravenous
  • Oxygen—by a tube inserted into your nose, as needed

After the emergent treatment of a heart attack, there are number of medications that will be continued or considered by your physician to improve your risk factors and lower your chances of having another heart attack. Cholesterol lowering drugs, beta-blockers to decrease the workload of the heart, ACE inhibitors, other blood pressure medications, and aspirin or another type of blood thinner are amongst the possible drugs he or she will recommend.


Nutrition and Dietary Supplements

In addition to the recommendations listed under Lifestyle, the AHA suggests that individuals who have heart disease follow the more specialized recommendations below, depending on what types of risk factors you have.

Diets for People with High Cholesterol

The National Cholesterol Education Program (NCEP) recommends saturated fat intake of no more than 7% of total calories, cholesterol limited to less than 200 mg/day, little to no trans fatty acids (such as fried and partially hydrogenated foods), intake of both plant stanols/sterols (2 grams/day) and soluble fiber (10 to 25 grams/day), weight loss, and exercise.

Studies have also shown that replacing dietary animal protein with soy protein may reduce total cholesterol, LDL ("bad") cholesterol, and triglycerides (a major form of fat in the blood) without affecting HDL ("good") cholesterol levels. The AHA also recommends a diet high in unsaturated fat diet rather than a very low-fat diet for individuals with a condition called "metabolic syndrome" marked by high triglycerides, low HDL cholesterol, obesity, high blood pressure, and/or diabetes).

Diets for People with High Blood Pressure

The Dietary Approaches to Stop Hypertension (DASH) emphasizes a diet rich in fruits, vegetables, and low-fat or non-fat dairy products to provide high intake of potassium, magnesium, and calcium sources. Sodium intake should be less than 6 g/day. Weight loss, regular physical activity, and limiting of alcohol intake are also very important factors for lowering blood pressure.

Mediterranean Diet

The Mediterranean Style Diet is comprised of whole grains, fresh fruits and vegetables, fish, olive oil, and moderate, daily wine consumption. Unlike the AHA diets, the Mediterranean Style Diet is not low in all fats; it is low in saturated fat but high in monounsaturated fatty acids. In a long-term study of 423 patients who suffered a heart attack, those who followed a Mediterranean Style Diet had a 50% to 70% lower risk of recurrent heart disease compared with controls who received no special dietary counseling. The intervention diet emphasized bread, root and green vegetables, daily intake of fruit, fish and poultry, olive and canola oils, margarine high in alpha-linolenic acid (an omega-3 polyunsaturated fatty acid found in flaxseed, walnuts, and canola oil), along with discouragement of ingestion of red meat and total avoidance of butter and cream.

Supplements and Vitamins

Bromelain

Bromelain, which has anti-inflammatory properties and antithrombotic properties (meaning that it may prevent blood clot formation), may prove to have a useful role in treating angina and preventing heart attacks.

Coenzyme Q10

Researchers believe that the beneficial effect of CoQ10 in the prevention and treatment of heart disease is due to its ability to improve energy production in cells, inhibit blood clot formation, and act as an antioxidant. One important study, for example, found that people who received daily CoQ10 supplements within 3 days of a heart attack were significantly less likely to experience subsequent heart attacks and chest pain. In addition, these same patients were less likely to die of heart disease than those who did not receive the supplements.

Folic Acid, Vitamin B6, Vitamin B12, Betaine

Many studies indicate that patients with elevated levels of the amino acid homocysteine are more likely to develop coronary artery disease. Homocysteine levels are strongly influenced by dietary factors, particularly vitamin B9 (folic acid) along with vitamin B6, vitamin B12, and betaine. Folic acid, along with these other B vitamins, breaks down homocysteine in the body. Therefore, taking a multivitamin with adequate vitamin B complex, particularly folic acid (at least 400 micrograms) can be very helpful if you have heart disease. Talk to your doctor about folic acid and the other B vitamins. Be sure to ask whether you should take folic acid or other vitamin B supplements and how much he or she thinks you should take. Some doctors recommend higher amounts of folic acid when you already have heart disease, especially if you have an elevated homocysteine level. Blood tests to follow how your homocysteine level responds to folic acid supplements may be performed. This helps determine just the right amount of folic acid for you.

L-Carnitine

Studies suggest that people who take L-carnitine supplements soon after suffering a heart attack may be less likely to have a subsequent heart attack, die of heart disease, experience chest pain and abnormal heart rhythms, or develop congestive heart failure. (Congestive heart failure is a condition that leads to a back up of blood into the lungs and legs because the heart loses its ability to pump blood efficiently).

In addition, people with coronary artery disease who use L-carnitine along with standard medications may be able to sustain physical activity for longer periods of time.

Magnesium

Magnesium is essential to heart health. This mineral is particularly important for maintaining a normal heart rhythm and is often used by physicians to treat an irregular heartbeat (arrythmia). Results of studies using magnesium to treat heart attack survivors, however, have been inconsistent. Some studies have reported reduced death rates as well as fewer arrythmias and improved blood pressure when magnesium is used as part of the treatment following a heart attack. But, again, not all research trials agree. In a hospital setting, if you have had a heart attack, the doctor will determine if magnesium supplementation, either intravenously or orally, is necessary.

Omega-3 Fatty Acids

There is strong evidence that omega-3 fatty acids from fatty, cold-water fish (namely EPA and DHA) can help prevent and treat atherosclerosis by inhibiting the development of plaque and blood clots. In fact, taking omega-3 fatty acid supplements every day after a heart attack may reduce your risk of a subsequent heart attack or a stroke and improve your chances for survival.

Because omega-3 fatty acids from fish oil can thin your blood, care MUST be taken if using these supplements in conjunction with blood thinners like warfarin. Talk to your doctor before using such supplements. If you are on warfarin and taking omega-3 fatty acids, your bleeding time should be followed very closely.

Other foods rich in another kind of omega-3 fatty acid called alpha-linolenic acid (ALA) are walnuts, flaxseeds, soybeans, pumpkin seeds, and flaxseed, canola (rapeseed), soybean, and walnut oils. Walnuts, and possibly other food sources of ALA, may help improve endothelial function.

Omega-3 fatty acids can also help improve certain risk factors for heart disease like high blood pressure, high cholesterol, and depression.

Selenium

Low levels of selenium in your body may worsen atherosclerosis or even increase your chances for a heart attack. It is not known, however, whether selenium supplementation can prevent either a heart attack or development and progression of atherosclerosis. Although animal studies suggest that selenium might have such positive benefits, research in people is needed. Some researchers are concerned, however, that selenium supplements may minimize the benefits of cholesterol lowering drugs. Until more information is available regarding supplementation, it is best to obtain adequate amounts of selenium through your diet.

Vitamin C

Results of scientific studies regarding the benefit of vitamin C for heart disease or stroke is somewhat confusing. While not all of the studies agree, some information suggests that vitamin C may help protect blood vessels from the damaging effects that lead to or result from atherosclerosis.

For example, those with low levels of vitamin C may be more likely to have a heart attack, stroke, or peripheral artery disease. (Peripheral artery disease is the term used to describe atherosclerosis of the blood vessels to the legs. This can lead to pain with walking, known as intermittent claudication.)

In terms of damage that can cause atherosclerosis, some studies have shown that vitamin C helps prevent oxidation of LDL (bad) cholesterol (a process that contributes to plaque buildup in the arteries) as well as other negative outcomes related to oxidative stress and improve endothelial dysfunction.

Under most circumstances, dietary vitamin C is adequate for protecting against the development of or consequences from cardiovascular disease. If you have low levels of this nutrient, however, and find it difficult to obtain through dietary sources, a knowledgeable healthcare provider may recommend vitamin C supplements.

Vitamin E

Vitamin E helps prevent arteries from clogging by blocking the conversion of cholesterol into the waxy fat deposits called plaque that stick to blood vessel walls. Vitamin E also thins the blood, allowing for blood to flow more easily through arteries even when plaque is present and it may work together with other antioxidants to improve endothelial function.

Many studies over the last decade or two have reported beneficial results from use of vitamin E supplements as part of a prevention strategy for heart disease and other types of cardiovascular disease. However, four large, well-designed trials have called this practice into question. Many experts conclude, therefore, that obtaining vitamin E through dietary sources, along with other antioxidants from foods, is the way to go for preventing heart disease and its consequences. Supplements do not appear, at this time, to be necessary.


Herbs

Herbs should not be used in place of IMMEDIATE medical attention for a heart attack. Herbs can be used as general heart tonics and for the treatment of conditions associated with MI, like atherosclerosis, congestive heart failure, high cholesterol levels, high blood pressure, and obesity. See the articles on these condition topics for further information.

Bilberry (Vaccinium myrtillus) and other Flavonoids

A close relative of the cranberry, bilberry fruits contain flavonoid compounds called anthocyanidins. Flavonoids are plant pigments that have excellent antioxidant properties. This means that they scavenge damaging particles in the body known as free radicals and may help prevent a number of long-term illnesses including heart disease and diabetes. Animal studies have found that anthocyanidins and other flavonoids including quercetin, resveritrol, and catechins (all found in high concentration in red wine) may strengthen blood vessels, improve circulation, and prevent the oxidation of LDL ("bad") cholesterol. Research in people is needed.

Dong Quai (Angelica sinensis)

When used in combination with ginseng (Asian ginseng) and astragalus (Astragalus membranaceus), dong quai decreased symptoms of chest pain and improved exercise tolerance in a small group of people with heart disease. Talk to your doctor about whether use is safe and appropriate for you.

Garlic (Allium sativum)

Studies suggest that fresh garlic and garlic supplements may prevent blood clots and destroy plaque. Garlic may also improve risk factors for heart disease, including high blood pressure, high cholesterol, and diabetes. An animal study suggests that garlic may help lower homocysteine levels as well. If you take aspirin or other blood thinners (like warfarin [Coumadin], ACE inhibitors (a class of blood pressure medications), sulfonylureas for diabetes, or statins for high cholesterol, talk to your doctor before using garlic supplements. Often adding garlic to your diet is enough.

Ginseng, Asian (Panax ginseng)

Ginseng is considered an adaptogen, meaning that this herb can help you and your body cope with stress. Ginseng, especially Asian ginseng, may reduce endothelial cell dysfunction, thereby rendering a heart attack less likely. Ginseng may also help raise HDL (the good cholesterol), while reducing total cholesterol levels. Ginseng may thin your blood and, therefore, should not be used with warfarin (Coumadin) unless advised and followed closely by your doctor. In addition, ginseng should NOT be used if you have high blood pressure unless specifically instructed by a qualified practitioner.

Green Tea (Camellia sinensis)

Population studies indicate that the antioxidant properties of green tea may prevent atherosclerosis, particularly in the coronary arteries. In addition, although much more research is needed, it may help you lower your cholesterol and your weight.

Gugulipid (Commiphora mukul)

Used in Ayurvedic medicine to treat high cholesterol levels. Certain ingredients in this herbal remedy may have antioxidant properties and may therefore convey health benefits similar to hawthorn, garlic, and green tea.

Hawthorn (Crataegus monogyna)

Used traditionally as a remedy for cardiovascular diseases. Animal and laboratory studies demonstrate that this herb has antioxidant properties that help protect against the formation of plaques and may help control high cholesterol and high blood pressure.

Pseudo ginseng root/notoginseng root (Panax notoginseng)

Used in Traditional Chinese Medicine to treat chest pain and coronary artery disease. Laboratory studies suggest this herb may help prevent blood clots and protect against the formation of plaques.

Turmeric (Curcuma longa)

Early studies suggest that turmeric may prove helpful in preventing the build up of atherosclerosis in one of two ways. First, in animal studies an extract of turmeric lowered cholesterol levels and inhibited the oxidation of LDL ("bad") cholesterol. Oxidized LDL deposits in the walls of blood vessels and contributes to the formation of atherosclerotic plaque and to disruption of the blood vessel wall.

Turmeric may also prevent platelet build up along the walls of an injured blood vessel. Platelets collecting at the site of a damaged blood vessel cause blood clots to form and blockage of the artery. Studies of the use of turmeric to prevent or treat heart disease in people would be interesting in terms of determining if these mechanisms discovered in animals apply to people at risk for this condition.


Homeopathy

Homeopathy should NEVER be used instead of immediate medical attention for a heart attack. Homeopathy may, however, be used to help reduce your risk factors for heart disease and its consequences. Although few studies have examined the effectiveness of specific homeopathic remedies, professional homeopaths would recommend appropriate therapy to lower high blood pressure and cholesterol. Before prescribing a remedy, homeopaths take into account your constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath would assess all of these factors when determining the most appropriate remedy for you as an individual.


Acupuncture

Acupuncture may be useful for reducing risk factors for heart disease. It is considered an excellent treatment for people who wish to quit smoking and some studies indicate that it may aid in weight loss as well as cholesterol and blood pressure reduction. Acupuncture may also help you recover more quickly from a heart attack, particularly if by pass surgery was necessary.


Massage and Physical Therapy

Although few studies have examined the effectiveness of massage therapy for heart disease, massage has a relaxing effect and reduces stress-related hormone levels. Lowering stress hormone levels can lower cholesterol and blood pressure and may, therefore, prove to be beneficial for reducing your risk of heart disease. In addition, relaxation techniques may help you comply with habits necessary to reduce the risk of heart disease, such as dieting, quitting smoking, and exercising. Also, at least one study has found that massage can lower blood pressure.


Mind/Body Medicine

There is some evidence that the use of prayer may help you recover more quickly and successfully from a heart attack. In fact, a few studies conducted suggest that you don't have to be the one praying. Others, even people you don't know, praying for you may translate into clinical benefit. This is called intercessory prayer or distance healing.


Other Considerations
Prognosis and Complications

The expected outcome varies with the amount and location of damaged tissue. The outcome is worse if there is damage to the electrical conduction system (the impulses responsible for guiding heart contraction).

Heart attack accounts for 1 out of every 5 deaths. It is a major cause of sudden death in adults. Approximately one-third of heart attacks are fatal. If the person is alive 2 hours after an attack, the probable outcome for survival is good, but may include complications such as:

  • Irregular heart rhythm, called an arrhythmia; this may increase your chances for sudden death and may require electrical cardioversion or placement of a device to protect you from sudden death or a pacemaker to direct the electrical system of your heart.
  • Congestive heart failure
  • Shock
  • Infarct extension (extension of the amount of affected heart tissue) or recurrent heart attack(s)
  • Pericarditis (infection around the lining of the heart)
  • Pulmonary embolism (blood clot in the lungs)
  • Complications of treatment (For example, thrombolytic agents increases the risk of bleeding.)

The good news, however, is that heart attacks are not necessarily disabling, especially when there are no complications. In fact, full recovery is possible including resumption of a normal lifestyle and usual activities, even sexual activity. Cardiac rehabilitation and sticking with lifestyle changes can help lead to a positive recovery.


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Review Date: April 2004
Reviewed By: Participants in the review process include: Jacqueline A. Hart, MD, Department of Internal Medicine, Division of Cardiac Rehabilitation, Newton-Wellesley Hospital, Newton, Ma., and Senior Medical Editor, A.D.A.M., Inc.; Lonnie Lee, MD, Internal Medicine, Silver Springs, MD; Richard A. Lippin, MD, President, The Lippin Group, Southampton, PA.

Copyright © 2004 A.D.A.M., Inc

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