1. Maximum sudden cardiac deaths peak in the morning.
2. Primary arrhythmic event is more likely to occur in the morning because increased adrenergic activity at this time may increase electrical instability or induce myocardial ischemia without heart attack.
3. Mortality reports of the Massachusetts Department of Public Health, of 2203 individuals who in 1983 died an out-of-hospital death from ischemic heart disease one hour or less after the onset of symptoms, showed peak frequency of sudden death between 9 and 11 AM [Circulation 1987;75:131].
4. Framingham Heart Study: The hourly risk of sudden cardiac death was at least 70 percent greater between 7 and 9 AM than the average risk during the remaining 22 hours of the day [Am J Cardiol 1987;60:801].
5. Data from the Berlin emergency care system found a peak frequency of ventricular fibrillation between 6 AM and noon; in contrast, asystolic episodes were more evenly distributed throughout the day [Circulation 1993;88:2284].
6. The morning peak in sudden death is particularly related to the first three hours after awakening and onset of activity [Am J Cardiol 1992;70:65]
7. Data from the Seattle Fire Department, based upon 6603 cases of out-of-hospital cardiac arrest, of which 3690 were witnessed, also exhibited a diurnal variation, with a low incidence at night and two peaks of approximately the same size [Circulation 1998;98:31]. An evening peak at 4 to 7 PM was attributed primary to patients found in ventricular fibrillation, while arrests that showed other rhythms exhibited mainly a morning peak from 8 to 11 AM.
8. Cardiac arrests also show a weekly and seasonal variation; the daily incidence peaks on Monday and the seasonal incidence is greatest in the winter [Eur Heart J 2000;21:315, Am Heart J 1999;137:512].
9. One 12 year analysis of 222,265 cases of death from coronary heart disease found that there were approximately 33 percent more deaths in December and January than in June through September [Circulation 1999;100:1630].
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