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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 86-92

Varied profile in acute coronary syndrome: One size does not fit all


1 Department of Medicine, Pramukh Swami Medical College, Ahmedabad, Gujarat, India
2 Department of Medicine, Pramukh Swami Medical College, Karamsad, Gujarat, India
3 Department of Medicine, Pramukh Swami Medical College, Vadodara, Gujarat, India
4 Department of Medicine, Pramukh Swami Medical College, Anand, Gujarat, India

Date of Submission13-Mar-2021
Date of Decision14-Jun-2021
Date of Acceptance17-Jun-2021
Date of Web Publication05-Apr-2022

Correspondence Address:
Dr. Labani M Ghosh
Department of Medicine, Pramukh Swami Medical College, D 403, Sepal Residency, New Alkapuri, Vadodara - 390 021, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajim.ajim_33_21

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  Abstract 


Objective: The objective was to study the clinical profiles of patients undergoing coronary angiography (CAG). Setting and Design: It was a cross-sectional retrospective study of 207 patients who have undergone CAG at B and M Cardiac Centre, Shree Krishna Hospital, from study period of September 2018 to April 2019. Materials and Methods: The patients included were those undergoing CAG of more than 20 years of age. Those who underwent coronary artery bypass graft in the past or re-do CAG and those under 20 years of age were excluded. Data were entered and analyzed with Epi Info version 7. Statistical Analysis: Association between categorical variables was tested with Chi-square test. P <0.05 was considered statistically significant. Observations and Results: Males were higher in the age group of 50–59 years while females predominated in the higher age groups. Hypertension was the most common comorbidity (43.48%) followed by diabetes. Males presented predominantly with anterior and inferior wall myocardial infarction (MI) whereas non-ST-elevation MI, unstable angina, chronic cardiac failure, and atypical presentation were higher in females. Twenty-two percent had normal electrocardiogram whereas a CAG was normal in 22.7% of the patients. Left anterior descending (LAD) involvement was predominant in both males (78.81%) and females (78.57%). Single-vessel disease (SVD) was significantly higher in females (45%). Chest pain (87.4%) and dyspnea (23.2%) were the most common complaints. Smoking was the most significantly associated addiction (P < 0.05). Conclusion: The most common presentation is unstable angina followed by anterior wall MI (AWMI). SVDs are common in females, but when presented with AWMI, triple-vessel disease was found to be most commonly associated with AWMI in females than males. As age progresses, the number of vessels involved increases. Echo is best correlated with anterior and inferior wall MI. LAD is the most common culprit vessel in both males and females. Multiple vessel involvement was common in diabetics. SVD was most common in hypertensives.

Keywords: Acute coronary syndrome, clinical profile, demography, echo, electrocardiogram


How to cite this article:
Shah C, Bhende P, Ghosh LM, Mannari JG. Varied profile in acute coronary syndrome: One size does not fit all. APIK J Int Med 2022;10:86-92

How to cite this URL:
Shah C, Bhende P, Ghosh LM, Mannari JG. Varied profile in acute coronary syndrome: One size does not fit all. APIK J Int Med [serial online] 2022 [cited 2022 May 26];10:86-92. Available from: https://www.ajim.in/text.asp?2022/10/2/86/342538




  Introduction Top


Cardiovascular disease (CVD) led to 17.5 million deaths in 2012.[1] More than 75% of these deaths occurred in developing countries. Coronary heart disease (CHD) is epidemic in India. The Registrar General of India reported that CHD led to 17% of total deaths and 26% of adult deaths in 2001–2003, which increased to 23% of total and 32% of adult deaths in 2010–2013. The World Health Organization and Global Burden of Disease Study also have highlighted increasing trends in years of life lost and disability-adjusted life years from CHD in India.[1],[2] In India, studies have reported increasing CHD prevalence over the last 60 years, from 1% to 9%–10% in urban populations and <1% to 4%–6% in rural populations. Case–control studies have reported that important risk factors for CHD in India are dyslipidemias, smoking, diabetes, hypertension, abdominal obesity, psychosocial stress, unhealthy diet, and physical inactivity. Other striking features of CVD epidemiology in India are high mortality rates, premature CHD, and increasing burden.[3],[4] CVDs and its associated complications alone account for approximately 12 million deaths annually in the Indian subcontinent.[5],[6] Studies carried out in India, and other places suggest that Asians in general and Indians, in particular, are at an increased risk of myocardial infarction (MI) at a younger age (<40 years).[7]


  Materials and Methods Top


It was a cross-sectional retrospective study conducted in B and M Heart Centre, Shree Krishna Hospital, from September 2018 to April 2019. Two hundred and seven subjects of age more than or equal to 20 years being admitted in the B and M Heart Centre, Shree Krishna Hospital, and undergoing coronary angiography (CAG) in the stipulated period were included. Those aged more than 20 years of age, with a history of previous coronary artery bypass graft (CABG), or a re-do CAG were excluded. Their data including history, risk factors, addictions, electrocardiogram (ECG) findings, echo, and CAG reports were derived from SOLACE. Approved pro formas were duly filled and the compiled data were studied for associations and correlations using Epi Info version 7. Categorical data were expressed as percentages and continuous data were expressed as mean and standard deviation. Association between categorical variables was tested with Chi-square test. P < 0.05 was considered statistically significant.

Inclusion criteria

  1. All patients more than 20 years of age
  2. Subjects undergoing CAG
  3. Those admitted in B and M Heart Centre, Shree Krishna Hospital, between September 2018 and April 2019.


Exclusion criteria

  1. Age <20 years
  2. Past history of CABG or a re-do CAG.


Ethical issues: None


  Results Top


The mean age of the study participants was 55.60 years. Approximately 90% of the patients were above the age of 40 [Figure 1]. 36.7% were in the age group of 50–59 years while 29% were in the age group of 60–69 years. Seventy percent of the study participants were male and 30% were female [Table 1].
Figure 1: Age distribution of study participants (n = 207)

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Table 1: Gender distribution of study participants (n=207)

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Males were higher among the age group of 50–59 years (38.62%) while females were higher among the age group of 60–69 years (40.32%) [Figure 2].
Figure 2: Age- and sex-wise distribution among study participants (n = 207)

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Chest pain was the main complaint (87.4%) [Figure 3]. Dyspnea was present among 23.2% while syncope and palpitation were seen among 2.9% of each among the patients. As per [Table 2], overall, the most common diagnosis was unstable angina (28.5%), males (26.21%) and females (33.87%). Anterior wall MI (AWMI) was seen among 26.21% of males and 11.29% of females while inferior wall MI was seen among 22.76% of males and 9.68% of females.
Figure 3: Complaints among study participants (n = 207)

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Table 2: Diagnosis among study participants (n=207)

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Non-ST-elevation MI (NSTEMI) was seen among 11.11% of all patients. Among males, NSTEMI was seen in 8.28%, and among females, it was seen in 17.74%. There were 33.33% of smokers, all of which were male. Tobacco chewing was seen among 15.94% of the patients, 20.70% in males and 4.84% in females [Table 3]. Hypertension was seen among 43.48% of the study participants while 33.33% of the patients were known cases of diabetes mellitus. Dyslipidemia and CCF were seen among 2.9% of the patients. Chronic obstructive pulmonary disease, coronary artery disease (CAD), and CVA were seen among 1.4%, 7.7%, and 2.4%, respectively. Around 22% of the study participants were having normal ECG. The most common ECG finding among study participants was AWMI (33.8%). Next to AWMI, there was inferior wall MI (15.9%). Arrhythmias were seen among 2.9% of the patients. LBBB and RBBB were seen among 1.4% and 0.5% of the study participants, respectively [Table 4].
Table 3: Addictions among study participants (n=207)

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Table 4: Electrocardiogram findings among study participants (n=207)

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Normal CAG was seen in 22.7% of the study participants while 23.7% had single-vessel disease (SVD). Double-vessel disease (DVD) and triple-vessel disease (TVD) were seen among 30.9% and 22.7% of the study participants, respectively [Table 5].
Table 5: Coronary angiography findings among study participants (n=207)

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Involvement of left anterior descending (LAD) artery among males was 78.81% and females was 78.57%. Among males, involvement of right coronary artery (RCA) and left circumflex (LCX) artery was also high as compared to females, but the association was not statistically significant [Table 6].
Table 6: Coronary vessels involved among study participants (n=160; normal coronary angiographics excluded)

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SVD was found higher among the age group of 30–39 years (57%). DVD was found higher among the age group of 50–59 years (46.6%) and 42% in those more than 70 years of age. TVD was found higher among the age group of >70 years [Table 7]. However, the relation of age with CAD was statistically not significant.
Table 7: Association of age with coronary artery disease (n=160)

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As per [Table 8], SVD was significantly higher among females (45%) than males, with DVD and TVD being more common in males by 41% and 33%, respectively. There was no significant association between gender and CAD with NSTEMI (P > 0.05) although DVD and TVD were high among males as compared to females [Table 9].
Table 8: Association of gender with coronary artery disease among patients diagnosed with non-ST-elevation myocardial infarction

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Table 9: Association of gender with coronary artery disease (total n=160)

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SVD and DVD are higher among males with STEMI while TVD was higher among females with STEMI (30.76%). The relation between CAD with STEMI and Gender was not statistically significant (P > 0.05) [Table 10].
Table 10: Association of gender with coronary artery disease among patients diagnosed with ST-elevation myocardial infarction

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DVD (54.5%) and TVD (27.74%) were high among diabetic study participants as compared to nondiabetics, while SVD was high among nondiabetics. The relation between diabetes and CAD was not statistically significant (P > 0.05) [Table 11].
Table 11: Association of diabetes with coronary artery disease (n=160)

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SVD was higher in percentages among hypertensives as compared to nonhypertensives while DVD and TVD were higher among nonhypertensives (P > 0.05) [Table 12].
Table 12: Association of hypertension with coronary artery disease (n=160)

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RCA was most commonly involved in inferior wall MI (43.75%) followed by AWMI (31.25%). LMCA was the most common culprit in AWMI (43.75%) and inferior wall MI (31.25%). LAD was involved among 44.35% and 25.81% in AWMI and IWMI patients, respectively. LCX was involved among 28.71% of the patients each in AWMI and ASMI [Table 13].
Table 13: Association of electrocardiogram findings and vessel involvement

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  Discussion Top


The mean age of the study participants was 55.60 years. A study done by Adhikari and Baral and Joshi et al. had a mean age of 59.98 ± 12.99 and 58.9 ± 11.8, respectively, which is similar to our study.[8],[9] In our study, approximately 90% of the patients were above the age of 40 and around 40% were above 60 years of age group. Holay et al. found that 53.3% of the enrolled patients in their study were of >60 years of age.[10] In our study, 70% of the study participants were male and 30% were female. Males were higher among the age group of 50–59 years (38.62%) while females were higher among the age group of 60–69 years (40.32%). A study done by Adhikari and Baral demonstrated that with increasing age, the number of females with MI also increased.[8] The most common clinical complaint was chest pain (87.4%) in our study. Similar percentages (86.36%) for chest pain were found in Adhikari and Baral[8] while Sharma et al. found atypical symptoms such as abdominal pain, dizziness, and syncope as the presenting complaints in the elderly.[11] In our study, SVD was found higher among the age group of 30–39 years (57.14%). DVD was found higher among the age group of >70 years (47.37%). TVD was found higher among the age group of >70 years (42.10%). However, the relation of age with CAD was statistically not significant. In a study done by Ramya et al., angiographic CAD was found to be more among patients aged over 40 years. A total of 45 cases aged over 40 years were found to have one or more coronary vessel diseases and 26 of those were between the age group of 41 and 60 years and 19 cases were aged above 60 years.[12] In our study, SVD was significantly high (45.24%) among females than males (25.42%) while DVD and TVD were significantly high among males as compared to females (P < 0.05). Similar proportion has been found in Dave et al. and Ezhumalai and Jayaraman (P < 0.05).[13],[14] A study done by Ramya et al. found that DVD was found to be more when compared to SVD or TVD with a total of 20 cases and most of those were in males.[12] In the present study, NSTEMI was seen among 11.11% of all patients while STEMI was seen among 40.58%. Adhikari and Baral showed similar results in which STEMI was more prevalent (90.15%) as compared to NSTEMI (9.84%)[8] while Sharma et al. had found NSTEMI among 50.97% as compared to STEMI (49.03%).[11] A proportion of DVD and TVD were higher in males in NSTEMI, while in females, TVD was common occurrence in STEMI. In our study, gender was not significantly associated with either STEMI or NSTEMI patients while a study done by Weissler-Snir et al. found that female sex is independently associated with multivessel disease as compared to SVD among STEMI.[15]

In the present study, 30.6% had SVD. DVD and TVD were seen among 40% and 47% of the study participants, respectively. Sukhija et al. reported SVD in 11%, DVD in 27%, and TVD in 45% among 82 patients undergoing angiography.[16] In a study done by Ramya et al., CAG showed that 48% of the study population had a SVD and 32% with DVD while 20% had TVD. In the present study, involvement of LAD artery (73.81%) was involved most followed by RCA (63.56%). Similar findings were seen in Ramya et al.[12] Smokers were 33.33% and all of them were male. However, the association between smoking and CAD was not significant. A study done by Beig et al. found that smoking was the most common cardiovascular risk factor observed in our population (79.8%), and was more frequent in males (93.6% in males vs. 3.2% in females, P < 0.0001).[17] Diabetes was prevalent among 33.33% of the patients in our study. Among diabetics, 68.11% were male and 31.89% were female. A study done by Afsar et al. found that the prevalence of CAD is more in DM patients (82.22%) compared to their non-DM counterparts (56%).[18] In the present study, the incidence of DVD (54.55%) and TVD (27.77%) was high among diabetic study participants as compared to nondiabetics while SVD was high among nondiabetics. The relation between diabetes and CAD was not statistically significant (P > 0.05). Afsar et al. also demonstrated that diabetic patients had a higher prevalence of TVD (32.43% versus 26.19%) and a lower prevalence of SVD.[18] Hypertension was seen among 43.48% of the study participants in our study. Among hypertensives, 58.89% were male and 41.11% were female. SVD was higher in percentages among hypertensives as compared to nonhypertensives while DVD and TVD were higher among nonhypertensives. The relation between hypertension and CAD was not statistically significant (P > 0.05). Sukhija et al. reported more multivessel disease in hypertensive patients than in nonhypertensives (P < 0.0003).[16]

The most common ECG finding among study participants was AWMI (33.8%). Next to AWMI, there was inferior wall MI (15.9%). In our study, it was found that a total of 85.7% of all patients with AWMI (AWMI + ASMI + ALMI) showed ECG changes correlating with the findings while 68% of the patients with IWMI had corresponding correlating basal wall hypokinesia. Shah et al., in their study, agreed that ECG and echocardiography have a good correlation to localize the site of infarction, but in echocardiography, segmental wall motion abnormalities are frequently more extensive than on ECG and may occur in areas, apparently remote from the putatively infracted zone.[19] LAD artery occlusion was involved among 44.35% in AWMI patients in the present study. This is in agreement with a previous study by Engelen et al. and Ghosh et al.[20],[21] Inferior wall MI is more commonly seen among occlusion of RCA, LAD, and LCX. This result again confirms the results from Gupta et al. and Verouden et al.[22],[23]

Furthermore, an important finding in our study was that total 46 patients were found to have normal ECGs, out of which 22 patients showed normal findings and 24 showed significant CAD. In a study by Joorey in 1997, the ECG is found to be completely normal 15% of the time.[24]


  Conclusion Top


The salient points brought put from the study were as follows:

  • The most common diagnosis was unstable angina which is higher in females. AWMI and inferior wall MI were higher among males
  • SVD was significantly higher in females in general while DVD and TVD occurred more in males
  • Females with STEMI showed a propensity for TVD
  • Among smokers, DVD was high as compared to nonsmokers
  • DVD (34.78%) and TVD (21.74%) were high among diabetic study participants as compared to nondiabetics while SVD was high among nondiabetics
  • Normal ECGs may have findings of CAD.


There was a smaller turnover of female patients in our cardiac center. The reasons vary from financial to social stigmas. Thereby, females are underdiagnosed and often missed. As our study confirms, females are at risk almost at par with the male counterparts. There should be a lower threshold for performing interventional procedures in females. Normal ECG findings sometimes miss serious diagnosis since CAD cannot be ruled out even among normal ECGs. Patients presenting with atypical chest pain, especially females, should be investigated in detail since many noncardiac chest pains herald as serious cardiac manifestations. We suggest early risk stratification, identification of the disease, and its management which may prevent fatal outcomes in a large number of cases. Lifestyle modification and stress management is strongly advocated. A large sample and multicenter study should be carried out to explore for the roles of these risk factors so that appropriate policymaking and public health measures can be taken to prevent premature CAD and its serious ramifications.

Acknowledgments

We acknowledge all the authors for their valuable correlation as well as the department of statistics for helping us formulating our data into relevant results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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World Health Organization. WHO Global Status Report on Non-Communicable Diseases 2014. Geneva: World Health Organization; 2019.  Back to cited text no. 1
    
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Gupta R, Mohan I, Narula J. Trends in coronary heart disease epidemiology in India. Ann Glob Health 2016;82:307-15.  Back to cited text no. 2
    
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Banerjee AK, Kumar S. Guidelines for management of acute myocardial infarction. J Assoc Physicians India 2011;59:37-42.  Back to cited text no. 5
    
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Adhikari G, Baral D. Clinical profile of patients presenting with acute myocardial infarction. Int J Adv Med 2018;5:228-33.  Back to cited text no. 8
    
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Joshi P, Islam S, Pais P, Reddy S, Dorairaj P, Kazmi K, et al. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. JAMA 2007;297:286-94.  Back to cited text no. 9
    
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Holay MP, Janbandhu A, Javahirani A, Pandharipande MS, Suryawanshi SD. Clinical profile of acute myocardial infarction in elderly (prospective study). J Assoc Physicians India 2007;55:188-92.  Back to cited text no. 10
    
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Ramya N, Prabakaran V, Abbas A, Shankar SP. Study on risk factors and angiographic pattern of coronary artery involvement in patients presenting with angina. Int J Adv Med 2019;6:232.  Back to cited text no. 12
    
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Dave TH, Wasir HS, Prabhakaran D, Dev V, Das G, Rajani M, et al. Profile of coronary artery disease in Indian women: Correlation of clinical, non invasive and coronary angiographic findings. Indian Heart J 1991;43:25-9.  Back to cited text no. 13
    
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Ezhumalai B, Jayaraman B. Angiographic prevalence and pattern of coronary artery disease in women. Indian Heart J 2014;66:422-6.  Back to cited text no. 14
    
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Weissler-Snir A, Gurevitz C, Assali A, Vaknin-Assa H, Bental T, Lador A, et al. Prognosis of STEMI patients with multi-vessel disease undergoing culprit-only PCI without significant residual ischemia on non-invasive stress testing. PLoS One 2015;10:e0138474.  Back to cited text no. 15
    
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Sukhija R, Fahdi I, Garza L, Fink L, Scott M, Aude W, et al. Inflammatory markers, angiographic severity of coronary artery disease, and patient outcome. Am J Cardiol 2007;99:879-84.  Back to cited text no. 16
    
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Beig JR, Shah TR, Hafeez I, Dar MI, Rather HA, Tramboo NA, et al. Clinico-angiographic profile and procedural outcomes in patients undergoing percutaneous coronary interventions: The Srinagar registry. Indian Heart J 2017;69:589-96.  Back to cited text no. 17
    
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Afsar MN, Ahmed K, Rahman S. A comparative study of coronary angiographic (CAG) findings between diabetic and nondiabetic patients. Med Today 2014;26:95-9.  Back to cited text no. 18
    
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Shah PK, Pichler M, Berman DS, Maddahi J, Peter T, Singh BN, et al. Noninvasive identification of a high risk subset of patients with acute inferior myocardial infarction. Am J Cardiol 1980;46:915-21.  Back to cited text no. 19
    
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Engelen DJ, Gorgels AP, Cheriex EC, de Muinck ED, Ophuis AJ, Dassen WR, et al. Value of the electrocardiogram in localizing the occlusion site in the left anterior descending coronary artery in acute anterior myocardial infarction. J Am Coll Cardiol 1999;34:389-95.  Back to cited text no. 20
    
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Ghosh B, Indurkar M, Jain MK. ECG: A simple noninvasive tool to localize culprit vessel occlusion site in acute STEMI. Indian J Clin Pract 2013;23:590-5.  Back to cited text no. 21
    
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Gupta R, Sharma KK, Gupta A, Agrawal A, Mohan I, Gupta VP, et al. Persistent high prevalence of cardiovascular risk factors in the urban middle class in India: Jaipur heart watch-5. J Assoc Physicians India 2012;60:11-6.  Back to cited text no. 22
    
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Verouden NJ, Barwari K, Koch KT, Henriques JP, Baan J, van der Schaaf RJ, et al. Distinguishing the right coronary artery from the left circumflex coronary artery as the infarct-related artery in patients undergoing primary percutaneous coronary intervention for acute inferior myocardial infarction. Europace 2009;11:1517-21.  Back to cited text no. 23
    
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    Figures

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