From the Department of Preventive Medicine, Rush Medical College of Rush
University, and Rush–Presbyterian–St Luke's Medical Center,
Chicago, Ill.
Correspondence to William J. Elliott, MD, PhD, Department of Preventive Medicine, Rush–Presbyterian–St Luke's Medical Center, 1725 West Harrison St, Suite 117, Chicago, IL 60612.
Background and Purpose—Acute
myocardial infarction and sudden death display a circadian rhythm, with
a higher risk between 6 AM and noon. Some reports suggest
that stroke does not follow such a circadian variation and that
hemorrhagic stroke occurs more often during the evening.
Methods—A meta-analysis of 31 publications reporting the
circadian timing of 11 816 strokes was performed, subdividing (when
possible) by the type of stroke, according to the time of onset of
symptoms. When precise timing was not given, strokes were distributed
evenly (that is, biasing toward the null hypothesis of lack of
circadian variation).
Results—All subtypes of strokes displayed a significant
(P<0.001) circadian variation in time of onset, whether
divided into 3-, 4-, or 6-hour time periods. There was a 49% increase
(95% confidence interval, 44% to 55%) in stroke of all types between
6 AM and noon (compared with expectations if no circadian
variation was present), which is a 79% (95% confidence interval,
72% to 87%) increase over the normalized risk of the other 18 hours
of the day. There were 29% fewer strokes between midnight and 6
AM, a 35% decrease compared with the other 18 hours of the
day. All three subtypes of stroke had a significantly higher risk
between 6 AM and noon (55% for 8250 ischemic
strokes; 34% for 1801 hemorrhagic strokes, and 50% for 405 transient
ischemic attacks).
Conclusions—These data support the presence of a circadian
pattern in the onset of stroke, with a significantly higher risk in the
morning.
© 1998 American Heart Association, Inc.
Original Contributions
Circadian Variation in the Timing of Stroke Onset
A Meta-analysis
Key Words: circadian variation • meta-analysis • stroke onset
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