Relation between time of symptom onset of ST-segment elevation myocardial infarction and patient baseline
Owen Mogabgab1, Stephen D Wiviott, Elliot M Antman
1Cardiology Division, The University of Texas Southwestern Medical School, Dallas, Texas 75390, USA. owen@mogabgab.com
Insights
A morning excess of ST-elevation myocardial infarction (STEMI) persists. Patient characteristics vary by STEMI onset time, suggesting a physiologic link that may inform preventative strategies for heart attacks.
Area of Science:
- Cardiology
- Circadian Biology
- Public Health
Background:
- A morning peak in ST-segment elevation myocardial infarction (STEMI) has been documented.
- Understanding patient characteristics associated with STEMI timing may reveal underlying biological mechanisms.
Purpose of the Study:
- To investigate variations in patient baseline characteristics based on the timing of STEMI symptom onset.
- To test the hypothesis that patient characteristics differ with STEMI timing.
Main Methods:
- Analysis of a large national registry (N=45,218) of unselected STEMI patients.
- Categorization of STEMI onset into early (6 am-2 pm), late day (2 pm-10 pm), and overnight (10 pm-6 am) periods.
- Evaluation of demographic, clinical, and treatment-related factors across STEMI onset time groups.
Main Results:
- A significant circadian variation in STEMI onset was observed, with 41% occurring early, 32% late day, and 26% overnight (P<0.001).
- Early STEMI onset was associated with younger patients, lower rates of smoking, diabetes, and home beta-blocker use, but higher rates of white race, male sex, home aspirin use, and lower obesity.
- Overnight STEMI onset was linked to higher rates of cardiovascular disease, including prior heart failure, three-vessel coronary artery disease, and reduced left ventricular ejection fraction.
Conclusions:
- The observed morning excess of STEMI highlights a potential window for preventative interventions.
- Variations in patient characteristics across STEMI onset times suggest a physiological relationship that warrants further investigation for targeted prevention.
Background:
The presence of a morning excess of ST-segment elevation myocardial infarction (STEMI) has been observed. The relation between patient characteristics and timing of STEMI may provide insight into the biological processes responsible for this phenomenon.
Hypothesis:
Patient baseline characteristics will vary with timing of STEMI.
Methods:
We performed an analysis using a large national registry of unselected patients with STEMI (N=45,218). Patients were categorized by time of symptom onset: early (6 am-2 pm), late day (2 pm-10 pm), and overnight (10 pm-6 am) then evaluated for variations in characteristics.
Results:
A circadian variation in the timing of symptom onset of STEMI was observed (early 41%, late day 32%, and overnight 26%, P<0.001). Circadian variations in factors known to alter timing of events were seen, including lower rates of home β-blocker use, smoking, and diabetes, with early onset of STEMI symptoms. In addition, patients in the 6 am to 2 pm subgroup were more likely older, white race, and male, with higher rates of home aspirin use and lower rates of obesity. Higher rates of coexisting cardiovascular disease, including prior heart failure, 3-vessel coronary artery disease, and depressed left ventricular ejection fraction, were observed in the overnight group. More robust antiplatelet therapy with home clopidogrel use was not associated with a change in the timing of events.
Conclusions:
A morning excess of STEMI continues to exist and represents a potential target for preventative strategies. Patient baseline characteristics vary with the onset of STEMI and may reflect a physiologic relationship between these factors and the timing of events.
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