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Initial history includes widowhood, three children, rare alcohol use, non-smoking status, and a strong family history of acute myocardial infarction in her mother at age 52. Clinical evaluation shows elevated blood pressure on later presentation and normal cardiovascular and respiratory examinations with a normal ECG earlier in the course. Treatment involved starting and then increasing Noten dosing with advice to keep a symptom frequency record and review intervals. Symptoms initially improved, then recurred with increased frequency, accompanying marked nervousness and distress. 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