Washington Lawyer magazine
January 2003

Feature Story
Death by Heart Attack

by Joan Indiana Rigdon

One day, at the age of 37, Frank Marino was doing what a lot of lawyers do every day. He was sitting in a meeting with his employer, a real estate management company owned by the beleaguered Haft family of Falls Church, Virginia. The family had built up a retail empire including Crown Books and Trak Auto, and was in the process of losing much of it to family squabbles. Marino was associate counsel for the real estate company.

As usual, the meeting was somewhat stressful, but it was “normal pressure,” Marino recalls. Status reports were requested, explanations given. “It wasn’t necessarily me. It could have been someone else that was getting questioned.”

And then Marino felt something in his chest.

For over a decade he had managed to keep his high blood pressure and high cholesterol under control with medication and exercise. But over the previous month he had undergone two angioplasties, following bouts of breathlessness and strange sensations in his arm and chest. The first time he felt the symptoms, he wasted a week before seeing a doctor because he could only get through to the doctor’s nurse, who erroneously told him that all he needed to do was change the dosage of his medication.

This time Marino had no doubt about what to do. He turned to his boss and said, “I think I have to call my doctor.”

His boss, the general counsel, accompanied him out of the room, and waited while Marino called his cardiologist. Minutes later Marino was on his way to the emergency room in a cab. For the third time in a month, the young lawyer was in grave danger of death by heart attack.

Without Warning

Many of us in the Washington area have thought a lot about death over the past few years, but mainly of threats least likely to kill us: terrorists, snipers, anthrax, and sharks, to name a few. To safeguard our lives, many of us chose not to fly, and not to breathe too deeply while opening our mail. Some of us even resorted to stooping over while pumping gas, just in case a sniper happened to be lurking nearby.

Meanwhile most of us haven’t done anything to protect ourselves from one of the leading killers in the nation: coronary heart disease, the buildup of fatty plaque in the arteries that often leads to heart attack. The American Heart Association estimates that 1.1 million Americans will have new or recurrent heart attacks this year. About 495,000 of these will die, and about half of those before they make it to a hospital.

It’s tempting to think that heart attacks are mostly for the old. In fact, nearly half of all heart attacks strike people under 65, according to the Framingham Heart Study, which is based on 50 years of data collected from more than 1,000 residents of Framingham, Massachusetts. Heart attacks aren’t common among people under age 45, but they do happen. Vice President Dick Cheney, for one, suffered his first heart attack at 37. Last year St. Louis Cardinals pitcher Darryl Kile died of a heart attack at 33.

Heart attacks often kill without warning. More than half of those who die suddenly from coronary heart disease had no previous symptoms of the disease, according to the Framingham Heart Study. The most common risk factors for heart attack are diabetes, smoking, obesity, high blood pressure, high cholesterol, and a family history of heart disease.

Lawyers may be especially susceptible, for two reasons: they often lead sedentary lifestyles and their work can be very stressful.

According to a November 1999 study published in the Journal of the American Medical Association, people with sedentary lifestyles are 30 times more likely to suffer a heart attack when they push their physical limits. That “push” could be something as simple as trying to move furniture or run for a bus.

Stress is a risk factor, too. Last year researchers at Utrecht University in the Netherlands reported a strange coincidence. On June 22, 1996, Holland recorded a 50 percent jump in the number of men aged 45 and older who died of heart attack or stroke. That happened to be the same day the Dutch soccer team was eliminated from the European soccer championship. David Brown, associate professor at the Albert Einstein College of Medicine in New York, documented a similar coincidence. On January 17, 1994, Los Angeles County recorded a 110 percent spike in hospital admissions for heart attacks. That was the day of the Northridge earthquake.

Of course, some lawyers handle risk better than others. “Being a lawyer in and of itself does not confer a greater risk of heart attack,” says Joel Rosenberg, director of clinical cardiology at the George Washington University Hospital. “[But] if you’re with one of the larger, high-powered firms and they demand that you work 16 hours a day under very stressful conditions, that can hardly be good for yourself.”

Though most people don’t talk about their heart attacks, it’s clear that coronary heart disease has taken its toll on the Washington, D.C., legal community, young and old. J. Gordon Forester, immediate past president of the Bar Association of the District of Columbia, is recovering from a quadruple bypass. And this year marks the 13th anniversary of Lawyers Have Heart, a 10-kilometer race and fundraiser for the American Heart Association founded by D.C. lawyers Richard Frank and Alan Charles Raul after some of their colleagues suffered heart attacks.

To get a better idea of how young, stressed professionals endure and survive heart attacks, the Washington Lawyer interviewed three survivors, including two lawyers and one journalist. All three suffered their heart attacks between the ages of 37 and 42; two went for at least a few days without treatment because they were misdiagnosed and one, a trim jogger and veggie burger fan, had no risk factors at all. Here are their stories.

Race Against Time

A lot of people end up dying from heart attacks because they don’t recognize the symptoms, which vary a lot by gender and from person to person. The symptoms can range from crushing chest pain to unusually clammy skin (see box). Vice President Dick Cheney has likened some of his symptoms to indigestion.

Some people recognize the symptoms, but die because they are too slow or embarrassed to call for help. They’re afraid of rushing to the emergency room only to find out they’re suffering from a muscle spasm.

Still the embarrassment of a false alarm may be worth it, considering the consequences of overlooking an actual heart attack. When an artery is blocked, the heart begins starving for oxygen. At a certain point the heart can no longer function, and stops. Once it does, death is close behind. Brain death begins about four to six minutes after someone experiences cardiac arrest. The American Heart Association estimates that the victim’s odds of surviving decrease by 7 to 10 percent with each minute that passes without treatment. After 10 minutes of full cardiac arrest, the victim will almost certainly die.

Yet many heart attack victims take their time getting to the hospital. Two years ago University of Minnesota epidemiologist Russell Luepker and colleagues studied nearly 60,000 adults who went to emergency rooms with heart attack symptoms. On average the patients took two hours and 20 minutes to arrive. Another study of heart attack patients, led by gerontologist Jerry Gurwitz of the University of Massachusetts, found that 40 percent of the patients took more than six hours to get to the hospital; 19 percent took over a day.

Among those most likely to delay: women, men living alone, and people who had never before experienced heart attack symptoms.

John Kelly is one of the lucky ones. Two summers ago, when he was 38, he survived a massive heart attack because he was relatively quick to recognize the symptoms and race to the hospital. Thanks in part to quick thinking by his wife, he made it to the emergency room in just 45 minutes.

Sense of Doom

Like a lot of people who have heart attacks, Kelly, a general assignment reporter for the Washington Post, seemed to be in relatively good shape. At five feet nine inches tall, he was only slightly overweight at 170 pounds. “I wasn’t a walking heart attack,” he recalls.

Yet in a subtle way, like a lot of Americans, he really was. Two years earlier, during a routine physical, his doctor told him he had high cholesterol. So Kelly cut back on fatty foods, including some of his favorites, corn dogs and rubens. He also started working out at the Silver Spring, Maryland, YMCA one to three times a week, though sometimes he missed going for three weeks in a row.

On July 17, 2001, Kelly walked into the Y, started as usual with the exercise bike, and immediately felt tired, more tired than his effort warranted. “The main thing I remember is this sweat,” he says. “I was really, really sweaty.”

Kelly didn’t know it, but he was experiencing one of the classic harbingers of a heart attack: sudden inability to perform usual exercise. He should have called 911 right away, but he didn’t recognize the symptom, so he continued biking for a total of 20 minutes. Then he plopped down on a nearby couch, and felt pressure in the middle of his chest and pain in his left arm.

Realizing he was sick, Kelly jumped in his minivan and made the five-minute drive home. His wife Ruth hadn’t left for work yet, and was surprised to see him home so soon. He told her his symptoms, including the pain in his left arm, between the shoulder and the elbow. “That’s what caused her to perk up,” says Kelly.

His wife immediately called 911. As first one and then another ambulance pulled up outside their home, Kelly felt a little embarrassed. “I think that’s a big thing for men. You have to sort of get over the embarrassment,” he says. After all, he reasons, “that’s really what they live for, is to burst into people’s houses with stretchers and IVs, and so they burst into ours.”

As the ambulance sped to Washington Adventist Hospital in Takoma Park, sirens wailing, the paramedics gently chided Kelly for not having called them sooner, from the gym.
Meanwhile, Kelly felt a sense of impending doom, which by itself is one of the symptoms of a heart attack. “When your body is really seriously messed up, it knows something is wrong,” he says. “It thinks you’re going to die. And I thought, oh [no], I’m going to die.”

As it turned out, Kelly came quite close. In a typical heart attack fat builds up inside an artery and is then covered by a fibrous cap. The plaque and cap form a bulge that restricts the flow of blood. Most attacks are triggered when “unstable” plaque breaks, tearing a hole in the artery wall. The body responds by sending red blood cells to patch the hole, but those cells form a clot, which stops the blood flow.

In Kelly’s case plaque had built up in his left anterior descending artery, the one that cardiologists call “the widow maker.” Then it had burst, causing a blood clot. No one knows for sure why plaque breaks, but many researchers think that one cause is a sudden change in blood pressure, which can occur when a relatively sedentary person suddenly does something strenuous, like exercising.

Until 25 years ago most blockages were treated with bypass surgery, and then in the late 1970s a much less invasive procedure called angioplasty came on the scene. In an angioplasty a tiny balloon is threaded into the patient’s heart and then inflated and deflated several times to clear the blockage.

Kelly watched his heart on a monitor as doctors performed the procedure. When they cleared the clot, he felt immense relief. The doctors told him his was a massive heart attack—a 9 on a scale of 1 to 10.

Misdiagnosis

Even when patients are quick to recognize their symptoms, sometimes their doctors are not. Various studies say that at least 8 percent of heart attacks are misdiagnosed each year.

Misdiagnosis is especially common for female patients, who are much less likely to have heart attacks early in life (their odds increase dramatically after menopause) and who don’t usually have the same symptoms as men. Whereas men might complain of chest pain and shortness of breath, women might have subtle pain in the jaw or neck, or clammy skin. Either gender might report no pain at all, just a strange feeling that something is wrong.

Frank Marino says his symptoms were misdiagnosed for over a week, and they were classic: tightness in the chest and shortness of breath.

Marino never actually had a heart attack. He had his near–heart attack in 1989. He had a history of high blood pressure and high cholesterol, but medication was keeping both under control. Then one day at a health store in Takoma Park he read that one of his medications might actually be decreasing his HDL, or “good” cholesterol, which results in a higher ratio of LDL, or “bad” cholesterol. Soon after Marino consulted with his doctor. The two agreed to change Marino’s medication.

After the change Marino began feeling an unusual sensation in his left arm and pressure in his chest. Suddenly he found that running for a bus left him breathless. That struck him as odd because he was in pretty good shape. At five feet nine inches tall, he weighed under 160 pounds. He had been working out fairly regularly in a gym, but had suspended his workouts for three weeks while he moved into a condo.

Marino called his internist to report his symptoms, but couldn’t get through. Instead his call was funneled through a nurse, who assured him she would relay his concerns to the doctor. Later she called back and said, “The doctor thinks you ought to increase the dose of your ACE inhibitor,” Marino recalls, referring to a drug that widens blood vessels and reduces blood pressure.

When the symptoms persisted, Marino called again, and again the nurse told him the doctor advised changing the dosage. Finally, after about two weeks, Marino called again and did something that probably saved his life: he insisted on speaking directly to the doctor.

Marino explained his symptoms. “The doctor said, ‘This is very different from what I’ve been hearing from the nurse,’ ” says Marino. The doctor then said Marino had just described the classic symptoms of angina, which can be a precursor to a heart attack. He told Marino to go to a cardiologist for testing.

The next day Marino took a stress test to evaluate the efficiency of his heart. In the test technicians closely monitor the patient’s heartbeat while the patient works harder and harder to keep up with a treadmill. If an electrocardiogram, or EKG, shows abnormalities, the doctor orders an angiogram. In an angiogram dye is injected into the coronary arteries and then X-rays are taken to check for any blockages.
 
When Marino’s stress test showed a clear abnormality, his doctor gave him nitroglycerine, which he could use to dilate his blood vessels immediately in case of a heart attack. A few days later an angiogram showed that Marino’s right coronary artery was 90 percent blocked and the other coronary arteries somewhat blocked. When so many arteries are clogged, it’s not unusual for a patient to die suddenly of cardiac arrest. Amazingly, Marino discovered his problem without having to have a heart attack first.

Doctors performed an angioplasty, but the chest pain persisted. Like a lot of people who have had arteries cleared, Marino doubted what he felt. Over the next week or two, he says, “I would find myself getting kind of neurotic. I wasn’t sure. Should I call them or not? Maybe this is just my mind getting carried away.”

But the symptoms were real. His doctors performed a second angioplasty. That weekend Marino and a friend drove up to the Himalayan Institute, a yoga retreat outside Scranton, Pennsylvania. While his friend did yoga, Marino took vegetarian cooking lessons. It was the next day that he felt the symptoms that sent him to the emergency room.

His doctors performed a quadruple bypass. That was 14 years ago, and Marino hasn’t had any heart problems since. Last December he turned 51.

Now a staff attorney at Piper Rudnick LLP, he does intense cardiovascular exercise five or six days a week, and lifts weights with a trainer at least three days a week. “I’m very, very active,” he says. He no longer needs his emergency bottle of nitroglycerine. His cardiologist told him he could stop carrying it after the bypass.

Clean Living

Cliff Sloan is another young heart attack survivor whose symptoms were misdiagnosed. In his case, however, it’s easier to fathom why his doctor didn’t suspect his heart: he had no known risk factors.

Now general counsel at Washingtonpost.Newsweek Interactive, Sloan was 42 when he had his heart attack two years ago. He didn’t have diabetes and he didn’t smoke. His blood pressure was normal and his cholesterol, if anything, was on the low side. He wasn’t at all overweight. At five feet nine inches tall, he weighed 160 pounds.

His diet had always been relatively healthful, but two years earlier, he had made it even more so by cutting out red meat, desserts, and snacks like potato chips, while adding more fruit and vegetables. At family barbecues his three kids would laugh at him for eating veggie burgers. They couldn’t stand the smell.

Then a partner at Wiley Rein & Fielding, Sloan says he wasn’t unduly stressed. He wasn’t sedentary, either. Since high school he had been jogging five times a week; sometimes he ran in 10-kilometer races. Just one month before the attack he had gone jogging with an old law school buddy. Sloan usually got winded trying to keep up with his friend, but this time he was clearly setting the pace.

“I felt like I was in really great shape,” he says. “I would have thought I was the last person in the world who would be facing heart disease.”

In retrospect, Sloan realizes that his first symptoms appeared about a week before Valentine’s Day, 2000. That’s when he began feeling what he calls a strange “presence” in his chest, during his morning jog. Not a tightening, but a feeling. It wasn’t incapacitating, painful, or even uncomfortable; he had no trouble finishing his jog.

He felt the same symptom on Valentine’s Day, but this time it didn’t go away after his run. The same day, Sloan saw his internist, who diagnosed him with adult-onset asthma. She prescribed an inhaler, which he dutifully began using. He remembers feeling relieved that it was only asthma.

Three days later the asthma seemed to be getting worse. Sloan had to cut short his jog because he was breathless after two or three houses. That fatigue dogged him all the way to the Metro and into the office.

Like Kelly, Sloan didn’t realize that the sudden inability to perform usual exercise was a sign of a heart attack, but he knew something was wrong, so once he reached his office he called his internist again. She thought he needed a different type of inhaler, and called the prescription in to a nearby pharmacy. Sloan picked it up that morning and began using it.

Later that day, as Sloan attended a meeting about an Internet matter, he began feeling very strange. He didn’t feel any pain, but his sense of temperature and time felt way off. At 3 p.m. the meeting ended and Sloan went back to his private office, where he began feeling even worse. He kept checking the thermostat. He had no idea what was happening to him.

“Nothing in the world would have surprised me,” he says. “If someone had told me that an alien had taken over my body, I think I would have nodded and accepted it.”

Fortunately, Sloan had a very powerful feeling that he should get himself to his doctor, whose office was two blocks away. Like Kelly, he didn’t suspect his heart and didn’t consider calling an ambulance. Instead he began lumbering down K Street. “I remember passing a tall building and seeing my reflection and thinking that I didn’t look well, that my face looked contorted, that I was grimacing,” Sloan recalls. By the time he arrived, he felt nauseous, very sick, and very disoriented.

This time a different doctor in the practice quickly performed an EKG and suspected a heart attack. He was rushed to George Washington University Hospital, where doctors discovered a blockage in his left anterior descending artery. They cleared it with an angioplasty, and then inserted a stent, a tiny spring that helps hold the damaged artery open. He went home a few days later.

Changing Lifestyle

Surviving a heart attack is not the same as surviving coronary heart disease. Many angioplasty patients undergo further angioplasties, and some get bypasses.

However, the first repercussion a heart attack victim faces is usually not related to the heart; it’s psychological. In an article published in 2001 in the Journal of the American Medical Association, Roy Ziegelstein of the Johns Hopkins Bayview Medical Center estimated that one-half of heart attack survivors suffer significant or major depression after the event. Others experience anxiety. Frank Marino, John Kelly, and Cliff Sloan say that especially right after their attacks they began obsessing about whether they were about to suffer a repeat performance.

Kelly, for one, says for weeks after his attack he was scared to sleep in the dark. He found himself listening to his heart and worrying about whether it might miss a beat.

Sloan was scared, too. Most people tend to have the same symptoms from heart attack to heart attack; since Sloan’s symptoms were so subtle, he worried he might miss them. He became hypervigilant. Sometimes at work he would think, “Was that something, or not?”

About five weeks after his attack, he thought he felt a presence in his chest again. He joked that there were gremlins in his chest. Just in case, he took another stress test. An angiogram showed that everything was normal.

Unfortunately, a normal stress test and angiogram don’t necessarily mean a heart attack survivor is out of the woods. “You can have a normal stress test today and have a heart attack tomorrow,” says Gina Price Lundberg, director of women’s health care for the American Cardiovascular Research Institute, and an expert witness on the subject of misdiagnoses of heart attacks. “A stress test a week ago doesn’t mean bing,” she adds.

The patients who are least likely to have recurrent heart attacks are the ones who have the will and discipline to change their lifestyles permanently. Stress plays a role here, too. Patients who are stressed out are less likely to take the time to make the changes, says Robert DiBianco, director of cardiology research at Washington Adventist Hospital.

Frank Marino has made some radical changes, and has stuck by them for 14 years. Though he had always worked out fairly regularly, his diet was terrible. In college he had eggs with bacon or sausage every day for breakfast, followed by kosher corned beef or hot dogs for lunch. After college his diet didn’t improve much. Sunday mornings, for instance, he cooked bacon, used the bacon grease to make hash browns, and then topped the hash browns with cheese.

After his heart attack, inspired by nothing less than fear of death, he cut back on fat, with some help from his friends. He recalls they would watch what he ate and offer helpful but annoying comments. Within a few months he managed to cut out a lot of fat from his diet. These days he no longer eats red meat, butter, cream, egg yolk, whole milk, or cheese. His biggest vice is an occasional serving of KFC chicken strips.

Group Support

Marino got some help from a class for heart attack survivors organized by Joel Rosenberg of the George Washington University Hospital. Modeled on a similar program by Dean Ornish, a University of California, San Francisco, medical professor who believes that heart disease can be reversed without drugs or surgery, Rosenberg’s 12-week class gives patients and their families a chance to practice yoga and stress management with other heart attack survivors. The class also gives lessons in nutrition.

Rosenberg started the program after he realized that many of the patients in his practice were ignoring advice about nutrition and exercise. “It doesn’t really work to tell people to change something they’ve been doing for 10 or 15 years and expect them to do it,” he says. He also thought his practice wasn’t addressing the patients’ psychological needs.

Marino went through two cycles of the program in the early 1990s. It wasn’t a silver bullet, but he took comfort from the support group, especially when he noticed that one of his fellow classmates was even younger.

Kelly, the former corn dog fan, was inspired to change his lifestyle by a new sense of mortality. He now carries a cell phone, so he can call for help from anywhere. After years of putting it off, he and his wife wrote their wills.

“What it told me,” Kelly says of his heart attack, “is that bad stuff happens. Young, decent guys drop dead of heart attacks. You feel your mortality in a pretty real way.”

Since the attack Kelly has dropped 20 pounds by cutting more fat out of his diet and exercising every day. But not at the Y. He and his wife bought a treadmill for their home. “I don’t go to that Y anymore. I have bad memories,” says Kelly.

Setback
After his heart attack Sloan found himself in an odd position. He already had an optimum diet and exercise regime, so there was no room for improvement. In other words, aside from taking his heart medication, there wasn’t much he could do to reduce his chances of having another attack. It was frustrating. One doctor did recommend that he drink a glass of wine every day, so he started doing that.

Like a lot of patients, Sloan was afraid to exercise after his attack. To overcome that fear he enrolled in a rehabilitation program. Most of his fellow rehabbers were at least a decade older. At first the idea of getting on a treadmill with a portable EKG device and working out under the watchful eye of nurses was depressing. “In some ways it really brought home what had happened to me,” says Sloan.

That feeling passed quickly. After about eight weeks Sloan regained the confidence to exercise on his own, and gradually he began to worry less about his heart. Though it had been harrowing to have to undergo an angioplasty at 42, he took comfort in the fact that at least he hadn’t needed a bypass.

That summer Sloan suffered a big setback. At his six-month checkup in August a stress test turned up an abnormality in his heart. An angiogram showed that his left anterior descending artery had closed up again. It was 90 percent blocked.

 “This was a terrible shock,” says Sloan. “It was very upsetting and depressing. There was the initial shock, then coming to terms with it. I felt that I had put it behind me. Now to have it come up again was devastating.”

Sloan’s doctor gave him two choices: another angioplasty or a bypass. His doctor urged him to decide quickly. His wife Mary scoured the Internet for information and quizzed several doctors. They decided on the bypass.

Sloan remembers being wheeled into surgery at Washington Hospital Center. He said goodbye to his wife and brother and sister-in-law as he rolled past. The anesthesiologist tried to joke about Sloan’s age. “We don’t take them this young,” he said. In the operating room Sloan marveled at how so many people in green gowns were all preparing to work on him. Over the next few hours his doctor performed an off-pump bypass, a relatively new type of operation in which the bypass is performed while the heart is still beating.

Everything worked out well. These days Sloan still goes for his morning jog. Since his bypass he has even joined the steering committee of Lawyers Have Heart.

It’s Never Too Late

For the most part, Sloan has gotten over the fact that he had to have a bypass. Every day, when he takes his five heart medications, he is grateful to be alive. He has one piece of advice: “Even in a seemingly healthy person, the worst thing is to ignore signs that anything is amiss and to just kind of bull through it. The thing that saved my life was having the instinct to go to the doctor’s office.”

Of course, the best time to visit the doctor is before a heart attack. Doctors now have several ways to predict which patients are most likely to suffer from heart disease. Besides asking questions about general health and family history, they can give a stress test, examine pictures of the heart, and check blood for certain proteins that are correlated with a higher risk of heart attack, says DiBianco. Most insurance plans will cover the test for people who have symptoms of heart disease. If you do have symptoms, there’s no reason to wait, he says. “It’s a morning out of your life.”

And it’s never too late. Consider Gordon Forester. Early this year his daughter wrote him a letter begging him to see a doctor. She had just given birth, and was afraid her child would lose a grandfather. She had reason to worry. Forester was 67, a heavy smoker, and not keen on exercise or diet. He hadn’t seen a doctor for eight years. Her letter convinced him to go, and it saved his life. His doctors found four clogged arteries, including two that were entirely blocked.

“‘You know, you’re a walking heart attack,’ ” Forester says his doctor told him. “ ‘It could occur any minute.’ ” On February 21 he had a quadruple bypass. During the surgery he suffered a mild stroke, but has since almost fully recovered.

Forester keeps the letter handy in his office. “I don’t know if I’m typical, but I tend to ignore these things, because I don’t want to think about them,” he says. “It takes someone like your daughter to hit you over your head and make you do what you should.”

SIDEBAR

Warning Signs of a Heart Attack

Chest discomfort. This can be pain in the center of the chest that lasts for more than a few minutes, or that goes away and recurs. Or it might not be painful at all; it might just feel like pressure, squeezing, or fullness.
Discomfort in other areas of the upper body. This can range from pain to discomfort, in one or both arms, the back, neck, jaw, or stomach.
Shortness of breath, or sudden inability to perform usual exercise. Shortness of breath often accompanies chest discomfort, but sometimes precedes it.
Cold sweat, nausea, or lightheadedness.
A growing sense of dread.

What to Do

Call 911, lie down, and chew an aspirin. Paramedics can treat you en route to the hospital. Also, you will probably get faster treatment at the hospital when you arrive by ambulance.
Source: American Heart Association and cardiologists

Joan Indiana Rigdon wrote about online pro bono legal services in the May 2002 issue.
 

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