Morning increase in the time of onset of sustained ventricular tachycardia

doi:10.1016/0002-9149(89)90881-3

The American Journal of Cardiology

Volume 64, Issue 18, 15 November 1989, Pages 1204-1206

https://doi.org/10.1016/0002-9149(89)90881-3 Get rights and content

Abstract

A morning increase in the occurrence of cardiac events has recently been described in patients with coronary artery disease who present with acute myocardial infarction, sudden cardiac death and unstable angina.¹ Almost all of these reports have demonstrated that these events are more likely to occur between 6 a.m. and noon than during other times of the day. Several mechanisms have been postulated to explain this phenomenon, including increased platelet aggregation,² elevated plasma catecholamines,³ increased coronary artery tone⁴ or other factors either acting alone or in combination.

Patients with sustained ventricular tachycardia (VT) frequently have advanced structural heart disease, most often related to underlying coronary artery disease. Data from ambulatory electrocardiographic recordings of patients who have an out-of-hospital cardiac arrest without acute myocardial infarction show that the most common initial arrhythmia is monomorphic VT, which is frequently preceded by a period of acceleration of the sinus rate.⁵ Therefore, we investigated if the time of onset of VT might show a similar pattern.

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Ventricular arrhythmias (ventricular tachycardia [VT] and ventricular fibrillation [VF]) and sudden cardiac death (SCD) demonstrate a prominent circadian rhythm, being more common in the morning on waking (Figure 7B). This is apparent from studies looking at the symptomatic onset of VT,48 VT onset during 24-hour Holter monitoring,49 and ICD shocks delivered in patients at risk for VT/VF.50,51 Several of these studies found an additional late afternoon peak in VT onset.52,53
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Thus, difference in study conditions confounds the comparison of the respective patterns in VT between the two patient groups. In another study, Twidale et al.242 studied the clock time of VT onset in 68 AMI patients. VT was not associated with AMI in 53 of them, as documented by 12-lead ECG.
The functional organization of the cardiovascular system shows clear circadian rhythmicity. These and other circadian rhythms at all levels of organization are orchestrated by a central biological clock, the suprachiasmatic nuclei of the hypothalamus. Preservation of the normal circadian time structure from the level of the cardiomyocyte to the organ system appears to be essential for cardiovascular health and cardiovascular disease prevention. Myocardial ischemia, acute myocardial infarct, and sudden cardiac death are much greater in incidence than expected in the morning. Moreover, supraventricular and ventricular cardiac arrhythmias of various types show specific day-night patterns, with atrial arrhythmias – premature beats, tachycardias, atrial fibrillation, and flutter – generally being of higher frequency during the day than night – and ventricular fibrillation and ventricular premature beats more common, respectively, in the morning and during the daytime activity than sleep span. Furthermore, different circadian patterns of blood pressure are found in arterial hypertension, in relation to different cardiovascular morbidity and mortality risk. Such temporal patterns result from circadian periodicity in pathophysiological mechanisms that give rise to predictable-in-time differences in susceptibility-resistance to cyclic environmental stressors that trigger these clinical events. Circadian rhythms also may affect the pharmacokinetics and pharmacodynamics of cardiovascular and other medications. Knowledge of 24-h patterns in the risk of cardiac arrhythmias and cardiovascular disease morbidity and mortality plus circadian rhythm-dependencies of underlying pathophysiologic mechanisms suggests the requirement for preventive and therapeutic interventions is not the same throughout the day and night, and should be tailored accordingly to improve outcomes.
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Brief reportMorning increase in the time of onset of sustained ventricular tachycardia

Abstract

Clin Chim Acta

Am J Cardiol

JACC

Circadian variation and triggers of onset of acute cardiovascular disease

Circulation

Brief report
Morning increase in the time of onset of sustained ventricular tachycardia