Abstract
Background: Analysis of the chronology of acute cardiovascular events may provide important pathophysiologic information. There is a circadian pattern in the onset of acute myocardial infarction (AMI) with a mid‐morning peak, ascribed to the catecholamine surge that accompanies awakening and assuming the upright posture. However, in up to 27% of patients the onset of AMI occurs during sleep (without apparent precipitating factors). The reasons for this finding are unknown.
Hypothesis: The aim of the study was to determine why the onset of symptoms of AMI occurs during sleep in some individuals rather than being precipitated by known trigger factors such as physical exertion.
Methods: Using the database from a large multicenter clinical trial, patients were grouped according to whether or not they were awakened from sleep by the symptoms of AMI.
Results: In all, 870 of 3,309 patients (26%) were awakened by AMI. In general, these patients were older and sicker, with poorer left ventricular function, lower quality of life indices, more frequent heart failure, lower ejection fractions, higher incidence of angina, and a greater frequency of atrial arrhythmias. On multivariate analysis, only low ejection fraction and older age were independently associated with awakening by the symptoms of AMI.
Conclusions: Patients who are older and sicker are more likely to be awakened from sleep by the onset of symptoms of AMI. Although the reasons are unknown, we speculate that these individuals are less active and therefore less vulnerable to established trigger factors such as vigorous physical exertion.
Keywords: acute myocardial infarction, Cardiac Arrhythmia Suppression Trial (CAST), circadian variation, trigger factors, sleep
Full Text
The Full Text of this article is available as a PDF (100.1 KB).
References
- 1. Muller JE, Stone PH, Turi ZG, Rutherford JD, Czeisler CA, Parker C, Poole WK, Pasamani E, Roberts R, Robertson T, Sobel BE, Willerson JT, Braunwald E, and the MILIS Study Group : Circadian variation in the frequency of onset of acute myocardial infarction. N Engl J Med 1985; 313:1315–1322 [DOI] [PubMed] [Google Scholar]
- 2. Goldberg RJ, Brady P, Muller JE, Chen Z, deGroot M, Zonnevald P, Dalen JE: Time of onset of symptoms of acute myocardial infarction. Am J Cardiol 1990; 66:140–144 [DOI] [PubMed] [Google Scholar]
- 3. Hjalmarson A, Gilpin EA, Nicod P, Dittrich H, Henning H, Engler R, Blacky R, Smith SC, Ricou F, Ross J Jr: Differing circadian patterns of symptom onset in subgroups of patients with acute myocardial infarction. Circulation 1989; 80:267–275 [DOI] [PubMed] [Google Scholar]
- 4. Willich SN, Linderer T, Wegscheider K, Leizorovicz A, Alamercery I, Schroder R, and the ISAM Study Group : Increased morning incidence of myocardial infarction in the ISAM study: Absence with prior beta‐adrenergic blockade. Circulation 1989; 80:853–858 [DOI] [PubMed] [Google Scholar]
- 5. Tofler GH, Brezinski D, Schafer AI, Czeisler CA, Rutherford JD, Willich SN, Gleason RE, Williams GH, Muller JE: Morning increase in platelet response to ADP and epinephrine: Association with the time of increased risk of acute myocardial infarction and sudden cardiac death. N Engl J Med 1987; 316:1514–1518 [DOI] [PubMed] [Google Scholar]
- 6. Brezinski DA, Tofler GH, Muller JE, Pohjola‐Sintonen S, Willich SN, Schafer AI, Czeisler CA, Williams GH: Morning increase in platelet aggregability: Association with assumption of the upright posture. Circulation 1988; 78:35–40 [DOI] [PubMed] [Google Scholar]
- 7. Peters RW, Zoble RG, Liebson PR, Pawitan Y, Brooks MM, Proschan M: Identification of a secondary peak in myocardial infarction onset 11 to 12 hours after awakening: The Cardiac Arrhythmia Suppression Trial (CAST) experience. J Am Coll Cardiol 1993; 22:998–1003 [DOI] [PubMed] [Google Scholar]
- 8. Goldberg RJ, Brady P, Muller JE, Chen Z, de Groot M, Zonneveld P, Dalen JE: Time of onset of symptoms of acute myocardial infarction. Am J Cardiol 1990; 66:140–144 [DOI] [PubMed] [Google Scholar]
- 9. Stewart RAH, Robertson MC, Wilkins GT, Low CJS, Restieaux NJ: Association between activity at onset of symptoms and outcome of acute myocardial infarction. J Am Coll Cardiol 1997; 29:250–253 [DOI] [PubMed] [Google Scholar]
- 10. Willich SN, Lewis M, Lowell H, Arntz H, Schubert F, Schroeder R: Physical exertion as a trigger of acute myocardial infarction. N Engl J Med 1993; 329:1684–1690 [DOI] [PubMed] [Google Scholar]
- 11. Willich SN, Lewis M, Lowell H, Arntz H‐R, Schubert F, Schroeder R, for the Triggers and Mechanisms of Myocardial Infarction Study Group : Physical exertion as a trigger of acute myocardial infarction. N Engl J Med 1993; 329:1684–1690 [DOI] [PubMed] [Google Scholar]
- 12. Mittelman MA, Maclure M, Sherwood JB, Mulry RP, Tofler GH, Jacobs SC, Friedman R, Benson H, Muller JE: Triggering of acute myocardial infarction by episodes of anger. Circulation 1995; 92:1720–1725 [DOI] [PubMed] [Google Scholar]
- 13. Muller JE, Mittelman MA, Maclure M, Sherwood JB, Tofler GH: Triggering myocardial infarction by sexual activity: Low absolute risk and prevention by regular physical exertion. J Am Med Assoc 1996; 275:1405–1409 [DOI] [PubMed] [Google Scholar]
- 14. French AJ, Dock W: Fatal coronary arteriosclerosis in young soldiers. J Am Med Assoc 1944; 124:1233–1237 [Google Scholar]
- 15. Yater WM, Traum AH, Brown WG, Fitzgerald RP, Geisler MA, Wilcox BB: Coronary artery disease in men 18 to 39 years in age: Report of 866 cases, 450 with necropsy examinations. Am Heart J 1948; 36:334–372 [PubMed] [Google Scholar]
- 16. The Cardiac Arrhythmia Suppression Trial (CAST) Investigators : Preliminary report. Effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med 1989; 321:406–412 [DOI] [PubMed] [Google Scholar]
- 17. The CAST II Investigators : Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med 1992; 327:227–233 [DOI] [PubMed] [Google Scholar]
- 18. Pell S, D'Alonzo A: Acute myocardial infarction in a large industrial population: Report of a 6‐year study of 1,356 cases. J Am Med Assoc 1963; 185:831–838 [DOI] [PubMed] [Google Scholar]
- 19. Ridker PM, Manson JE, Buring JE, Muller JE, Hennekens CH: Circadian variation of acute myocardial infarction and the effect of low‐dose aspirin in a randomized trial of physicians. Circulation 1990; 82:897–902 [DOI] [PubMed] [Google Scholar]