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Circadian pattern of symptoms onset in patients ≤35years presenting with ST-segment elevation acute myocardial infarction

      Highlights

      • Our study suggests that AMI in young adults has a circadian pattern with a morning peak.
      • ~20% of young patients with AMI have atypical clinical presentation.
      • Smoking is the most prevalent risk factor for AMI in young adults.

      Abstract

      Background

      There are scarce data regarding the circadian pattern of symptoms onset in young patients presenting with acute myocardial infarction (AMI). We explored whether young patients with ST-segment elevation AMI exhibit a circadian variation in symptoms onset.

      Methods

      We recruited prospectively 256 consecutive patients who had survived their first ST-segment elevation AMI ≤35 years of age. Patients were categorized into 4 groups by 6-h intervals over 24 h.

      Results

      In 49 patients (19.1%) the clinical presentation of AMI was atypical. The symptoms onset was as follows: 00:01 to 06:00, 19.1%, 06:01 to 12:00, 32.4%; 12:01 to 18:00, 28.1%; and 18:01 to 24:00, 20.3%. There was a significant association between the time of day and the likelihood of symptoms onset (Rayleigh test, p < 0.001). Between 00:01 and 06:00 the incidence of AMI onset was lower than expected and between 06:01 and 12:00 was higher (p = 0.034 and p = 0.011, respectively), whereas in the other 6-h period groups no difference was found between expected and observed AMI incidence (p = 0.280 and p = 0.131). No significant differences were found regarding clinical characteristics, i.e. traditional risk factors, reperfusion treatment of AMI, ejection fraction of left ventricle, time interval from pain onset to hospital arrival, dietary habits and physical activity, among the 6-h period groups.

      Conclusions

      ST-segment elevation AMI in individuals ≤35 years of age follows a circadian pattern with a morning peak. This information might be useful for the prompt diagnosis and treatment of AMI in very young patients which occurs rarely and frequently with atypical clinical presentation.

      Keywords

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      References

        • Suárez-Barrientos A.
        • López-Romero P.
        • Vivas D.
        • Castro-Ferreira F.
        • Núñez-Gil I.
        • Franco E.
        • et al.
        Circadian variations of infarct size in acute myocardial infarction.
        Heart. 2011; 97: 970-976
        • Rudic R.D.
        Time is of the essence: vascular implications of the circadian clock.
        Circulation. 2009; 120: 1714-1721
        • Muller J.E.
        • Tofler G.H.
        • Stone P.H.
        Circadian variation and triggers of onset of acute cardiovascular disease.
        Circulation. 1989; 79: 733-743
        • ISIS-2 (Second International Study of Infarct Survival) Collaborative Group
        Morning peak in the incidence of myocardial infarction: experience in the ISIS-2 trial.
        Eur Heart J. 1992; 13: 594-598
        • Hjalmarson A.
        • Gilpin E.A.
        • Nicod P.
        • Dittrich H.
        • Henning H.
        • Engler R.
        • et al.
        Differing circadian patterns of symptom onset in subgroups of patients with acute myocardial infarction.
        Circulation. 1989; 80 (267-5)
        • Hansen O.
        • Johansson B.W.
        • Gullberg B.
        Circadian distribution of onset of acute myocardial infarction in subgroups from analysis of 10,791 patients treated in a single center.
        Am J Cardiol. 1992; 69: 1003-1008
        • Holmes D.R.
        • Aguirre F.V.
        • Aplin R.
        • Lennon R.J.
        • Nestler D.M.
        • Bell M.R.
        • et al.
        Circadian rhythms in patients with ST-elevation myocardial infarction.
        Circ Cardiovasc Qual Outcomes. 2010; 3: 382-389
        • Behar S.
        • Halabi M.
        • Reicher-Reiss H.
        • Zion M.
        • Kaplinsky E.
        • Mandelzweig L.
        • et al.
        Circadian variation and possible external triggers of onset of myocardial infarction. SPRINT Study Group.
        Am J Med. 1993; 94: 395-400
        • Willich S.N.
        • Linderer T.
        • Wegscheider K.
        • Leizorovicz A.
        • Alamercery I.
        • Schröder R.
        Increased morning incidence of myocardial infarction in the ISAM Study: absence with prior beta-adrenergic blockade. ISAM Study Group.
        Circulation. 1989; 80: 853-858
        • World Health Organization Regional Office for Europe
        Myocardial infarction community registers: results of a WHO international collaborative study coordinated by the Regional Office for Europe.
        World Health Organization, Regional Office for Europe, Copenhagen1976
        • Doughty M.
        • Mehta R.
        • Bruckman D.
        • et al.
        Acute myocardial infarction in the young. The University of Michigan experience.
        Am Heart J. 2002; 143: 56-62
        • Schoenenberger A.W.
        • Radovanovic D.
        • Stauffer J.C.
        • Windecker S.
        • Urban P.
        • Niedermaier G.
        • et al.
        Acute coronary syndromes in young patients: presentation, treatment and outcome.
        Int J Cardiol. 2011; 148: 300-304
        • Zimmerman F.H.
        • Cameron A.
        • Fisher L.D.
        • Ng G.
        Myocardial infarction in young adults: angiographic characterization, risk factors and prognosis (Coronary Artery Surgery Study Registry).
        J Am Coll Cardiol. 1995; 26: 654-661
        • Rallidis L.S.
        • Gialeraki A.
        • Komporozos C.
        • Vavoulis P.
        • Pavlakis G.
        • Travlou A.
        • et al.
        Role of methylenetetrahydrofolate reductase 677C → T polymorphism in the development of premature myocardial infarction.
        Atherosclerosis. 2008; 200: 115-120
        • Chan C.M.
        • Chen W.L.
        • Kuo H.Y.
        • Huang C.C.
        • Shen Y.S.
        • Choy C.S.
        • et al.
        Circadian variation of acute myocardial infarction in young people.
        Am J Emerg Med. 2012; 30: 1461-1465
        • Grundy S.M.
        • Cleeman J.I.
        • Daniels S.R.
        • Donato K.A.
        • Eckel R.H.
        • Franklin B.A.
        • et al.
        American Heart Association; National Heart, Lung, and Blood Institute. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement.
        Circulation. 2005; 112: 2735-2752
        • Panagiotakos D.B.
        • Pitsavos C.
        • Stefanadis C.
        Dietary patterns: a Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk.
        Nutr Metab Cardiovasc Dis. 2006; 16: 559-568
        • Craig C.L.
        • Marshall A.L.
        • Sjöström M.
        • Bauman A.E.
        • Booth M.L.
        • Ainsworth B.E.
        • et al.
        International physical activity questionnaire: 12-country reliability and validity.
        Med Sci Sports Exerc. 2003; 35: 1381-1395
        • Lang R.M.
        • Bierig M.
        • Devereux R.B.
        • Flachskampf F.A.
        • Foster E.
        • Pellikka P.A.
        • et al.
        Recommendations for chamber quantification.
        Eur J Echocardiogr. 2006; 7: 79-108
        • Rana J.S.
        • Mukamal K.J.
        • Morgan J.P.
        • Muller J.E.
        • Mittleman M.A.
        Circadian variation in the onset of myocardial infarction: effect of duration of diabetes.
        Diabetes. 2003; 52: 1464-1468
        • Sayer J.W.
        • Wilkinson P.
        • Ranjadayalan K.
        • Ray S.
        • Marchant B.
        • Timmis A.D.
        Attenuation or absence of circadian and seasonal rhythms of acute myocardial infarction.
        Heart. 1997; 77: 325-329
        • Gilpin E.A.
        • Hjalmarson A.
        • Ross Jr., J.
        Subgroups of patients with atypical circadian patterns of symptom onset in acute myocardial infarction.
        Am J Cardiol. 1990; 66: 7G-11G
        • Cohen M.C.
        • Rohtla K.M.
        • Lavery C.E.
        • Muller J.E.
        • Mittleman M.A.
        Meta-analysis of the morning excess of acute myocardial infarction and sudden cardiac death.
        Am J Cardiol. 1997; 79: 1512-1516
        • Tofler G.H.
        • Brezinski D.
        • Schafer A.I.
        • Czeisler C.A.
        • Rutherford J.D.
        • Willich S.N.
        • 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
        • Pepine C.J.
        Circadian variations in myocardial ischemia. Implications for management.
        JAMA. 1991; 265: 386-390
        • Andreotti F.
        • De Luca L.
        • Renda G.
        • Ferro A.
        • Mongiardo R.
        • Zecchi P.
        • et al.
        Circadianicity of hemostatic function and coronary vasomotion.
        Cardiologia. 1999; 44: 245-249
        • Turton M.B.
        • Deegan T.
        Circadian variations of plasma catecholamine, cortisol and immunoreactive insulin concentrations in supine subjects.
        Clin Chim Acta. 1974; 55: 389-397
        • Rosing D.R.
        • Brakman P.
        • Redwood D.R.
        • Goldstein R.E.
        • Beiser G.D.
        • Astrup T.
        • et al.
        Blood fibrinolytic activity in man. Diurnal variation and the response to varying intensities of exercise.
        Circ Res. 1970; 27: 171-184
        • Ehrly A.M.
        • Jung G.
        Circadian rhythm of human blood viscosity.
        Biorheology. 1973; 10: 577-583
        • Brezinski D.A.
        • Tofler G.H.
        • Muller J.E.
        • Pohjola-Sintonen S.
        • Willich S.N.
        • Schafer A.I.
        • et al.
        Morning increase in platelet aggregability. Association with assumption of the upright posture.
        Circulation. 1988; 78: 35-40
        • Kawahara J.
        • Sano H.
        • Fukuzaki H.
        • Saito K.
        • Hirouchi H.
        Acute effects of exposure to cold on blood pressure, platelet function and sympathetic nervous activity in humans.
        Am J Hypertens. 1989; 2: 724-726
        • Weitzman E.D.
        • Fukushima D.
        • Nogeire C.
        • Roffwarg H.
        • Gallagher T.F.
        • Hellman L.
        Twenty-four hour pattern of the episodic secretion of cortisol in normal subjects.
        J Clin Endocrinol Metab. 1971; 33: 14-22
        • Leibetseder V.
        • Humpeler S.
        • Svoboda M.
        • Schmid D.
        • Thalhammer T.
        • Zuckermann A.
        • et al.
        Clock genes display rhythmic expression in human hearts.
        Chronobiol Int. 2009; 26: 621-636
        • Panagiotakos D.B.
        • Rallidis L.S.
        • Pitsavos C.
        • Stefanadis C.
        • Kremastinos D.
        Cigarette smoking and myocardial infarction in young men and women; a case–control study.
        Int J Cardiol. 2007; 116: 371-375
        • Panagiotakos D.
        • Rallidis L.S.
        • Katsiotis E.
        • Pitsavos C.
        • Stefanadis C.
        • Kremastinos D.T.
        Background dietary habits are strongly associated with the development of myocardial infarction at young ages; a case-control study.
        Eur J Clin Nutr and Metab. 2008; 3: e328-e334