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1 KapnHOJIOrHH HaUHOHaJlbHOe PYKOBOllCTBO noLI pen IOHneneHKoBa p fOraHoBa-M f30TAP-MeJlHa 2007-1232 c

2 Goldberg R Larson M Levy D Factors associated with survival to 75 years of age in middle-aged men and women the Framingam study Arch I ntern M ed1998156505-S09

3 Habib GB Reappraisal of hear t rate as a r isk factor in t he general population Eur Heart] 1999 (Suppl H) H 2-H 10

4 Ky waK08C1CUU M C ApHTMHI1 cepnla ctgtomfaHT-M 1999

5 McAlister FA Teo KK Antiarrhythmic t herapies for t he prevention of sudden card iac death Drugs 1997 54(2) 235-252

6]ulius S Palatini P Nesbitt SD Tachycardia an important determinant of coronary risk in hypertension J Hypertens 1998 16 (Suppl 1) S9-1S

7 Levine HJ Rest heart r at e and life expectancy J Am Coli Card iol 199730 1104- 1106

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15 FOllUUbl1l ClI AliTHapI-ITMIfleCKHe cpencTsa B KH Qa30B EYI neJIeHshyKOB IOH (pelI) PauHOHaJIbHaH ltgtapMaKOTepamul cepneHo-cocynHCTbIX 3a60JleBaIDl~i M JlJrrTeppa 2005 602

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17 ACCAHA Guidelines for the M anagement of Pat ients W ith U nstable Angina and Non-ST-Segment Elevat ion Myocardial Infarction A Report of the American College of Cardiology American Heart Associat ion Task Force on Practice Guidelines (Committee on t he M anagement of Patients With Unstable Angina)]ACC 2000 36 970- 1062

18 AC C AHA gu ideliness for implantation of card iac pacemakers and antiarrhythmia devices Circulation 2002 106 2145-21 6

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