Document Type : Original Article(s)


Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran


BACKGROUND: Circadian variation is known as an important factor in acute myocardial infarction (AMI). Moreover, the circadian pattern may help in disease prevention and better medication prescription. Therefore, the aim of our study was to investigate the circadian pattern of symptom onset in patients with ST-segment elevation myocardial infarction (STEMI).METHODS: This cross-sectional study was conducted on 777 patients admitted to the Imam Ali Cardiovascular Center, Kermanshah, Iran, with a diagnosis of STEMI from March 2018 to February 2019. Data were collected using a checklist developed based on the study's objectives. Differences between subgroups were assessed using one-way analysis of variance (ANOVA) with post-hoc testing and chi-square test (or Fisher’s exact test).RESULTS: Out of the 777 patients, 616 (79.3%) were men. The mean and standard deviation (SD) of age of the patients was 60.93 ± 12.86 years. 380 patients (48.9%) were current smoker, 40.3% were hypertensive, 21.1% had hypercholesterolemia, 18.3% had diabetes mellitus (DM), 25.2% had history of angina, and about 15.0% had history of myocardial infarction (MI). The occurrence of STEMI was most common during hours between 06:01-12:00 (27.7%), followed by 12:01-18:00 (27.3%), 00:00-06:00 (24.3%), and 18:01-24:00 (20.7%), respectively. Gender was significantly associated with circadian pattern of STEMI. Women showed a double peak of symptom onset in 06:01-12:00 and 12:01-18:00.CONCLUSION: The present study of Iranian patients displayed circadian pattern of STEMI with 2 peaks in the morning and afternoon, and the both peaks were dominated by women.


  1. Goodacre S, Cross E, Arnold J, Angelini K, Capewell S, Nicholl J. The health care burden of acute chest pain. Heart 2005; 91(2): 229-30.
  2. Muller JE, Tofler GH, Stone PH. Circadian variation and triggers of onset of acute cardiovascular disease. Circulation 1989; 79(4): 733-43.
  3. Suarez-Barrientos A, Lopez-Romero P, Vivas D, Castro-Ferreira F, Nunez-Gil I, Franco E, et al. Circadian variations of infarct size in acute myocardial infarction. Heart 2011; 97(12): 970-6.
  4. Organization World Health. Myocardial infarction community registers: Results of a WHO international collaboration study coordinated by the regional office for Europe. Geneva, Switzerland: WHO; 1976.
  5. Hjalmarson A, Gilpin EA, 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(2): 267-75.
  6. 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(3): 897-902.
  7. Bergheanu SC, van der Laarse A, van der Bom JG, van der Hoeven BL, le Cessie S, de Jong MG, et al. Asymmetric dimethylarginine (ADMA) levels display a morning peak in patients with acute myocardial infarction. Dis Markers 2011; 30(5): 245-52.
  8. Hammoudeh AJ, Alhaddad IA. Triggers and the onset of acute myocardial infarction. Cardiol Rev 2009; 17(6): 270-4.
  9. Singh RB, Pella D, Neki NS, Chandel JP, Rastogi S, Mori H, et al. Mechanisms of acute myocardial infarction study (MAMIS). Biomed Pharmacother 2004; 58(Suppl 1): S111-S115.
  10. Itaya H, Takagi T, Sugi K, Nakamura M. Contents of second peak in the circadian variation of acute myocardial infarction in the Japanese population. J Cardiol 2012; 59(2): 147-53.
  11. Lopez F, Lee KW, Marin F, Roldan V, Sogorb F, Caturla J, et al. Are there ethnic differences in the circadian variation in onset of acute myocardial infarction? A comparison of 3 ethnic groups in Birmingham, UK and Alicante, Spain. Int J Cardiol 2005; 100(1): 151-4.
  12. Chan CM, Chen WL, Kuo HY, Huang CC, Shen YS, Choy CS, et al. Circadian variation of acute myocardial infarction in young people. Am J Emerg Med 2012; 30(8): 1461-5.
  13. Sari I, Davutoglu V, Erer B, Tekbas E, Ucer E, Ozer O, et al. Analysis of circadian variation of acute
  14. myocardial infarction: Afternoon predominance in Turkish population. Int J Clin Pract 2009; 63(1): 82-6.
  15. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al. Third universal definition of myocardial infarction. J Am Coll Cardiol 2012; 60(16): 1581-98.
  16. Rallidis LS, Triantafyllis AS, Sakadakis EA, Gialeraki A, Varounis C, Rallidi M, et al. Circadian pattern of symptoms onset in patients
  17. Gallerani M, Manfredini R, Ricci L, Goldoni C, Cocurullo A, Pareschi PL. Circadian variation in the onset of acute myocardial infarction: Lack of an effect due to age and sex. J Int Med Res 1993; 21(3): 158-60.
  18. Park HE, Koo BK, Lee W, Cho Y, Park JS, Choi JY, et al. Periodic variation and its effect on management and prognosis of Korean patients with acute myocardial infarction. Circ J 2010; 74(5): 970-6.
  19. Zhou RH, Xi B, Gao HQ, Liu XQ, Li YS, Cao KJ, et al. Circadian and septadian variation in the occurrence of acute myocardial infarction in a Chinese population. Jpn Circ J 1998; 62(3): 190-2.
  20. Sumiyoshi T, Haze K, Saito M, Fukami K, Goto Y, Hiramori K. Evaluation of clinical factors involved in onset of myocardial infarction. Jpn Circ J 1986; 50(2): 164-73.
  21. Willich SN, Linderer T, Wegscheider K, Leizorovicz A, Alamercery I, Schroder R. Increased morning incidence of myocardial infarction in the ISAM Study: Absence with prior beta-adrenergic blockade. ISAM Study Group. Circulation 1989; 80(4): 853-8.
  22. Tofler GH, Muller JE, Stone PH, Forman S, Solomon RE, Knatterud GL, et al. Modifiers of timing and possible triggers of acute myocardial infarction in the Thrombolysis in Myocardial Infarction Phase II (TIMI II) Study Group. J Am Coll Cardiol 1992; 20(5): 1049-55.
  23. Tsukada T, Ikeda T, Ishiguro H, Abe A, Miyakoshi M, Miwa Y, et al. Circadian variation in out-of-hospital cardiac arrests due to cardiac cause in a Japanese patient population. Circ J 2010; 74(9): 1880-7.
  24. Kono T, Morita H, Nishina T, Fujita M, Hirota Y, Kawamura K, et al. Circadian variations of onset of acute myocardial infarction and efficacy of thrombolytic therapy. J Am Coll Cardiol 1996; 27(4): 774-8.
  25. Leiza JR, de Llano JM, Messa JB, Lopez CA, Fernandez JA. New insights into the circadian rhythm of acute myocardial infarction in subgroups. Chronobiol Int 2007; 24(1): 129-41.
  26. Holmes DR Jr, Aguirre FV, Aplin R, Lennon RJ, Nestler DM, Bell MR, et al. Circadian rhythms in patients with ST-elevation myocardial infarction. Circ Cardiovasc Qual Outcomes 2010; 3(4): 382-9.
  27. Dimitrov I, Khadzhikhristev A. Dynamics of the incidence of myocardial infarct in Smolyan District 1965-1979. Vutr Boles 1983; 22(4): 40-6.
  28. D'Negri CE, Nicola-Siri L, Vigo DE, Girotti LA, Cardinali DP. Circadian analysis of myocardial infarction incidence in an Argentine and Uruguayan population. BMC Cardiovasc Disord 2006; 6: 1.
  29. Fujita M, Franklin D. Diurnal changes in coronary blood flow in conscious dogs. Circulation 1987; 76(2): 488-91.
  30. Panza JA, Epstein SE, Quyyumi AA. Circadian variation in vascular tone and its relation to alpha-sympathetic vasoconstrictor activity. N Engl J Med 1991; 325(14): 986-90.
  31. Brezinski DA, Tofler GH, Muller JE, Pohjola-Sintonen S, Willich SN, Schafer AI, et al. Morning increase in platelet aggregability. Association with assumption of the upright posture. Circulation 1988; 78(1): 35-40.
  32. Andreotti F, Davies GJ, Hackett DR, Khan MI, De Bart AC, Aber VR, et al. Major circadian fluctuations in fibrinolytic factors and possible relevance to time of onset of myocardial infarction, sudden cardiac death and stroke. Am J Cardiol 1988; 62(9): 635-7.
  33. Siegel D, Black DM, Seeley DG, Hulley SB. Circadian variation in ventricular arrhythmias in hypertensive men. Am J Cardiol 1992; 69(4): 344-7.
  34. White WB. Circadian variation of blood pressure: Clinical relevance and implications for cardiovascular chronotherapeutics. Blood Press Monit 1997; 2(1): 47-51.
  35. Goldstein JA, Demetriou D, Grines CL, Pica M, Shoukfeh M, O'Neill WW. Multiple complex coronary plaques in patients with acute myocardial infarction. N Engl J Med 2000; 343(13): 915-22.
  36. Kinjo K, Sato H, Sato H, Shiotani I, Kurotobi T, Ohnishi Y, et al. Circadian variation of the onset of acute myocardial infarction in the Osaka area, 1998-1999: Characterization of morning and nighttime peaks. Jpn Circ J 2001; 65(7): 617-20.
  37. 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(16): 7G-11G.
  38. Hansen O, Johansson BW, 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(12): 1003-8.
  39. Liu XK, Katchman A, Whitfield BH, Wan G, Janowski EM, Woosley RL, et al. In vivo androgen treatment shortens the QT interval and increases the densities of inward and delayed rectifier potassium currents in orchiectomized male rabbits. Cardiovasc Res 2003; 57(1): 28-36.