Abstract
Background
The frequency of acute myocardial infarction (AMI) peaks on Mondays and in the mornings. However, the distribution of the types of acute coronary syndromes (ACS), including unstable angina (UA), has not been systematically evaluated.
Hypothesis
The distribution of the types of ACS and clinical presentations varies by time and day of admission.
Methods
A retrospective cohort study was conducted in 1,946 consecutive nontransfer ACS admissions (1999–2004) to a tertiary‐care academic center to assess presenting clinical variables in patients admitted on days versus nights (6 p.m.–6 a.m.) and weekdays versus weekends (Friday 6 p.m.–Monday 6 a.m.).
Results
There were fewer ACS admissions than expected on nights and weekends (p < 0.001), but the proportion of patients with ACS presenting with ST‐elevation myocardial infarction (STEMI) is 64% higher on weekends (p < 0.001) and 31% higher on nights (p = 0.001). This increased proportion with STEMI results in a greater proportion of ACS with AMI on weekends (↑10%, p = 0.001) and nights (↑7%, p = 0.001). Using multivariate modeling, the increase in patients with AMI on weekends was not explained by conventional risk predictors.
Conclusions
Although fewer patients with ACS presented on nights and weekends, patients at those times were more likely to have an AMI, driven largely by an increased proportion with STEMI at those times. Consideration should be given to these findings when developing clinical care paradigms, health care staffing needs, and when comparing new treatment outcomes in patients with ACS. Copyright © 2006 Wiley Periodicals, Inc. Wiley Periodicals, Inc.
Keywords: acute coronary syndrome, circadian pattern, circaseptan pattern, acute myocardial infarction, unstable angina
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REFERENCES
- 1. Cohen MC, Rohtla KM, Lavery CE, Muller JE, Mittleman MA: Meta‐analysis of the morning excess of acute myocardial infarction and sudden cardiac death. Am J Cardiol 1997; 79: 1512–1516. [DOI] [PubMed] [Google Scholar]
- 2. Spielberg C, Falkenhahn D, Willich SN, Wegscheider K, Voller H: Circadian, day‐of‐week, and seasonal variability in myocardial infarction: Comparison between working and retired patients. Am Heart J 1996; 132: 579–585. [DOI] [PubMed] [Google Scholar]
- 3. Willich SN, Lowel H, Lewis M, Hormann A, Arntz HR, et al: Weekly variation of acute myocardial infarction. Increased Monday risk in the working population. Circulation 1994; 90: 87–93. [DOI] [PubMed] [Google Scholar]
- 4. Manfredini R, Gallerani M, Salmi R, Fersini C: Circadian rhythms and the heart: Implications for chronotherapy of cardiovascular diseases. Clin Pharmacol Ther 1994; 56: 244–247. [DOI] [PubMed] [Google Scholar]
- 5. Granger C, Goldberg R, Dabbous O, Pieper KS, Eagle KA, et al: Predictors of hospital mortality in the global registry for acute coronary events. Arch Intern Med 2003; 163: 2345–2353. [DOI] [PubMed] [Google Scholar]
- 6. Cannon CP, McCabe CH, Stone PH, Schactman M, Thompson B, et al: Circadian variation in the onset of unstable angina and non‐Q‐wave acute myocardial infarction (The TIMI III registry and TIMI IIIB). Am J Cardiol 1997; 79: 253–258. [DOI] [PubMed] [Google Scholar]
- 7. Gilpin EA, Hjalmarson A, Ross J Jr: Subgroups of patients with atypical circadian patterns of symptom onset in acute myocardial infarction. Am J Cardiol 1990; 66: 7G–11G. [DOI] [PubMed] [Google Scholar]
- 8. Zahn R, Schiele R, Seidl K, Schuster S, Hauptmann KE, et al: Daytime and nighttime differences in patterns of performance of primary angioplasty in the treatment of patients with acute myocardial infarction. Am Heart J 1999; 138: 1111–1117. [DOI] [PubMed] [Google Scholar]
- 9. Henriques JPS, Haasdijk AP, Zijlstra F: Outcome of primary angioplasty for acute myocardial infarction during routine duty hours versus during off‐hours. J Am Coll Cardiol 2003; 41: 2138–2142. [DOI] [PubMed] [Google Scholar]
- 10. Magid DJ, Wang Y, Herrin J, McNamara RL, Bradley EH, et al: Relationship between time of day, day of week, timeliness of reperfusion, and in‐hospital mortality for patients with acute ST‐segment elevation myocardial infarction. J Am Med Assoc 2005; 294: 803–812. [DOI] [PubMed] [Google Scholar]
- 11. Ladwig KH, Lehmacher W, Roth R, Breithardt G, Budde T, et al: Patient‐specific determinants of delay in goal‐oriented patient behavior in acute myocardial infarct. Results of the post‐infarct late potentiaal study. Z Kardiol 1991; 80: 649–656. [PubMed] [Google Scholar]
- 12. Goldberg RJ, Yarzebski J, Lessard D, Gore JM: Decade‐long trends and factors associated with time to hospital presentation in patients with acute myocardial infarction. The Worcester Heart Attack Study. Arch Intern Med 2000; 160: 3217–3223. [DOI] [PubMed] [Google Scholar]
- 13. Mittleman MA, Maclure M, Tofler GH, Sherwood JB, Goldberg RJ, et al: Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exertion. Determinants of myocardial infarction onset study investigators. N Engl J Med 1993; 329: 1677–1683. [DOI] [PubMed] [Google Scholar]
- 14. Tofler GH, Stone PH, Maclure M, Edelman E, Davis VG, et al: Analysis of possible triggers of acute myocardial infarction (the MILIS study). Am J Cardiol 1990; 66: 22–27. [DOI] [PubMed] [Google Scholar]
- 15. Peters A, von Klot S, Heier M, Trentinaglia I, Hormman A, et al: Exposure to traffic and the onset of myocardial infarction. N Engl J Med 2004; 351: 1721–1730. [DOI] [PubMed] [Google Scholar]
- 16. Strike PC, Steptoe A: New insights into the mechanisms of temporal variation in the incidence of acute coronary syndromes. Clin Cardiol 2003; 26: 495–499. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Tofler GH, Brezinski D, Schafer AI, Czeisler CA, Rutherford JD, et al: Concurrent morning increase in platelet aggregability and the risk of myocardial infarction and sudden cardiac death. N Engl J Med 1987; 316: 1514–1518. [DOI] [PubMed] [Google Scholar]
- 18. Sayer JW, Gutteridge C, Syndercombe‐Court D, Wilkinson P, Timmis AD: Circadian activity of the endogenous fibrinolytic system in stable coronary artery disease: Effects of beta‐adrenoreceptor blockers and angiotensin‐converting enzyme inhibitors. J Am Coll Cardiol 1998; 32: 1962–1968. [DOI] [PubMed] [Google Scholar]
- 19. Kono T, Morita H, Nishina T, Fujita M, Hirota Y, et al: Circadian variations of onset of acute myocardial infarction and efficacy of thrombolytic therapy. J Am Coll Cardiol 1996; 27: 774–778. [DOI] [PubMed] [Google Scholar]
- 20. Onaka H, Hitota Y, Shimada S, Mishima T, Shimoyama H, et al: Circadian variation of myocardial ischemia in patients with unstable angina pectoris secondary to fixed and/ or spastic coronary narrowing. Am J Cardiol 1998; 81: 629–632. [DOI] [PubMed] [Google Scholar]
- 21. Kloner RA, Jennings RB: Consequences of brief ischemia: Stunning, preconditioning, and their clinical implications: Part 1. Circulation 2001; 104: 2981–2989. [DOI] [PubMed] [Google Scholar]
- 22. Bahr RD, Leino EV, Christenson RH: Prodromal unstable angina in acute myocardial infarction: Prognostic value of short‐ and long‐term outcome and predictor of infarct size. Am Heart J 2000; 140: 126–133. [DOI] [PubMed] [Google Scholar]