Objective: Allan S Jaffe, Professor of Medicine and Professor of Laboratory Medicine and Pathology, Mayo Clinic and Medical School, Gonda 5, 200 First St SW, Rochester, MN 55905, USA. 3. Acute myocardial infarction (MI) can occur from increased myocardial oxygen demand and/or reduced supply in the absence of acute atherothrombotic plaque disruption; a condition called type 2 myocardial infarction (T2MI). Division of Core Clinical Laboratory Service, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA. ICare-ACS (Improving Care Processes for Patients With Suspected Acute Coronary Syndrome): A Study of Cross-System Implementation of a National Clinical Pathway. High-sensitivity cardiac troponin (hs-cTn) assays detect troponin concentrations in the ng/L range. The editorial board of European Heart Journal: Acute Cardiovascular Care We studied consecutive new patients referred to the Heart Failure Clinic who had the FLC assay performed for routine screening at Mayo Clinic's campus in Rochest... High-sensitivity cardiac troponin (hs-cTn) I or T methods have been in use in certain regions for years but are now increasingly globally adopted, including in the United States. 2020 Dec 19 [Epub ahead of print] View PubMed; Vallabhajosyula S, Verghese D, Subramaniam AV, … Corrigendum to "Measuring the contribution of Lp(a) cholesterol towards LDL-C interpretation" [Clin. (2)Advisor to residents and Consultant in Cardiovascular Diseases, Mayo … Author information: (1)Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN. Multisociety guidelines define LDL-C>160mg/dL as a risk factor for CAD and LDL-C>190mg/dL as an indication for lipid lowering medication, regardless of other clinical factors. Biochem. All rights reserved. Aims Only verified researchers can join ResearchGate and send messages to other members. Prior studies have demonstrated that the cardiac intensive care unit (CICU) patient population has evolved over time. Describes the nature of a clinical study. Korley FK, Jaffe AS. Methods Methods and results: * Consultant and Professor of Cardiology & Laboratory Medicine and Pathology Chair, CCLS Division, Department of Laboratory Medicine and Pathology Mayo Clinic and Medical School Rochester, Minnesota *Dr. Jaffe is or has been a consultant to most of the major diagnostic companies as well as Novartis. To determine the utility of the serum free light chain (FLC) assay for routine screening of light chain amyloidosis (AL) in patients with heart failure. Are high-sensitivity cardiac troponin I values stable between preoperative visit and day of non-cardiac surgery? He is accepting new patients and has indicated that he accepts telehealth … 10/20/2020 9:27 AM. To evaluate outcomes by sex in older adults with cardiogenic shock complicating acute myocardial infarction (AMI-CS). 2018;138:e618-e651. Sex Disparities in the Management and Outcomes of Cardiogenic Shock Complicating Acute Myocardial Infarction in the Young, Sex and Gender Disparities in the Management and Outcomes of Acute Myocardial Infarction–Cardiogenic Shock in Older Adults, 99th Percentile Upper-Reference Limit of Cardiac Troponin and the Diagnosis of Acute Myocardial Infarction, Abstract MP01: Vasopressin Contributes To Differences In The Physiology Of Hypertension Between Non-Hispanic Blacks And Whites, Measuring the contribution of Lp(a) cholesterol towards LDL-C interpretation, Intracranial Hemorrhage Complicating Acute Myocardial Infarction: An 18-Year National Study of Temporal Trends, Predictors, and Outcomes, Biomarkers Enhance Discrimination and Prognosis of Type 2 Myocardial Infarction. Dr. Allan Jaffe M.D. Background A noninvasive, rapid, broadly available, home-based test to detect hs-cTn increases would facilitate risk-stratification. Aims: … How is cardiac troponin release from injured myocardium? Allan Jaffe, MD: Mayo Clinic: Chair of the Division of Clinical Core Laboratory Services in the Department of Laboratory Medicine and Pathology: Frank Peacock, MD: Baylor College of Medicine: Associate Chair of Emergency Medicine. Professor, Rochester, MN, Cardiovascular Medicine; Email [email protected]; 55719 Citations Source: Scopus; 108 Scopus h-Index Calculated based on no. 86 (2020) 45-51]. This study sought to evaluate the prevalence and outcomes of ARF in AMI-CS. A retrospective cohort of older (≥75 years) AMI-CS admissions during January 1, 2000, to December 31, 2014, was identified using the National Inpatient Sample. Email Email E-mail Address: [email protected] Allan S. Jaffe, M.D. To guide patient stratification and treatment in AS, echocardiographically defined cardiac damage classes have been proposed. His specialties include Cardiovascular Disease, Internal Medicine, Radiology. The primary endpoint was... Background: Sections for Allan S. Jaffe, M.D. Allan Jaffe, M.D., Consultant and Chair of Mayo Clinic’s Division of Clinical Core Laboratory Services, with a joint appointment in the Division of Cardiovascular Diseases, and Loralie Langman, Ph.D., Consultant in the Department of Laboratory Medicine and Pathology at Mayo, were recipients of this year's honors. Simply select your manager software from … A noninvasive, rapid, home-based test to exclude acute myocardial injury at the time of the test and for the next 7 hours would help manage patients with suspected myocardial infarction. Adult (>18 years) STEMI admissions were identified using the National Inpatient Sample databa... Ceramides are bioactive lipids that act as secondary messengers for both intra- and inter-cellular signaling. His efforts have since focused on the measurement of cardiac troponin and how to use the value obtained from clinical studies. However, as with all testing, the quality of biomarker samples, the assays that are used and proper interpretation of the results of such testing is critical. Update Profile. The cholesterol within Lp(a) (Lp(a)-C) contributes to the reported LDL-cholesterol (LDL-C) concentration by nearly all available methods. author = "Johannes Mair and Allan Jaffe and Fred Apple and Bertil Lindahl", Methods and Results Objective "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. El-Sabawi B(1), Zheng PP(1), Jaffe AS(2). Search for more papers by this author. Biochem. © 2008-2021 ResearchGate GmbH. He has 48 years of experience. That’s the message from a review by Yader Sandoval, MD, and Allan Jaffe, MD (both Mayo Clinic, Rochester, MN), along with James Januzzi Jr, MD (Massachusetts General Hospital, Boston). Moritz Biener, Matthias Mueller, Mehrshad Vafaie, Allan S Jaffe, Christian Widera, Hugo A Katus, and Evangelos Giannitsis. High-sensitivity cardiac troponin testing was recommended, as these assays have improved precision at low concentrations, but concerns over specificity may have limited implementation. In this small pilot study (n=18) among patients with cardiac risk undergoing non-cardiac surgery, we determined if high-sensitivity cardiac troponin I (hscTnI) changes b... Background: High-sensitivity cardiac troponin testing is recommended because these assays have improved precision at low concentrations, but concerns over specificity may have limited their implementation. Adult (>18 years) admissions with AMI receiving ECMO support were identified from the National Inpatient Sample database between 2000 and 2016. Concerns have been raised on the long-term analytical performance of high-sensitivity cardiac troponin (hs-cTn) assays with respect to different reagent formulations, lots and instrumentation. is a male health care provider in Rochester with Cardiovascular Disease Internal Medicine listed as his primary medical specialization. 2018 Mar;6(3):187-197. [email protected] PMID: 20360122 [Indexed for MEDLINE] Publication Types: Research Support, Non-U.S. Gov't; MeSH terms. E-mail address: [email protected]. Heart disorders identified and treated by a cardiologist can include arrhythmia, angina, heart aneurysms, heart failure, coronary artery disease, congenital heart defects and rheumatic heart disease, to name a few. AACC Academy Award for Outstanding Contributions to Clinical Chemistry in a Selected Area of Research. of publications stored in Pure and citations from Scopus; 1974 … 2020. We sought to describe the temporal changes in comorbidities, illness severity, diagnoses, procedures and adjusted mortality within our CICU practice in recent years. Quality Assessment of Included Studies Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA. In this single-centre prospective observational cohort study, serial high-sensitivity cardiac troponin T (hscTnT) plasma conc... Cardiac troponin I and cardiac troponin T are nowadays the criterion biomarkers for the laboratory diagnosis of acute myocardial infarction due to their very high sensitivities and specificities for myocardial injury. Interventional study (clinical trial) — studies new tests, treatments, drugs, surgical procedures or devices. Correspondence. hs-cTn assays have higher analytic precision... Cardiac troponin (cTn) testing has evolved significantly in recent times. Allan Jaffe, MD (Mayo Clinic, Rochester, MN), agreed that the availability of this new assay will have a beneficial impact on practice, noting that high-sensitivity assays are helpful both in evaluating patients with chest pain and with triaging patients who may be at risk for other cardiovascular morbidities that do not involve ischemic heart disease. There are limited data on how sex influences the outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS) in young adults. Using the National Inpatient Sample from 2000 to 2016, we identified adults with a primary diagnosis of AMI and concomitant CS admitted to the United States census regions of Northeast, Mid... Background: Type 2 myocardial infarction (T2MI) occurs due to an acute imbalance in myocardial oxygen supply and demand in the absence of athero-thrombosis. Methods: The studies to date suggest that the signals observed presage events within the next five-year period,” says Allan Jaffe, M.D., cardiologist at Mayo Clinic and chair of the Division of Clinical Core Laboratory Services, with joint appointments in the Department of Cardiovascular Diseases and the Department of Laboratory Medicine and Pathology. Low-Density Lipoprotein Subfractionation: What Is the Role of the Lab When Reporting Discrepant Results? Clin Biochem. Methods Allan S. Jaffe, MD. Mayo Clinic does not endorse any of the third party products and services advertised. Methods Dr. Allan S Jaffe is a Cardiovascular Disease (cardiology) Specialist in Rochester, Minnesota. However, it remains to be determined how to diagnose, risk stratify and treat patients with T2MI. It rises rapidly in multiple acute disorders including acute myocardial infarction. Learn more. Clin. Allan S Jaffe; Correspondence to Dr Allan S Jaffe, Cardiovascular Division and Division of Core Clinical Laboratory Service, Department of Laboratory Medicine and Pathology, Mayo Clinic and Medical School, Rochester, MN 55905, USA; jaffe.allan{at}mayo.edu As a cardiologist in La Crosse, Dr. Jaffe delivers comprehensive treatment for your cardiovascular system and heart. © 1998-2021 Mayo Foundation for Medical Education and Research (MFMER). There are few studies evaluating regional disparities in the care of acute myocardial infarction-cardiogenic shock (AMI-CS). Management and outcomes of uncomplicated ST-segment elevation myocardial infarction patients transferred after fibrinolytic therapy, Influence of Human Immunodeficiency Virus Infection on the Management and Outcomes of Acute Myocardial Infarction With Cardiogenic Shock, Epidemiological Trends in the Timing of In-Hospital Death in Acute Myocardial Infarction-Cardiogenic Shock in the United States, Cardiac Troponin for the Diagnosis and Risk-Stratification of Myocardial Injury in COVID-19: JACC Review Topic of the Week, Atherosclerotic Cardiovascular Disease Risk Stratification Based on Measurements of Troponin and Coronary Artery Calcium, Implementing High-Sensitivity Cardiac Troponin T in a US Regional Healthcare System, Weekend Effect in the Management and Outcomes of Acute Myocardial Infarction in the United States, 2000-2016, The Universal Definition of Myocardial Infarction: Present and Future, Pulmonary artery catheter use in acute myocardial infarction-cardiogenic shock: Pulmonary artery catheters in AMI-CS, ST-segment Elevation, Myocardial Injury, and Suspected or Confirmed COVID-19 Patients: Diagnostic and Treatment Uncertainties, Acute Myocardial Infarction Due to Fixed Coronary Artery Stenosis From Myocardial Bridging, Our nearly complete diagnostic trip of thousands of steps begets a new trip therapeutically, Complications in Patients with Acute Myocardial Infarction Supported with Extracorporeal Membrane Oxygenation, The Gloomy Long-Term Prognosis of Patients With Type 2 Myocardial Infarction or Myocardial Injury, HIGH SENSITIVITY CARDIAC TROPONIN: NOT JUST HEART DISEASE, Natriuretic Peptides to Predict Short-Term Mortality in Patients With Sepsis: A Systematic Review and Meta-analysis, Regional Variation in the Management and Outcomes of Acute Myocardial Infarction With Cardiogenic Shock in the United States, Incidence, Trends and Outcomes of Type 2 Myocardial Infarction in a Community Cohort, Extracorporeal Membrane Oxygenation Use in Acute Myocardial Infarction in the United States, 2000 to 2014, Early vs. delayed in-hospital cardiac arrest complicating ST-elevation myocardial infarction receiving primary percutaneous coronary intervention, Use of troponins in clinical practice: Evidence in favour of use of troponins in clinical practice, Estimating Short- and Long-term Reference Change Values and Index of Individuality for Tests of Platelet Function, Temporal trends, predictors, and outcomes of acute kidney injury and hemodialysis use in acute myocardial infarction-related cardiogenic shock, Real-Time Detection of Analytical Outliers on the Roche Troponin T Generation 5 Assay, Educational Recommendations on Selected Analytical and Clinical Aspects of Natriuretic Peptides with a Focus on Heart Failure: A Report from the IFCC Committee on Clinical Applications of Cardiac Bio-Markers, Acute respiratory failure and mechanical ventilation in cardiogenic shock complicating acute myocardial infarction in the USA, 2000–2014, Sex disparities in acute kidney injury complicating acute myocardial infarction with cardiogenic shock. Its main role remains... Background Overview; Fingerprint; Network; Grants (2) Research Output (694) Similar Profiles (10) If … Allan S. Jaffe's 318 research works with 26,563 citations and 7,075 reads, including: Application of the Fourth Universal Definition of Myocardial Infarction in Clinical Practice She had a history of... Open in new tabDownload slide He graduated from University Of Maryland School Of Medicine medical school in 1973. This document is an essential companion to the third iteration of the National Academy of Clinical Biochemistry [NACB,8 now the American Association for Clinical Chemistry (AACC) Academy] Laboratory Medicine Practice Guidelines (LMPG) on cardiac markers. Print. Yader Sandoval 1 , Allan S Jaffe 2 Affiliations 1 Department of ... Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn. Electronic address: [email protected]. “Novel disease entities like SARS-CoV-2 reinforce the tremendous importance of continuing our efforts at continuing to facilitate autopsy evaluations,” says Allan Jaffe, a cardiologist at the Mayo Clinic, in an email. Adult ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) hospital admissions were identified using the National (Nationwide) Inpatient Sample (2000-2016). Thygesen K, Alpert JS, Jaffe AS, et al. J Am Coll Cardiol 2013;61:1753–8. He graduated with honors from University Of Maryland School Of Medicine in 1973. Sex-specific 99th percentiles derived from the AACC Universal Sample Bank for the Roche Gen 5 cTnT assay: comorbidities and statistical methods influence derivation of reference limits. HQ Phone (507) 284-2511. Met... Background We hypothesized that genetically mediated differences in circulating vasopressin concentrations could contribute to features of hypertension that vary between non-... Background The diagnosis of myocardial infarction (MI) after noncardiac surgery has traditionally relied on using relatively insensitive contemporary cardiac troponin (cTn) assays. Methods... Background ROCHESTER, Minn. — Mayo Clinic has launched a new type of blood test that will be used to predict adverse cardiovascular events in patients with progressing coronary artery disease (CAD). The aim of this study was to determine... Two interferences recently brought to the forefront as patient safety issues include hemolysis (hemoglobin) and biotin (vitamin B7). 2. The use of cardiac biomarkers is expanding rapidly as patients and physicians look for more objective ways to diagnose and monitor patients. Methods: Tel: +1 507 284‐1648, Email: jaffe.allan@mayo… Last Update. There are limited data on the outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS) in patients with human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS). An additional interest relates to the intersection of depression and heart disease where he was the co-chair of the Enhancing Recovery in Coronary Heart Disease (ENRICHD) study of post-acute myocardial infarction patients. Adult (>18 years) AMI admissions using the National Inpatient Sample database (2000–2017) were evaluated for in‐hospital AIS. Myocyte injury due to ischemia or other pathologies cause blood levels to increase, which is prognostic. Author information: (1)Department of Laboratory Medicine and Pathology, Mayo Clinic and Foundation, Rochester, Minnesota. Loop is the open research network that increases the discoverability and impact of researchers and their work. Find Dr. Jaffe's phone number, address, insurance information, hospital affiliations and more. Fatica EM, Meeusen JW, Vasile VC, Jaffe AS, Donato LJ. Allan Jaffe first saw the play in 1965, during a painful breakup with a girlfriend. Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota. Dr. Jaffe graduated from the University of Maryland School of Medicine,University of Maryland School of Medicine in 1972. He is affiliated with Mayo Clinic Hospital - Rochester, Mayo Clinic Health System in Red Wing, and Mayo Clinic Health System in … As a single variable, it has only modest diagnostic accuracy for acute myocardial infarction. The authors thank the Executive Dean of Research at Mayo Clinic, Dr Gregory Gores, and the CEO of Mayo Clinic, Dr Gianrico Farrugia, for their support and assistance; the independent Data and Safety Monitoring Board for their work and oversight of the Expanded Access Program — Drs Allan S. Jaffe (chair), David O. Warner, William G. Morice II, Paula J. Cardiac troponin (cTn) elevations are also observed in clinical conditions without obvious connection to cardiac injury. Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Cardiovascular Disease and Outcomes Research Program, Advertising and sponsorship opportunities, Consultant, Division of Ischemic Heart Disease and Critical Care, Department of Cardiovascular Medicine, Consultant, Division of Clinical Core Laboratory Services, Department of Laboratory Medicine and Pathology, Professor of Laboratory Medicine And Pathology. Sorry, you need to be a researcher to join ResearchGate. However, still many aspects of their degradation, tissue release and elimination from the human circulation are incompletely underst... Background: Allan S. Jaffe, M.D., has spent his long academic career investigating the use of biomarkers to characterize the pathobiology of acute cardiovascular disease. If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Low values of high-sensitivity cardiac troponin (hs-cTn) and coronary artery calcium (CAC) scores of zero are associated with a low risk for atherosclerotic cardiovascular disease (ASCVD). Methods Should myocardial infarction type 2 be regarded as two separate entities? Jaffe AS(1), Miller WL(2). Korley FK, Jaffe AS. The authors thank the Executive Dean of Research at Mayo Clinic, Dr Gregory Gores, and the CEO of Mayo Clinic, Dr Gianrico Farrugia, for their support and assistance; the independent Data and Safety Monitoring Board for their work and oversight of the Expanded Access Program — Drs Allan S. Jaffe (chair), David O. Warner, William G. Morice II, Paula J. Whether amyotrophic lateral sclerosis (ALS)—the most common motor neuron disease—could be also associated with abnormal plasma or serum cTnT levels remains unclear. This was a retros... Introduction In order to manage risks of bleeding and thrombosis after some surgical procedures, platelet function is often measured repeatedly over days or weeks using laboratory tests of platelet function. Overview; Fingerprint; Network; Grants (2) Research Output (694) Similar Profiles (10) If … It is unclear if cardiac troponin values are stable in patients prior to undergoing non-cardiac surgery, or if they tend to rise towards the day of surgery. He holds the academic rank of professor of laboratory medicine and pathology and also professor of medicine. Fourth universal definition of myocardial infarction (2018). Overall, it’s reassuring that there was a modest increase in the number of patients discharged and a reduction in timing of decisions, said Allan Jaffe, MD, a cardiologist and chair of the division of clinical core laboratory services at Mayo Clinic in Rochester, Minnesota. Objec... Cardiac-specific troponins are elevated in blood following cardiac injury and are the preferred diagnostic biomarkers when acute myocardial infarction is suspected clinically. Open in new tabDownload slide. Allan Jaffe. Our objectives were to define the frequency of myocardial injury using high-sensitivity cardiac troponin I (hs-cTnI) and to understand how to use its prognostic abilities. Mayo Foundation for Medical Education and Research, Wilhelminespital, Wiener Krankenanstaltenverbund, Vienna, Austria, Using High Sensitivity Cardiac Troponin Values in Patients with SARS-CoV-2 Infection (COVID-19): The Padova Experience, ESC Study Group on Cardiac Biomarkers of the Association for Acute CardioVascular Care: A fond farewell at the retirement of CKMB, Corrigendum to “Measuring the contribution of Lp(a) cholesterol towards LDL-C interpretation” [Clin. International recommendations on high-sensitivity cardiac troponin (hs-cTn) testing recommend that laboratories select only one sample type for testing. The formation of a thrombus in an epicardial artery may result in an acute myocardial infarction (AMI). These increases are more likely to occur in those with chronic cardiovascular conditions and in those with severe COVID-19 presentations. Manufacturers of high-sensitivity cardiac troponin (hs-cTn) assays have restricted use of what sample types or matrices are acceptable to use for measurement. Allan S. Jaffe, MD, Department of Cardiovascular Diseases, Gonda 5, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Mayo Clinic, Rochester (United States of America) Speciality : Acute Coronary Syndromes 8 presentations Has spent career working on biomarkers of cardiac injury, thrombosis and hemodynamic stress. Methods: Baseline hs-cTnT (limit of detection [LoD] 3 ng/l) and CAC … Our goal for the present study was to compare three different versions of an hs-cTnI assay in two different study populations to evaluate if ass... Purpose of review: The recent introduction of high‐sensitivity cardiac troponin (hs‐cTn) assays has allowed clinicians to measure hs‐cTn before and after cardiac stress testing, but the hs‐cTn release pattern and potential utility in identifying inducible myocardial ischemia are unclear. (Doctor of Medicine).He graduated from University Of Maryland School Of Medicine in 1973 (around 48 years of experience). … Santalo M, Martin A, Velilla J, et al. Methods: Meta-Analyses and Interpretation of Troponin Values in Heart Failure, Comparing analytical outliers and the percent of emergency department patients with results above the 99th percentile upper reference limit for 2 conventional and one high sensitivity troponin assay, High Sensitivity Cardiac Troponin T in Young Healthy Adults Undergoing Non-Cardiac Surgery. Corresponding author. PMID: 29331273 Export. Changes in comorbidities, diagnoses, therapies and outcomes in a contemporary cardiac intensive care unit population, Galectin-3 Levels and Outcomes After Myocardial Infarction: A Population-Based Study, High‐Sensitivity Cardiac Troponin After Cardiac Stress Test: A Systematic Review and Meta‐Analysis, Utility of the Serum Free Light Chain Assay in the Diagnosis of Light Chain Amyloidosis in Patients With Heart Failure, Recommendations for Institutions Transitioning to High-Sensitivity Troponin Testing, Clinical use of cardiac troponin for acute cardiac care and emerging opportunities in the outpatient setting. Cardiovascular Medicine, 200 First Street Southwest, Rochester, Minnesota, 55905 United. ; MeSH Terms to guide patient stratification and treatment in AS, et al CICU ) population. The appropriate software installed, you need to be a researcher to join.! Present the case of a high-sensitivity cardiac troponin ( hs-cTn ) assays in this a... is! 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Group affiliations: Mayo Clinic College of Medicine in 1973 evaluate the comparability of the study S! Tests, treatments, drugs, surgical procedures or devices be of importance damage classes have been proposed thus appropriate! A study of Cross-System Implementation of a 59-year-old woman that presented with a girlfriend system-wide efforts affecting multiple emergency. Substantially to our knowledge of … dr. Allan Jaffe – Mayo Clinic does not endorse any of the Lab Reporting! Coagulation and fibrinolysis and resulted in an acute myocardial infarction is suspected clinically those with severe COVID-19 presentations address phone! ) Specialist in Rochester with Cardiovascular Disease, Internal Medicine and Radiology towards LDL-C interpretation '' Clin... Multiple acute disorders including acute myocardial infarction Terms and conditions and in those with COVID-19... 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