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Article

The Association Between Daylight Saving Time and Acute Myocardial Infarction in Canada

by
Ahmad Al Samarraie
1,2,*,
Roger Godbout
2,3,
Remi Goupil
2,4,
Catalin Paul Suarasan
1,2,
Samaya Kanj
1,2,
Melina Russo
1,2,
Mathilde Dano
1,2,
Justine Roy
1,2,
Laurence Reiher
1,2,
Guy Rousseau
2,5 and
Maxime Pichette
1,2
1
Division of Cardiology, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC H4J 1C5, Canada
2
Faculty of Medicine, University of Montreal, 2900 Boulevard Édouard-Montpetit, Montreal, QC H3T 1J4, Canada
3
Sleep Laboratory, Rivière-des-Prairies Mental Health Hospital, 7070 Boulevard Perras, Montreal, QC H1E 1A4, Canada
4
Division of Nephrology, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC H4J 1C5, Canada
5
Centre de Biomédecine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC H4J 1C5, Canada
*
Author to whom correspondence should be addressed.
Hearts 2024, 5(4), 575-583; https://doi.org/10.3390/hearts5040044
Submission received: 17 October 2024 / Revised: 15 November 2024 / Accepted: 21 November 2024 / Published: 22 November 2024
(This article belongs to the Collection Feature Papers from Hearts Editorial Board Members)
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Versions Notes

Abstract

:
Background: Recent studies have suggested an increased risk of acute myocardial infarction (AMI) following daylight saving time (DST) transitions in cohorts of American and European patients. We aim to validate this finding in a Canadian population. Methods: We performed a retrospective cohort study of patients admitted to the Hôpital du Sacré-Coeur de Montréal with a diagnosis of AMI requiring a coronary angiogram from 28 February 2016 to 3 December 2022. The transition period was defined as two weeks following DST, while the control periods were two weeks before and two weeks after the transition period. Patients aged 18 years or older were included. The primary endpoint was the incidence rate ratio (IRR) of AMI following DST transitions while the secondary endpoint was infarct size by biomarkers. A subgroup analysis compared the pre-COVID-19 period (2016–2019) to the post-COVID-19 period (2020–2022). Results: A total of 1058 patients were included (362 in the transition group and 696 in the control group). The baseline clinical characteristics were comparable between both groups. The rate of AMI per day following the DST transitions was 1.85 compared to 1.78 during control periods. The DST transitions were not associated with an increase in AMI (IRR = 1.04, 95% CI 0.91–1.18, p = 0.56) nor with infarct size. In the subgroup analysis, DST was associated with a significant increase in the incidence of AMI only in the pre-COVID-19 period, with a rate of 2.04 AMI per day in the transition group compared to 1.71 in the control group (IRR = 1.19, 95% CI 1.01–1.41, p = 0.041). In contrast, there was a significant increase in the size of AMI following DST in the post-COVID-19 period subgroup, with a creatine phosphokinase-MB (CK-MB) concentration of 137 ± 229 µg/L compared to 93 ± 142 µg/L (p = 0.013). Conclusions: In this Canadian cohort, there was a significant increase in the incidence of AMI in the pre-COVID-19 period, and infarct sizes were significantly larger following the DST transitions in the post-COVID-19 period. No significant associations emerged when pre- and post-COVID-19 periods were pooled.

1. Introduction

Studies have identified an increased incidence of acute myocardial infarction (AMI) in the early morning hours and during winter [1,2]. In 2008, a study reported for the first time a significant increase in the incidence of AMI in Swedish people in the first days following the transition to daylight saving time (DST) in the spring with an incidence ratio (IR) of 1.051 (95% CI, 1.032–1.071) [3]. This increase was more pronounced in women. Several studies have followed, with some confirming a significant increase in the incidence of AMI following the transition to DST [4,5,6], while others observed no difference [7,8,9]. In 2019, a meta-analysis reported a significant, albeit modest, increase in AMI incidence following the spring DST transition [10].
These studies have evaluated the impact of DST on the first seven days following the transition (transition period), with control periods of two weeks before and one or two weeks after the transition period. Other findings suggest that the effects of DST adjustments can vary significantly based on factors such as age, sex, light exposure, and country of residence [11,12,13]. Additionally, the natural inclination to sleep at certain times, known as chronotype, influences these adjustments. Adaptations to the circadian clock after the spring transition can last up to four weeks in late chronotypes [14]. Late chronotypes, who are more common among men, have a higher risk of diabetes and hypertension, increasing their cardiovascular risk compared to early chronotypes [13,14,15]. Therefore, a transition period lasting longer than a week may be more appropriate to account for the extended adjustment required by late chronotypes [16].
Most studies investigating the association between AMI and DST have been published in Europe. Due to the increased incidence of cardiovascular events, immune-related diseases, accidents, suicides, and other health hazards linked to DST, the European Commission proposed its abolition in September 2018 [17,18]. In March 2019, the European Parliament voted in favor of abolishing DST by 2021. However, this deadline was not met due to the COVID-19 pandemic. To our knowledge, no studies examining the link between AMI and DST have been conducted in Canada. Therefore, we aim to investigate the impact of DST on the incidence of AMI in a Canadian population.

2. Methods

We performed a retrospective cohort study of patients aged ≥18 years admitted to the Hôpital du Sacré-Coeur de Montréal, a tertiary academic center in the Canadian province of Quebec, with a diagnosis of AMI requiring a coronary angiogram with or without percutaneous coronary intervention (PCI). AMI was defined according to the fourth universal definition of myocardial infarction, and patients with ST-segment-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) were included [19]. The transition period consisted of two weeks following the DST transitions in both fall and spring from 28 February 2016 to 3 December 2022. The control periods were the two weeks before and two weeks after the transition period. Data collection was performed through a chart review. The study protocol was approved by the institutional ethics committee.
The primary endpoint was the incidence rate ratio (IRR) of AMI during the transition period, calculated as the ratio of the rate of AMI during the transition period over the rate of AMI during the control period. The secondary endpoint was infarct size, obtained via biomarker assessments (creatine phosphokinase-MB [CK-MB]).
The variables are described as mean ± standard deviation (SD) for continuous variables. Discrete variables are reported as frequencies and percentages. Baseline characteristics were compared between patients admitted during the transition and control periods using Student’s t-test. The infarct size of both cohorts was also compared using Student’s t-test. Pre-specified subgroup analyses were performed to compare the season of transition (spring and fall), the type of MI (NSTEMI and STEMI), the gender, the day of the week following DST and the effect of the COVID-19 pandemic (pre-COVID-19 period from 2016 to 2019 and post-COVID-19 period from 2020 to 2022). A sensitivity analysis was also performed using a transition period of one week instead of two weeks. The control periods were still the two weeks before and two weeks following the transition period. A three-way ANOVA analysis was used to determine if there were any interactions between seasons, weeks surrounding the DST transitions, the COVID-19 pandemic, and their combined effect on infarct size. A level of significance of 0.05 was set for all the analyses. All the statistical analyses were performed on SPSS, version 28 (SPSS Inc., Chicago, IL, USA).

3. Results

3.1. Baseline Characteristics

A total of 1058 patients were included: 696 in the control group and 362 in the transition group. The mean age was 65 ± 12 years and was comparable between both the groups. Women represented 27% of the studied population. Baseline clinical characteristics including cardiovascular risk factors were comparable between both groups (Table 1). The clinical characteristics of patients in the pre-COVID-19 period (611 patients) and the post-COVID-19 period (447 patients) were also comparable (Table 1).

3.2. Incidence Rate Ratio of AMI Following DST

In the overall study group, the rate of AMI per day following the DST transitions was 1.85 compared to 1.78 during the control period. DST was not associated with a change in AMI (IRR = 1.04, 95% CI 0.91–1.18, p = 0.562; Table 2). Season, gender, AMI type, and the day of the week were not associated with significant changes in the incidence of AMI. In the pre-COVID-19 period, DST was associated with a significant increase in the incidence of AMI. The rate of AMI per day was 2.04 after DST compared to 1.71 in the control group (IRR = 1.19, 95% CI 1.01–1.41, p = 0.041; Table 2). The post-COVID-19 period was not associated with a significant change in AMI. Table 2 and Figure 1 illustrate the results for other subgroups. No significant changes in the IRR of AMI were noted in the first 7 days individually after the DST transition (Sunday to Saturday; Figure 2). A sensitivity analysis using a transition period of one week demonstrated similar results. The IRR for specific subgroups using this transition period is illustrated in Supplemental Figure S1.

3.3. Infarct Size Following DST

In the overall study group, infarct size was similar between the control and transition groups (CK-MB levels of 112 ± 246 µg/L and 107 ± 179 µg/L, p = 0.776, respectively; Table 3). However, there was a significant increase in the size of AMI in the post-COVID-19 period (CK-MB levels of 137 ± 229 µg/L vs. 93 ± 142 µg/L, p = 0.013; Table 3). There was no significant change in the infarct size in the pre-COVID-19 period. A sensitivity analysis using a transition period of one week demonstrated similar results (Table S1).
A three-way ANOVA analysis was conducted to determine the impact of seasons, weeks surrounding the DST transitions, and the COVID-19 pandemic, on infarct size assessed by CK-MB levels. The results revealed a significant interaction between COVID-19 and the weeks surrounding the time changes (F (5,813) = 3.461; p < 0.05; Figure 3). An analysis of the simple effects of this interaction indicated that during the week following DST, infarct size was significantly larger after the onset of the pandemic compared to the preceding period (p < 0.05). However, no difference was observed in infarct size during the weeks surrounding DST before COVID-19. Conversely, during the fall DST transition in the post-COVID-19 period, the first week following DST was associated with significantly larger infarcts when compared with all other adjacent weeks (p < 0.05). Two weeks following the spring DST transition, infarct size was significantly larger before COVID-19 as compared to after. These results suggest a complex interplay between COVID-19, DST transitions, and infarct size, thus suggesting temporal variations and season-specific associations.

4. Discussion

To the best of our knowledge, this is the first study that has assessed the impact of the pandemic on the incidence of AMI following DST. In this retrospective assessment of Canadian patients hospitalized for AMI, DST was associated with a significant 19% increased incidence of AMI during the pre-COVID-19 period (2016 to 2019), a finding that is concordant with other studies that have demonstrated an increased risk of AMI following DST [3,4,5,6].
During the post-COVID-19 period (2020 to 2022), AMI was not more frequent after DST, but infarct size assessed with CK-MB was significantly larger. Delayed reperfusion in acute coronary syndrome (ACS), particularly in STEMI, is associated with larger infarct size and an increased risk of malignant arrhythmias, cardiogenic shock, and death [20]. A Canadian study demonstrated a significant delay in reperfusion times for patients with STEMI during the COVID-19 lockdown, which seemed mainly driven by transfer delays and patients’ fear of contracting the virus in a hospital setting [21]. Studies in populations from the United States have shown a decreased rate of hospitalizations for AMI but a higher mortality during the COVID-19 pandemic compared to pre-pandemic patients [22,23]. Patients might have delayed their presentation to hospital or not consulted a doctor at all for symptoms of AMI, and this may have been exacerbated following DST and therefore resulted in larger infarcts.
The present findings stress the importance of taking into account major multisystem inflammatory syndromes such as the one caused by the SARS-CoV-2 virus when assessing the impact of DST on cardiac physiology over prolonged periods of time [24]. The patients included in our study were comparable when assessed with conventional risk factors (Table 1), but future studies should also take into consideration psychiatric diagnoses and related social factors [4]. It should also be noted that sleep–wake habits and chronotypes, both which are directly challenged by DST, are significant determinants of cardiac health [25,26]. Finally, countries’ latitude also determines the impact of DST on sleep and circadian rhythms [27]. This could explain the negative findings of a recent study that pooled patients from northern to southern states of the United States, notwithstanding the fact that adverse cardiovascular events such as myocardial infarction, stroke, cardiogenic shock, and cardiac arrest were pooled together [28].
Our study has its own limitations. It was restricted to one center in Canada, potentially limiting the generalizability of our results. We used a relatively small sample of patients, which could explain why some of our results did not reach statistical significance. Moreover, additional comparisons between spring and fall transitions could not be performed due to the small sample size. Still, both our sample size and the observed IRRs are within the range reported by previous studies. Another limitation is that we included patients with ACS who had undergone coronary angiogram with or without PCI. Patients with ACS treated medically without undergoing an angiogram were therefore excluded. It was not possible to calculate the incidence of AMI for transition and control periods separately because we were unable to calculate the size of the population at risk. We were able to minimize the effect of this limitation by calculating the IRRs with the very likely assumption that the population at risk was the same for both cohorts for each DST transition. To assess infarct size, we used CK-MB measurements instead of troponin, a more common biomarker, because our center treats patients referred from hospitals that use different troponin markers (troponin I, troponin T, and high-sensitivity troponin).

5. Conclusions

In a cohort of patients from Canada, DST was associated with a significant increase in the incidence of AMI before the COVID-19 pandemic (2016 to 2019), while a larger infarct size was observed following DST in the post-COVID-19 period (2020 to 2022). No significant associations emerged whatsoever when the pre- and post-COVID-19 periods were pooled.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/hearts5040044/s1, Table S1. Infarct size of control and transition groups before and after COVID-19 using a transition period of 1 week. Figure S1. Incidence rate ratio of acute myocardial infarction for specific subgroups using a transition period of 1 week.

Author Contributions

Conceptualization, A.A.S., R.G. (Roger Godbout), R.G. (Remi Goupil), G.R. and M.P.; Methodology, A.A.S., R.G. (Roger Godbout), R.G. (Remi Goupil), G.R. and M.P.; Software, A.A.S. and M.P.; Validation, A.A.S., R.G. (Roger Godbout), R.G. (Remi Goupil), C.P.S., S.K., M.R., M.D., J.R., L.R., G.R. and M.P.; Formal analysis, A.A.S. and M.P.; Investigation, A.A.S., R.G. (Roger Godbout), R.G. (Remi Goupil), C.P.S., S.K., M.R., M.D., J.R., L.R., G.R. and M.P.; Resources, A.A.S. and M.P.; Data curation, A.A.S., C.P.S., S.K., M.R., M.D., J.R., L.R. and M.P.; Writing—original draft, A.A.S. and M.P.; Writing—review and editing, A.A.S., R.G. (Roger Godbout), R.G. (Remi Goupil), G.R. and M.P.; Visualization, A.A.S., R.G. (Roger Godbout), R.G. (Remi Goupil), G.R. and M.P.; Supervision, M.P.; Project administration, A.A.S. and M.P. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The Hôpital du Sacré-Coeur de Montréal research ethics board approved this study.

Informed Consent Statement

Patient consent is not applicable to this study. This is a retrospective cohort study using de-identified data.

Data Availability Statement

The original contributions presented in this study are included in this article/Supplementary Materials; further inquiries can be directed to the corresponding author.

Conflicts of Interest

The authors declare no conflict of interest.

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Figure 1. Incidence rate ratio of acute myocardial infarction for specific subgroups.
Figure 1. Incidence rate ratio of acute myocardial infarction for specific subgroups.
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Figure 2. Incidence rate ratio of acute myocardial infarction for the first seven days following daylight saving time transitions.
Figure 2. Incidence rate ratio of acute myocardial infarction for the first seven days following daylight saving time transitions.
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Figure 3. Assessment of infarct size using a three-way ANOVA analysis. CK-MB: creatine phosphokinase-MB, COVID-19: coronavirus disease 2019, DST: daylight saving time.
Figure 3. Assessment of infarct size using a three-way ANOVA analysis. CK-MB: creatine phosphokinase-MB, COVID-19: coronavirus disease 2019, DST: daylight saving time.
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Table 1. Demographics, prior medical history, and medication use before admission for specific subgroups.
Table 1. Demographics, prior medical history, and medication use before admission for specific subgroups.
Total
(n = 1058)		Control Group *
(n = 696)		Transition Group *
(n = 362)		Pre-COVID-19
(n = 611)		Post-COVID-19
(n = 447)
Mean age65 ± 1265 ± 1265 ± 1264 ± 1265 ± 12
Women284 (27%)177 (25%)107 (30%)162 (27%)122 (27%)
BMI (kg/m2)28 ± 628 ± 628 ± 628 ± 628 ± 6
Hypertension543 (51%)361 (52%)182 (50%)325 (53%)219 (49%)
Dyslipidemia502 (47%)343 (49%)159 (44%)293 (48%)209 (47%)
Diabetes mellitus256 (24%)173 (25%)83 (23%)158 (26%)98 (22%)
Family history of CAD145 (14%)103 (15%)42 (12%)91 (15%)54 (12%)
Smoking status
  Never531 (50%)341 (49%)190 (53%)276 (45%)255 (57%)
  Former215 (20%)149 (21%)66 (18%)135 (22%)80 (18%)
  Current312 (30%)206 (30%)106 (29%)200 (33%)112 (25%)
Prior MI199 (19%)133 (19%)66 (18%)114 (19%)85 (19%)
Prior AF58 (6%)39 (6%)19 (5%)37 (6%)21 (5%)
Prior PCI180 (17%)119 (17%)61 (17%)100 (16%)80 (18%)
Prior CABG84 (8%)58 (8%)26 (7%)54 (9%)30 (7%)
Medications before admission
  Aspirin275 (26%)184 (26%)91 (25%)158 (26%)117 (26%)
  Beta blockers211 (20%)142 (20%)69 (19%)121 (20%)90 (20%)
  Statins331 (31%)222 (32%)109 (30%)188 (31%)143 (32%)
* The patients in the transition group were included two weeks following daylight saving time transitions (transition period). The patients in the control group were included two weeks before and after the transition period. The values are mean ± SD or frequencies (percentage). AF: atrial fibrillation, BMI: body mass index, CABG: coronary artery bypass graft, CAD: coronary artery disease, MI: myocardial infarction, PCI: percutaneous coronary intervention.
Table 2. Rate of acute myocardial infarction per day for specific subgroups during transitions and control periods.
Table 2. Rate of acute myocardial infarction per day for specific subgroups during transitions and control periods.
Rate of AMI per DayIRR95% CIp Value
Total
  Control group1.781.040.91–1.180.56
  Transition group1.85
Spring transition
  Control group1.681.050.87–1.260.66
  Transition group1.76
Fall transition
  Control group1.881.030.86–1.230.74
  Transition group1.94
Sundays (Day 0 after DST)
  Control group1.781.170.80–1.700.43
  Transition group2.07
Women
  Control group0.451.210.95–1.540.13
  Transition group0.55
Men
  Control group1.320.980.84–1.150.83
  Transition group1.30
STEMI
  Control group1.310.990.85–1.150.91
  Transition group1.30
NSTEMI
  Control group0.461.190.93–1.520.17
  Transition group0.55
Pre-COVID-19 (2016–2019)
  Control group1.711.191.01–1.410.04
  Transition group2.04
Post-COVID-19 (2020–2022)
  Control group1.860.860.70–1.050.14
  Transition group1.60
AMI: acute myocardial infarction, CI: confidence interval, COVID-19: coronavirus disease 2019, DST: daylight saving time, IRR: incidence rate ratio, NSTEMI: non-ST-elevation myocardial infarction, STEMI: ST-elevation myocardial infarction.
Table 3. Infarct size of control and transition groups before and after COVID-19.
Table 3. Infarct size of control and transition groups before and after COVID-19.
Overall CK-MB (µg/L)Transition Group CK-MB (µg/L)Control Group CK-MB (µg/L)p Value
Overall cohort110 ± 226107 ± 179112 ± 2460.776
Pre-COVID-19113 ± 25790 ± 140127 ± 3060.085
Post-COVID-19106 ± 174137 ± 22993 ± 1420.013
Values are mean ± SD or frequencies (percentage). p values compare infarct size between transition and control groups. CK-MB: creatine phosphokinase-MB.
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Al Samarraie, A.; Godbout, R.; Goupil, R.; Suarasan, C.P.; Kanj, S.; Russo, M.; Dano, M.; Roy, J.; Reiher, L.; Rousseau, G.; et al. The Association Between Daylight Saving Time and Acute Myocardial Infarction in Canada. Hearts 2024, 5, 575-583. https://doi.org/10.3390/hearts5040044

AMA Style

Al Samarraie A, Godbout R, Goupil R, Suarasan CP, Kanj S, Russo M, Dano M, Roy J, Reiher L, Rousseau G, et al. The Association Between Daylight Saving Time and Acute Myocardial Infarction in Canada. Hearts. 2024; 5(4):575-583. https://doi.org/10.3390/hearts5040044

Chicago/Turabian Style

Al Samarraie, Ahmad, Roger Godbout, Remi Goupil, Catalin Paul Suarasan, Samaya Kanj, Melina Russo, Mathilde Dano, Justine Roy, Laurence Reiher, Guy Rousseau, and et al. 2024. "The Association Between Daylight Saving Time and Acute Myocardial Infarction in Canada" Hearts 5, no. 4: 575-583. https://doi.org/10.3390/hearts5040044

APA Style

Al Samarraie, A., Godbout, R., Goupil, R., Suarasan, C. P., Kanj, S., Russo, M., Dano, M., Roy, J., Reiher, L., Rousseau, G., & Pichette, M. (2024). The Association Between Daylight Saving Time and Acute Myocardial Infarction in Canada. Hearts, 5(4), 575-583. https://doi.org/10.3390/hearts5040044

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