Join Us | Latest Articles | Contact

Journal Home

Editorial Board


Submit to this journal

Current issue

International Journal of Clinical Cardiology

DOI: 10.23937/2378-2951/1410051

Preventing Acute Cardiac Events during Marathons with Pre-Race Aspirin

Arthur J. Siegel*

Director, Internal Medicine, McLean Hospital, Belmont, Massachusetts

*Corresponding author: Arthur J. Siegel, M.D., Director, Internal Medicine, McLean Hospital, Belmont, Associate Professor of Medicine, Harvard Medical School, Boston, Massachusetts, USA, Tel: 617-855-2358, E-mail:
Int J Clin Cardiol, IJCC-2-051, (Volume 2, Issue 5), Review Article; ISSN: 2378-2951
Received: July 31, 2015 | Accepted: September 12, 2015 | Published: September 15, 2015
Citation: Siegel AJ (2015) Preventing Acute Cardiac Events during Marathons with Pre-Race Aspirin. Int J Clin Cardiol 2:051. 10.23937/2378-2951/1410051
Copyright: © 2015 Siegel AJ. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Objectives: Reducing sudden cardiac death during sport is the highest clinical priority in preventive sports cardiology. While the overall cardiovascular risk of long distance running is low, the frequency of cardiac arrest and sudden death in middle-aged males during marathons has increased since the year 2000. An evidence-based strategy for reducing race-related acute cardiac events in this vulnerable subgroup is considered based on identification of the underlying cause.

Method: Review of articles in PubMed on adverse cardiac events during marathons.

Findings: Recent epidemiological studies identified atherosclerotic heart disease as the underlying cause of cardiac arrest and sudden death in middle-aged males during marathons since the year 2000. Same-aged asymptomatic middle-aged male runners showed a post-race polymorphonuclear leukocytosis with sequential increases in interleukin-6 and C-reactive protein likely due to rhabdomyolysis after 'hitting the wall'. Elevated fibrinogen, von Willebrand factor and D-dimer with in vivo platelet activation indicated concurrent hyper-coagulability. Cardiac troponins I and T and NT-pro-B-type natriuretic peptide were transiently elevated after races in these same asymptomatic subjects.

Conclusion: Asymptomatic middle-aged male runners are at transient high risk for acute cardiac events during marathons as demonstrated by stratification of validated biomarkers. Pre-race aspirin usage is prudent to address the increasing frequency of race-related acute cardiac events in this vulnerable subgroup based on conclusive evidence for its ability to protect same-aged healthy males from first acute myocardial infarctions in a randomized prospective primary prevention trial. Prospective studies are needed to assess the efficacy of this strategy.


Marathon running, Sudden cardiac death, Atherothrombosis, Aspirin usage pre-race

The marathon is regarded by many as the road map to optimal cardiovascular health in middle age and beyond embodied in 'Life's Simple 7' by the American Heart Association (AHA) in spite of the index case of Pheidippides in 490 B.C. (Figure 1) [1,2]. Epidemiological studies addressing ongoing concerns over such marathon-related events provide robust evidence upon which to evaluate this risk.

Figure 1: Pheidippides' sudden cardiac death in the Atheneum in 490 B.C. after declaring victory over the invading Persian army on the Plains of Marathon (by anonymous).
Unforseeing one! Yes, he fought on Marathon day: So, when Persia was dust, all cried "To Akropolis! Run, Pheidippides, one race more. Till in Athens he broke, 'Rejoice, we conquer!" Joy in his blood bursting his heart, he died --- the bliss! 'Pheidippides' by Robert Browning, 1879 View Figure 1


While the cardiovascular risk of long distance running is acknowledged as low, A 10-year prospective registry of long distance road races in the United States beginning in the year 2000 characterized the low overall incidence of 1 cardiac arrest in every 184,000 participants as good news for runners [3,4]. Male gender and the full marathon compared to the half-marathon were significant risk factors for cardiac arrest, however, which events increased 2.3-fold in middle-aged males beginning in 2005. While the overall rate of cardiac arrest was reported as 1 in 57,000 runners in United States marathons from 1982 to 2009, such events increased to 1 in 22,000 from 1 in 29,000 in males over age 29 since the year 2000 [5,6]. Atherosclerotic heart disease was the main cause of marathon-related sudden cardiac death in males over age 40 including acute myocardial infarction in 17 of 18 cases in a retrospective study [7].

The increasing frequency of race-related cardiac arrests in runners with low baseline metrics for cardiovascular disease is unexpected especially occurring concurrently with a 38% decline in cardiac mortality in the general population [8,9]. An explanation for these findings may emerge from observations on asymptomatic middle-aged male physician-runners providing pre- and post-race blood samples as attendees of pre-race scientific symposia of the American Medical Athletic Association. Post-race elevations of creatine kinase as an index of skeletal muscle injury after glycogen depletion or 'hitting the wall' were accompanied by a polymorphonuclear leukocytosis with increased interleukin (IL)-6 and C-reactive protein [10-12]. Predictive of acute cardiac events in healthy persons, elevated inflammatory biomarkers occurred concurrently with increased fibrinogen, von Willebrand factor, D-dimer and in vivo platelet activation indicating transient hypercoagulability [13,14]. Cardiac troponins I and T and NT-pro-B-type natriuretic peptide were also transiently elevated post-race in these same asymptomatic runners [15-17].

Post-race changes in validated biomarkers in asymptomatic runners similar to those in patients with acute coronary syndromes demonstrate transient high risk for acute cardiac events. Atherothrombosis is the shared clinical paradigm with IL-6 implicated in promoting rupture of non-obstructive coronary plaques [18-21]. Leakage of high-sensitivity cardiac troponins has also been shown to stratify risk for cardiovascular events in healthy persons in primary prevention studies and in patients with ischemic heart disease [22,23]. The report of acute myocardial infarctions due to coronary plaque rupture in runners immediately after the 2011 Boston marathon provides closure regarding the pathophysiological relevance of biomarker findings in asymptomatic runners [24]. Acute cardiac events in susceptible runners during races are due to type 1 myocardial infarctions similar to the cause of exertional fatalities in first responders such as on-duty firemen and police officers [25-27].

Aspirin has been demonstrated to mitigate excess short-term acute cardiac risk during systemic inflammation in clinical conditions including septicemia, influenza and preeclampsia [28-30]. As proposed for cardio-protection in patients with life-threatening infections [31], aspirin pre-race usage has been proposed as prudent for middle-aged males based in part on conclusive evidence for protection of same-aged healthy male physicians from first acute myocardial infarctions in the randomized prospective Physicians Health Study [32-35].

Middle-aged males who do not qualify for continuous aspirin at baseline meet criteria for such usage during marathons as a high-risk subgroup in guidelines of the AHA, American College of Cardiology (ACC) and the European Society of Cardiology [36,37]. A single pre-race low-dose aspirin would provide susceptible runners with the only medication given a grade 1A recommendation for pre-hospital treatment for an acute coronary syndrome while minimizing the risk for adverse events such as gastrointestinal bleeding during continuous usage.

Responsibility for disclosure of the increased cardiac risk for middle-aged males during marathons rightly falls upon the medical community similar to the United States Food and Drug Administration's warning on excess sudden cardiac deaths during short-course treatment with azithromycin [38,39]. The 2014 Rio de Janeiro marathon was first to recommend pre-race aspirin usage for males over age 40 upon approval by their physicians based upon an advisory from the International Marathon Medical Directors Association (IMMDA) [40,41]. Successful resuscitation following cardiac arrest occurred at the finish line in the 2014 and 2015 races with a full recovery after coronary stent placements in the latter case (personal communication, Paulo Afonso Lourega de Menezes, M.D., medical director). (Figure 2)

Figure 2: Paulo Afonso Lourega de Menezes, M.D., medical director of the Rio de Janiero marathon, with his team at the finish line medical tent. Runners in cardiac arrest were successfully resuscitated in 2014 and 2015 in spite of their recommendation that males over age 40 take pre-race aspirin upon approval by their physicians. View Figure 2


Measurement of coronary artery calcium density may be especially useful for stratifying risk for pre-race aspirin usage in experienced runners among whom such scores are paradoxically higher than in matched non-running controls and correlate inversely with short-term event free survival [42-45]. Disclosure of his personal diagnosis of coronary heart disease by Dave McGillivray, race director of the Boston marathon since 1988, put runners on notice about the potential for development of symptomatic coronary heart disease including the 50% of runners above the most common age of 46 among the 35,384 entrants to the 2014 Boston race [46,47].

Middle-aged males morph into transiently increased risk for acute coronary events during marathons in contrast to beneficial effects of recreational marathon training on the myocardium [48]. Testing the efficacy of pre-race aspirin usage to reduce preventable acute cardiac events in middle-aged males as advocated by IMMDA would require staunch collaboration across the sports medicine community [49]. Aspirin usage to reduce sports-related acute cardiac risk is not yet on the radar screen in subspecialty articles by preventive cardiologists, which focus on mostly non-preventable causes of sudden cardiac death in athletes below the age of 30 [50-53].

Beyond standing up for better heart health and evidence that moderate-to-vigorous physical activity at a lower than currently recommended dose is associated by meta-analysis with lower 10-year all-cause mortality in older adults [54,55], the jury may now be in regarding excess cardiovascular morbidity and mortality associated with running marathon in middle-aged apparently healthy males [56,57]. As if crossing the Rubicon, running marathons for this vulnerable subgroup may enter the realm of 'you can have too much of a good thing' from the usual and customary terrain of 'if some is good, more is better' regarding the impact of exercise intensity on heart health [58].

Mitigation of the increasing frequency of acute cardiac events in middle-aged males during marathons with pre-race aspirin may be achievable as was accomplished in reducing fatal cerebral edema in young females through a robust consensus process (Figure 3) [58-60]. In contrast to the United States Preventive Services Task Force's recent recommendation for aspirin usage begin at age 50, [61] male runners over age 30 may benefit based on recent findings. While avid bystander cardiopulmonary resuscitation during races has improved survival, prevention trumps treatment in this domain [62,63]. The efficacy of pre-race aspirin usage can be assessed prospectively to determine if this remedy known to Hippocrates in the time of Pheidippides can prevent non-obstructive coronary artery plaques from becoming vulnerable to rupture during transient race-related inflammatory stress.

Figure 3: Rationale for pre-race aspirin usage to protect susceptible runners from marathon-related acute cardiac events View Figure 3


  1. Folsom AR, Shah AM, Lutsey PL, Roetker NS, Alonso A, et al. (2015) American Heart Association's Life's Simple 7: Avoiding Heart Failure and Preserving Cardiac Structure and Function. Am J Med 128: 970-976.

  2. Bassler TJ (1977) Marathon running and immunity to atherosclerosis. Ann N Y Acad Sci 301: 579-592.

  3. Kim JH, Malhotra R, Chiampas G, d'Hemecourt P, Troyanos C, et al. (2012) Cardiac arrest during long-distance running races. N Engl J Med 366: 130-140.

  4. Nearman S (2012) Cardiac deaths in marathons much lower than previously thought: good news for marathon runners. Am Med Athletic Assoc J: 7-8.

  5. Webner D, DuPrey KM, Drezner JA, Cronholm P, Roberts WO (2012) Sudden cardiac arrest and death in United States marathons. Med Sci Sports Exerc 44: 1843-1845.

  6. Roberts WO, Roberts DM, Lunos S (2013) Marathon related cardiac arrest risk differences in men and women. Br J Sports Med 47: 168-171.

  7. Mathews SC, Narotsky DL, Bernholt DL, Vogt M, Hsieh YH, et al. (2012) Mortality among marathon runners in the United States, 2000-2009. Am J Sports Med 40: 1495-1500.

  8. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, et al. (2010) Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond. Circulation 121: 586-613.

  9. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, et al. (2014) Heart disease and stroke statistics -2014 update: a report from the American Heart Association. Circulation 129: e28-e292.

  10. Siegel AJ, Silverman LM, Lopez RE (1980) Creatine kinase elevations in marathon runners: relationship to training and competition. Yale J Biol Med 53: 275-279.

  11. Kratz A, Lewandrowski KB, Siegel AJ, Chun KY, Flood JG, et al. (2002) Effect of marathon running on hematologic and biochemical laboratory parameters, including cardiac markers. Am J Clin Pathol 118: 856-863.

  12. Siegel AJ, Verbalis JG, Clement S, Mendelson JH, Mello NK, et al. (2007) Hyponatremia in marathon runners due to inappropriate arginine vasopressin secretion. Am J Med 120: 461.

  13. Siegel AJ, Stec JJ, Lipinska I, Van Cott EM, Lewandrowski KB, et al. (2001) Effect of marathon running on inflammatory and hemostatic markers. Am J Cardiol 88: 918-920.

  14. Kratz A, Wood MJ, Siegel AJ, Hiers JR, Van Cott EM (2006) Effects of marathon running on platelet activation markers : direct evidence for in vivo platelet activation. Am J Clin Pathol 125: 296-300.

  15. Saenz AJ, Lee-Lewandrowski E, Wood MJ, Neilan TG, Siegel AJ, et al. (2006) Measurement of a plasma stroke biomarker panel and cardiac troponin T in marathon runners before and after the 2005 Boston marathon. Am J Clin Pathol 126: 185-189.

  16. Neilan TG, Januzzi JL, Lee-Lewandrowski E, Ton-Nu TT, Yoerger DM, et al. (2006) Myocardial injury and ventricular dysfunction related to training levels among nonelite participants in the Boston marathon. Circulation 114: 2325-2333.

  17. Siegel AJ, Januzzi J, Sluss P, Lee-Lewandrowski E, Wood M, et al. (2008) Cardiac biomarkers, electrolytes, and other analytes in collapsed marathon runners: implications for the evaluation of runners following competition. Am J Clin Pathol 129: 948-951.

  18. Libby P, Crea F (2010) Clinical implications of inflammation for cardiovascular primary prevention. Eur Heart J 31: 777-783.

  19. Anderson DR, Poterucha JT, Mikuls TR, Duryee MJ, Garvin RP, et al. (2013) IL-6 and its receptors in coronary artery disease and acute myocardial infarction. Cytokine 62: 395-400.

  20. Siegel AJ, Mendelson JH, Mello N, Elizabeth Lee Lewandrowski, Kent Lewandrowski (2005) Interleukin-6 mediated non-ischemic injury to cardiac myocytes during marathon running. Med Sci Sports Exerc 37: S93.

  21. Lee T, Murai T, Yonetsu T, Suzuki A, Hishikari K, et al. (2015) Relationship between subclinical cardiac troponin I elevations and culrpit lesion characteristics assessed by optical coherence tomography in patients undergoing elective percutaneous coronary intervention. Circ Cardiovasc Interv 8: e 0011727.

  22. Everett BM, Zeller T, Glynn RJ, Ridker PM, Blankenberg S (2015) High-sensitivity cardiac troponin I and B-type natriuretic Peptide as predictors of vascular events in primary prevention: impact of statin therapy. Circulation 131: 1851-1860.

  23. Everett BM, Brooks MM, Vlachos HE, Chaitman BR, Frye RL, et al. (2015) Troponin and Cardiac Events in Stable Ischemic Heart Disease and Diabetes. N Engl J Med 373: 610-620.

  24. Albano AJ, Thompson PD, Kapur NK (2012) Acute coronary thrombosis in Boston marathon runners. N Engl J Med 366: 184-185.

  25. Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, et al. (2000) Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J Med 343: 1355-1361.

  26. Kales SN, Soteriades ES, Christophi CA, Christiani DC (2007) Emergency duties and deaths from heart disease among firefighters in the United States. N Engl J Med 356: 1207-1215.

  27. Varvarigou V, Farioli A, Korre M, Sato S, Dahabreh IJ, et al. (2014) Law enforcement duties and sudden cardiac death among police officers in United States: case distribution study. BMJ 349: g6534.

  28. Eisen DP, Reid D, McBryde ES (2012) Acetyl salicylic acid usage and mortality in critically ill patients with the systemic inflammatory response syndrome and sepsis. Crit Care Med 40: 1761-1767.

  29. Barnes M, Heywood AE, Mahimbo A, Rahman B, Newall AT, et al. (2015) Acute myocardial infarction and influenza: a meta-analysis of case-control studies. Heart .

  30. Henderson JT, Whitlock EP, O'Connor E, Senger CA, Thompson JH, et al. (2014) Low-dose aspirin for prevention of morbidity and mortality from preeclampsia: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 160: 695-703.

  31. Walkey AJ (2014) Preventing cardiovascular complications of acute infection: a missed opportunity? Circulation 129: 1375-1377.

  32. Siegel AJ (2012) Pheidippides redux: reducing risk for acute cardiac events during marathon running. Am J Med 125: 630-635.

  33. Siegel AJ (2013) Aspirin usage pre-race to prevent cardiac arrest in marathon runners during races. Am J Med 126: e47.

  34. Siegel AJ (2015) Prerace aspirin to protect susceptible runners from cardiac arrest during marathons: is opportunity knocking? Open Heart 2: e000102.

  35. (1989) Final report on the aspirin component of the ongoing Physicians' Health Study. Steering Committee of the Physicians' Health Study Research Group. N Engl J Med 321: 129-135.

  36. Pignone M, Alberts MJ, Colwell JA, Cushman M, Inzucchi SE, et al. (2010) Aspirin for primary prevention of cardiovascular events in people with diabetes. J Am Coll Cardiol 55: 2878-2886.

  37. Halvorsen S, Andreotti F, ten Berg JM, Cattaneo M, Coccheri S5, et al. (2014) Aspirin therapy in primary cardiovascular disease prevention: a position paper of the European Society of Cardiology working group on thrombosis. J Am Coll Cardiol 64: 319-327.

  38. Ray WA, Murray KT, Hall K, Arbogast PG, Stein CM (2012) Azithromycin and the risk of cardiovascular death. N Engl J Med 366: 1881-1890.

  39. Azithromycin poses fatal cardiac risk, FDA warns.

  40. Maharam LG, Arthur Siegel, Stephen Siegel, Bruce Adams, Pedro Pujol, et al. (2010) IMMDA's health recommendations for runners & walkers.

  41. Lourega de Menezes PA (2014) Official Handbook for Runners in the Rio de Janeiro Marathon. Marathon Publications: 12-13.

  42. Miedema MD, Duprez DA, Misialek JR, Blaha MJ, Nasir K, et al. (2014) Use of coronary artery calcium testing to guide aspirin utilization for primary prevention: estimates from the multi-ethnic study of atherosclerosis. Circ Cardiovasc Qual Outcomes 7: 453-460.

  43. Möhlenkamp S, Lehmann N, Breuckmann F, Bröcker-Preuss M, Nassenstein K, et al. (2008) Running: the risk of coronary events : Prevalence and prognostic relevance of coronary atherosclerosis in marathon runners. Eur Heart J 29: 1903-1910.

  44. Schwartz RS, Kraus SM, Schwartz JG, Wickstrom KK, Gretchen Peichel, et al. (2014) Increased coronary artery plaque volume among male marathon runners. Missour Med 111: 85-90.

  45. Möhlenkamp S, Leineweber K, Lehmann N, Braun S, Roggenbuck U, et al. (2014) Coronary atherosclerosis burden, but not transient troponin elevation, predicts long-term outcome in recreational marathon runners. Basic Res Cardiol 109: 391.

  46. Buckley S (2013) Dave McGillivray fights heart disease. Boston Herald.

  47. Knox L, Estaban C (2014) In the running, marathon demographics. Boston Globe C: 8-9.

  48. Zilinski JL, Contursi ME, Isaacs SK, Deluca JR, Lewis GD, et al. (2015) Myocardial adaptations to recreational marathon training among middle-aged men. Circ Cardiovasc Imaging 8: e002487.

  49. Siegel AJ (2015) pre-race aspirin to prevent heart attack and/or cardiac arrest during long distance running.

  50. Lawless CE, Asplund C, Asif IM, Courson R, Emery MS, et al. (2014) Protecting the heart of the American athlete: proceedings of the American College of Cardiology Sports and Exercise Cardiology Think Tank October 18, 2012, Washington, DC. J Am Coll Cardiol 64: 2146-2171.

  51. Harmon KG, Drezner JA, Wilson MG, Sharma S (2014) Incidence of sudden cardiac death in athletes: a state-of-the-art review. Br J Sports Med 48: 1185-1192.

  52. Maron BJ, Haas TS, Murphy CJ, Ahluwalia A, Rutten-Ramos S (2014) Incidence and causes of sudden death in U.S. college athletes. J Am Coll Cardiol 63: 1636-1643.

  53. Predel HG (2014) Marathon run: cardiovascular adaptation and cardiovascular risk. Eur Heart J 35: 3091-3098.

  54. Healy GN, Winkler EA, Owen N, Anuradha S, Dunstan DW (2015) Replacing sitting time with standing or stepping: associations with cardio-metabolic risk biomarkers. Eur Heart J .

  55. Hupin D, Roche F, Gremeaux V, et al. (2015) Even a low dose of moderate-to-vigorous physical activity reduces mortality by 22% in adults >60 years: a systematic review and meta-analysis. Br J Sports Med 1-8.

  56. Yared K, Wood MJ (2009) Is marathon running hazardous to your cardiovascular health? The jury is still out. Radiology 251: 3-5.

  57. Cooney E (2014) Enduring pleasures. Harvard Medicine winter/spring 87: 18-23.

  58. Siegel AJ (2015) Fatal water intoxication and cardiac arrest in runners during marathons: prevention and treatment based on validated clinical paradigms. Am J Med 21.

  59. Rosner MH (2015) Preventing Deaths Due to Exercise-Associated Hyponatremia: The 2015 Consensus Guidelines. Clin J Sport Med 25: 301-302.

  60. Hew-Butler T, Rosner MH, Fowkes-Godek S, Dugas JP, Hoffman MD, et al. (2015) Statement of the third international exercise-associated hyponatremia consensus development conference, Carlsbad, California, 2015. Clin J Sport Med 25: 303-320.

  61. Cohen SI, Ellis ER (2012) Death and near death from cardiac arrest during the Boston Marathon. Pacing Clin Electrophysiol 35: 241-244.

  62. Noakes T (2014) Time to quit that marathon running? Not quite yet! Basic Res Cardiol 109: 395.

International Journal of Anesthetics and Anesthesiology (ISSN: 2377-4630)
International Journal of Blood Research and Disorders   (ISSN: 2469-5696)
International Journal of Brain Disorders and Treatment (ISSN: 2469-5866)
International Journal of Cancer and Clinical Research (ISSN: 2378-3419)
International Journal of Clinical Cardiology (ISSN: 2469-5696)
Journal of Clinical Gastroenterology and Treatment (ISSN: 2469-584X)
Clinical Medical Reviews and Case Reports (ISSN: 2378-3656)
Journal of Dermatology Research and Therapy (ISSN: 2469-5750)
International Journal of Diabetes and Clinical Research (ISSN: 2377-3634)
Journal of Family Medicine and Disease Prevention (ISSN: 2469-5793)
Journal of Genetics and Genome Research (ISSN: 2378-3648)
Journal of Geriatric Medicine and Gerontology (ISSN: 2469-5858)
International Journal of Immunology and Immunotherapy (ISSN: 2378-3672)
International Journal of Medical Nano Research (ISSN: 2378-3664)
International Journal of Neurology and Neurotherapy (ISSN: 2378-3001)
International Archives of Nursing and Health Care (ISSN: 2469-5823)
International Journal of Ophthalmology and Clinical Research (ISSN: 2378-346X)
International Journal of Oral and Dental Health (ISSN: 2469-5734)
International Journal of Pathology and Clinical Research (ISSN: 2469-5807)
International Journal of Pediatric Research (ISSN: 2469-5769)
International Journal of Respiratory and Pulmonary Medicine (ISSN: 2378-3516)
Journal of Rheumatic Diseases and Treatment (ISSN: 2469-5726)
International Journal of Sports and Exercise Medicine (ISSN: 2469-5718)
International Journal of Stem Cell Research & Therapy (ISSN: 2469-570X)
International Journal of Surgery Research and Practice (ISSN: 2378-3397)
Trauma Cases and Reviews (ISSN: 2469-5777)
International Archives of Urology and Complications (ISSN: 2469-5742)
International Journal of Virology and AIDS (ISSN: 2469-567X)
More Journals

Contact Us

ClinMed International Library | Science Resource Online LLC
3511 Silverside Road, Suite 105, Wilmington, DE 19810, USA


Get Email alerts
Creative Commons License
Open Access
by ClinMed International Library is licensed under a Creative Commons Attribution 4.0 International License based on a work at
Copyright © 2017 ClinMed International Library. All Rights Reserved.