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Vol. 62. Issue 6.
Pages 709-710 (June 2009)
Vol. 62. Issue 6.
Pages 709-710 (June 2009)
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Primary Angioplasty and Diurnal Variations
Angioplastia primaria y variaciones diurnas
Alberto Domínguez Rodrígueza, Pedro Abreu Gonzálezb, Francisco Bosa Ojedaa
a Servicio de Cardiología, Hospital Universitario de Canarias, Tenerife, Santa Cruz, Spain
b Departamento de Fisiología, Universidad de la Laguna, La Laguna, Santa Cruz, Spain
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To the Editor:

We were extremely interested in the recent article by Mingo et al,1 which analyses delays before reperfusion, its determining factors and its prognostic repercussions in 389 patients with acute ST-elevation myocardial infarction (STEMI) who received a primary percutaneous coronary intervention (primary PCI) in a Spanish hospital between 2005 and 2007. The purpose of this letter is to reflect on the different aspects of primary PCI in elevated ST segments.

Firstly, the distribution of coronary syndromes is not uniform throughout the day; rather, it undergoes rhythmic variations.2 It has been clearly demonstrated that the beginning of an acute myocardial infarction most frequently occurs in the early hours of the morning, which has raised our interest in finding out what causes explain this circadian pattern, and what their clinical and therapeutic implications are.2

Secondly, various studies have provided data regarding the poor clinical results obtained by primary PCI performed outside normal working hours (between 17:00 and 8:00).3,4 In particular, Henriques et al3 demonstrated that a total of 1702 patients with STEMI who came to the hospital between 18:00 y and 8:00 had a higher mortality index and a greater rate of primary PCI failure. Furthermore, in a cohort study of 102 086 patients from the National Registry of Myocardial Infarction (NRMI-USA), Magid et al4 demonstrated that in patients who presented STEMI during the night, it took longer to perform a primary PCI than a fibrinolysis. The same authors concluded that 33 647 patients that were treated with primary PCI had a higher hospital mortality rate when symptoms began at night, in relation with the longer delay of reperfusion. In a similar way to the above studies, our group recently5 published the results of STEMI patients who were treated with primary PCI between the hours of 8:00 and 18:00 and between 18:00 and 8:00. We studied 90 consecutive patients with STEMI who had been treated with primary PCI, and the results obtained were worse when the PCI was performed between 18:00 and 8:00. On the other hand, other studies have not shown the differences in the results of primary PCI when it is performed outside of normal working hours.6,7

Thirdly, it is accepted that daily modifications occur in humoural factors such as the rise in platelet aggregability in the early hours of the morning and the circadian variability of the inflammatory molecules in patients with acute myocardial infarction.8 In addition, we have seen that there is a clear link between inflammation and thrombosis, which exercise reciprocal influences.9

In conclusion, we would like to raise the possibility that circadian variations in the balance between prothrombotic, natural fibrinolytic and inflammatory processes may have at least a partial effect on the success of a primary PCI.

Mingo S, Goicolea J, Nombela L, Sufrate E, Blasco A, Millán I, et al..
Angioplastia primaria en nuestro medio. Análisis de los retrasos hasta la reperfusión, sus condicionantes y su implicación pronóstica..
Rev Esp Cardiol, 62 (2009), pp. 15-22
Hernández-Fernandes E, Coelho D, Missel-Correa JR, Kumpinski D..
Alteraciones circadianas del sistema cardiovascular..
Rev Esp Cardiol, 53 (2000), pp. 117-22
Henriques JP, Haasdijk AP, Zijlstra F; Zwolle Myocardial Infarction Study Group..
Outcome of primary angioplasty for acute myocardial infarction during routine duty hours versus during off-hours..
J Am Coll Cardiol, 41 (2003), pp. 2138-42
Magid DJ, Wang Y, Herrin J, McNamara RL, Bradley EH, Curtis JP, et al..
Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute ST-segment elevation myocardial infarction..
JAMA, 294 (2005), pp. 803-12
Domínguez-Rodríguez A, García-González M, Abreu-González P..
Outcome of primary angioplasty for ST-segment elevation myocardial infarction during routine duty hours versus during off-hours. Results of a single-center in Spain..
Int J Cardiol, 119 (2007), pp. 227-9
Garot P, Juliard JM, Benamer H, Steg PG..
Are the results of primary percutaneous transluminal coronary angioplasty for acute myocardial infarction different during the "off" hours? Am J Cardiol..
, 79 (1997), pp. 1527-9
Zahn R, Schiele R, Seidl K, Schuster S, Hauptmann KE, Voigtlander T, et al..
Daytime and nighttime differences in patterns of performance of primary angioplasty in the treatment of patients with acute myocardial infarction. Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) Study..
Am Heart J, 138 (1999), pp. 1111-7
Domínguez Rodríguez A, Abreu González P, García MJ, de la Rosa A, Vargas M, Marrero F..
Ritmo luz/oscuridad de las citocinas proinflamatorias en el infarto agudo de miocardio..
Rev Esp Cardiol, 56 (2003), pp. 555-60
García-Moll X, Kaski JC..
Cardiopatía isquémica: marcadores de inflamación y riesgo cardiovascular..
Rev Esp Cardiol, 52 (1999), pp. 990-1003
Revista Española de Cardiología (English Edition)

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