Iranian Heart Journal

Iranian Heart Journal

Characteristics of Patients With Myocardial Infarction Occurring in the Early Morning Hours

Document Type : Original Article

Authors
Ahmed Alaarag
Mohamed Naseem
Cardiology Department, Tanta University, Tanta, Egypt.
Abstract
Background: Circadian fluctuations in acute myocardial infarction (AMI) onset have been noted, peaking between 06:00 and 12:00 hours. While myocardial ischemia can occur anytime, circadian variation may influence acute ischemic heart disease onset. This study aimed to evaluate the impact of circadian rhythm on clinical and angiographic characteristics of ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI).
 
Methods: In this prospective study, we enrolled 433 consecutive patients diagnosed with acute STEMI who underwent PPCI. Patients were assigned to 2 groups based on the time of AMI onset: the first group included patients with morning onset of AMI (between 06:00 and 12:00 hours), and the second group included those with AMI onset at other times.
 
Results: Patients with morning presentation had higher initial and post-flow achievement thrombus scores, lower initial TIMI flow scores (P=0.035, P=0.016, and P=0.004, respectively), and more frequent bailout glycoprotein IIb/IIIa use.
 
Conclusions: Patients experiencing STEMI symptom onset in the morning had a higher thrombus burden than those with symptom onset at other times. (Iranian Heart Journal 2024; 25(3): 27-34)
Keywords
Early morning
STEMI
Circadian rhythm
Primary percutaneous coronary intervention
TIMI flow
Acute coronary syndrome
  1. Nowbar AN, Gitto M, Howard JP, Francis DP, Al-Lamee R. Mortality From Ischemic Heart Disease. Circ Cardiovasc Qual Outcomes 2019; 12. https://doi.org/10.1161/CIRCOUTCOMES.118.005375.
  2. Aroche R, Naranjo AA, Rodríguez ÁY, Llera RE. Cardiovascular risk factors in the circadian rhythm of myocardial infarction. Revista de La Federacion Argentina de Cardiologia 2014; 43. https://doi.org/10.1016/s1885-5857(06)60650-6.
  3. Xin M, Zhang S, Zhao L, Jin X, Kim W, Cheng XW. Circadian and seasonal variation in onset of acute myocardial infarction. Medicine 2022; 101:e29839. https://doi.org/10.1097/MD.0000000000029839.
  4. Nakashima H, Mashimo Y, Kurobe M, Muto S, Furudono S, Maemura K. Impact of Morning Onset on the Incidence of Recurrent Acute Coronary Syndrome and Progression of Coronary Atherosclerosis in Acute Myocardial Infarction. Circulation Journal 2017; 81:361–7. https://doi.org/10.1253/circj.CJ-16-0817.
  5. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al. Third universal definition of myocardial infarction. Eur Heart J 2012; 33:2551–67. https://doi.org/10.1093/eurheartj/ehs184.
  6. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2018; 39:119–77. https://doi.org/10.1093/eurheartj/ehx393.
  7. Gibson CM, Cannon CP, Murphy SA, Ryan KA, Mesley R, Marble SJ, et al. Relationship of TIMI Myocardial Perfusion Grade to Mortality After Administration of Thrombolytic Drugs. Circulation 2000; 101:125–30. https://doi.org/10.1161/01.CIR.101.2.125.
  8. van ‘t Hof AWJ, Liem A, Suryapranata H, Hoorntje JCA, de Boer M-J, Zijlstra F. Angiographic Assessment of Myocardial Reperfusion in Patients Treated With Primary Angioplasty for Acute Myocardial Infarction. Circulation 1998; 97:2302–6. https://doi.org/10.1161/01.CIR.97.23.2302.
  9. Duman H, Çetin M, Durakoğlugil ME, Değirmenci H, Hamur H, Bostan M, et al. Relation of Angiographic Thrombus Burden with Severity of Coronary Artery Disease in Patients with ST Segment Elevation Myocardial Infarction. Medical Science Monitor 2015; 21:3540–6. https://doi.org/10.12659/MSM.895157.
  10. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography 2015; 28:1-39.e14. https://doi.org/10.1016/j.echo.2014.10.003.
  11. Kang H. Sample size determination and power analysis using the G*Power software. J Educ Eval Health Prof. 2021; 18:17. doi:10.3352/jeehp.2021.18.17
  12. Škrlec I, Marić S, Včev A. Myocardial Infarction and Circadian Rhythm. Visions of Cardiomyocyte - Fundamental Concepts of Heart Life and Disease [Working Title], IntechOpen; 2019. https://doi.org/10.5772/intechopen.83393.
  13. Buurma M, van Diemen JJK, Thijs A, Numans ME, Bonten TN. Circadian Rhythm of Cardiovascular Disease: The Potential of Chronotherapy With Aspirin. Front Cardiovasc Med 2019; 6. https://doi.org/10.3389/fcvm.2019.00084.
  14. Zhao F, Zhao X, Yang L, Li Y. Circadian rhythm and clinical characteristics in patients with acute myocardial infarction combined with obstructive sleep apnea. Annals of Noninvasive Electrocardiology 2022;27. https://doi.org/10.1111/anec.12995.
  15. Cimmino G, Conte S, Morello A, D’Elia S, Marchese V, Golino P. The complex puzzle underlying the pathophysiology of acute coronary syndromes: from molecular basis to clinical manifestations. Expert Rev Cardiovasc Ther 2012; 10:1533–43. https://doi.org/10.1586/erc.12.157.
  16. Santos-Gallego CG, Picatoste B, Badimón JJ. Pathophysiology of Acute Coronary Syndrome. Curr Atheroscler Rep 2014; 16:401. https://doi.org/10.1007/s11883-014-0401-9.
  17. Bentzon JF, Otsuka F, Virmani R, Falk E. Mechanisms of Plaque Formation and Rupture. Circ Res 2014; 114:1852–66. https://doi.org/10.1161/CIRCRESAHA.114.302721.
  18. Tofler GH, Muller JE. Triggering of Acute Cardiovascular Disease and Potential Preventive Strategies. Circulation 2006; 114:1863–72. https://doi.org/10.1161/CIRCULATIONAHA.105.596189.
  19. Kario K, White WB. Early morning hypertension: what does it contribute to overall cardiovascular risk assessment? Journal of the American Society of Hypertension 2008; 2:397–402. https://doi.org/10.1016/j.jash.2008.05.004.
  20. Scheer FAJL, Shea SA. Human circadian system causes a morning peak in prothrombotic plasminogen activator inhibitor-1 (PAI-1) independent of the sleep/wake cycle. Blood 2014; 123:590–3. https://doi.org/10.1182/blood-2013-07-517060.
  21. Dézsi CA, Szentes V. Effects of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers on Prothrombotic Processes and Myocardial Infarction Risk. American Journal of Cardiovascular Drugs 2016; 16:399–406. https://doi.org/10.1007/s40256-016-0185-0.
  22. Crnko S, Du Pré BC, Sluijter JPG, Van Laake LW. Circadian rhythms and the molecular clock in cardiovascular biology and disease. Nat Rev Cardiol 2019; 16:437–47. https://doi.org/10.1038/s41569-019-0167-4.
Iranian Heart Journal
Volume 25, Issue 3
Summer 2024
Pages 27-34