Cyclic and circadian variations in cardiovascular events*1

The incidence of many biologic phenomena displays a reproducible and cyclic variation. Cardiovascular disease, the most common cause of death in the United States and other developed countries, also has an intrinsic variation in events. These events are more common in winter, at the beginning of each month, on Mondays (in working people), and during the early morning hours of each day. Recent meta-analyses have quantitated the excess risk of cardiovascular events in the hours around and just after awakening. Between 6 AM and noon, there is a 40% higher risk of heart attack, a 29% increased risk of cardiac death, and a 49% increased risk of stroke (compared with what would be expected if these events happened at random and were evenly distributed throughout the day). These observations have major consequences for emergency medical personnel and medical transport systems. The reasons for these observations are less clear. The circadian pattern of blood pressure (BP) and heart rate may be a major contributor, and long-term "hard end-point" studies designed to test specific pharmacologic interventions targeting the early morning rise in BP and heart rate are underway. Individuals who work night shifts and those whose BP has a different circadian pattern have a higher risk of cardiovascular events, but may be less likely to have an increased risk of cardiovascular events in the morning.