It would be really interesting to see whether this holds in Middle Eastern countries or other places where the work week starts on a Sunday.
replies(1):
A lot of it boils down to blood pressure. High blood pressure is a serious contributing factor to cardiovascular incidents (as well as a slew of other negative health risks), and getting a good night's sleep will help keep blood pressure down. This is also why the amount of heart attacks are up around 24% after daylight savings[1]; an hour less sleep means higher blood pressure means higher risk of heart attack (relative to any other 'normal' day).
I can definitely see how the same logic could apply to Mondays. Less sleep, more stress = higher blood pressure = higher risk of heart attacks.
[0] https://www.goodreads.com/book/show/34466963-why-we-sleep
(I searched 'Laffan cardio monday' on Google Scholar, Laffan was quoted as lead author in OP.)
Your argument at least in its current form seems not to hold - there's higher incidence over the weekend too.
Don’t think late presentation STEMIs are that common to begin with for your argument to have logical sense, this is the worst form of a “heart attack”.
From this single center study presentations > 12 hours only comprised 10%.
https://www.ingentaconnect.com/content/wk/jcarm/2017/0000001...
Another possible factor could be the fact that doctors tend to make more mistakes during operations on Fridays compared to start of week.
STEMI centers (this is picked up by EMS and these ambulances are redirected to appropriate centers) have 24/7 cath lab coverage and any major one will have an ER bypass even during afterhours to expedite care.
In fact more and more hospitals (and all the major ones) announce a “Code STEMI” overhead either when the ambulance is dispatched or as soon as the ECG showing ST elevations is discovered in triage/ER to activate the team and reduce door-to-balloon time.
This doesn't seem that surprising to me, or at least I expect we should also see an increase on Saturday. People like to do harder work, like lawn projects on the weekend, and things like drinking that can affect the heart.
I had a moment trying to figure out when the clocks moved backwards before I remembered DST is a thing.
So it wasn’t so much about dreading the coming week but being still from the previous week and being sad about what they actually accomplished (or didn’t).
[0] https://www.cdc.gov/nchs/data/dvs/table14_99.pdf (in the US at least)
One early Sunday morning the clock started making noise. Chunk. Chunk. Chunk. Chunk. Moving the minute hand rapidly. It kept going and going and going.
The clock can only go forward. In order to set the time back 1 hour it had to advance the clock 23 hours, one minute at a time.
This also confused payroll when I handed in my time sheet.
12:00 AM - 3:00 AM (3h)
2:00 AM - 10:00 AM (8h)
12:00 AM - 10:00 AM (9h)
(I know I’ll get downvoted for using humor on HN, the “this isn’t Reddit no smiling” brigade will be here in a moment to express their scorn at any sign of pleasure)
I also remember the time between Christmas and New Year being very busy - I thought for a similar reason - people understandably just don't want to be in hospital for Christmas.
E.g., using sensors that are cheap, and are less invasive than EKG electrodes. Kinda like the way Apple watches can now continuously monitor stuff
I don't think that seems surprising. People working office jobs through the week go out and drink more on a Friday and Saturday night, and those of a more sporty bent will often push their bodies more at the weekend because that is when they can find the time for longer or multiple training sessions, and it is where you find organised events (the highest proportion of runs are on a Sunday, with the second highest being Saturday).
The problem obviously with heart attacks is the implications of false negatives and positives are huge, and the tracing from a watch would be less reliable than the gold-standard ECG / EKG.
That said, Office Space is my favorite movie so don't take it personally, mmkay? Yeahh, that'd be great.
It is very clear about the fact it cannot detect a heart attack though.
Then there’s these slightly more sophisticated things: https://store.kardia.com/products/kardiamobile6l
> In the Northern Hemisphere, the switch to daylight savings time in March results in most people losing an hour of sleep opportunity. Should you tabulate millions of daily hospital records, as researchers have done, you discover that this seemingly trivial sleep reduction comes with a frightening spike in heart attacks the following day. Impressively, it works both ways. In the autumn within the Northern Hemisphere, when the clocks move forward and we gain an hour of sleep opportunity time, rates of heart attacks plummet the day after.
I don't see a specific study cited, but my ebook copy doesn't seem to have all the footnotes.
I pulled up the article you linked on sci-hub: https://sci-hub.se/https://pubmed.ncbi.nlm.nih.gov/18971502/ The only use of the number "24" refers to hours in the day, and its summary doesn't seem to match your claim:
> The incidence of acute myocardial infarction was significantly increased for the first 3 week-days after the transition to daylight saving time in the spring (Fig. 1A). The incidence ratio for the first week after the spring shift, calculated as the incidence for all 7 days divided by the mean of the weekly incidences 2 weeks before and 2 weeks after, was 1.051 (95% confidence interval [CI], 1.032 to 1.071). In contrast, after the transition out of daylight saving time in the autumn, only the first weekday was affected significantly (Fig. 1B); the incidence ratio for the whole week was 0.985 (95% CI, 0.969 to 1.002
It's caused by sudden stress (e.g. bereavement, illness) which leads to weakening of the heart muscle, causing the heart to bulge out at the apex. It's named 'tako-tsubo' because the heart starts to resemble a round vessel used in Japan to catch octopuses.
(But then, this also means that knowing it for sure would be useless.)
Edit: aha--https://www.nature.com/articles/s41467-020-15432-4
When I was an intern I was 100x better than I am at this point in my career.
The basic atrial fibrillation and STEMI is something any doctor can interpret with confidence (I used myself as an example as I'm probably the least competent because I haven't looked at an ECG in 10 years). I doubt non-cardiac surgeons are much better on average as they don't really look at these themselves that often other than for basic things.
An ER or general internal medicine physician is expected to be competent in more advanced but common stuff like bundle branch blocks, left ventricular hypertrophy, non ST elevated MI.
Weird arrhythmias or conduction abnormalities is really only for cardiologists, and even then typically a subspecialist electrophysiologist.
US/Can healthcare systems still pay a cardiologist a couple of bucks to "finalize" the interpretation whenever they get around to it. It's a bit ironic, someone could have an MI on Friday, get treated and discharged and we're still paying someone on the Monday to read 40 ECGs (note these would have been acutely interpreted by the cardiologist treating the patient, most places have rules against self-referrals so you can't formally interpret anything you order yourself).
Just knowing the pathology of STEMI it's hard to buy that an effect of this size (in the Ireland study) is largely due patient's not seeking care on weekends unless you're somewhere extremely rural as this isn't your average heart attack.
If this was about ACS (acute coronary syndrome) in general I'd be more suspicious that patient delays are a relevant confounder, but we have other literature to support the trend (granted with some conflicting studies).
from [1]: > Many studies have shown an excess of cardiovascular events on Mondays (1,3,10,16,18,19). A relative trough has been seen on Saturdays and Sundays I compared with the expected number of cases. A similar pattern was seen in most subgroups irrespective of age, gender, cardiac medication, and in-fart characteristics (first or recurrent, Q or non-Q, site). The frequency of morning infarction is greater during the working week than on weekends, suggesting a superimposition of work-related stress on endogenous circadian rhythms.
>Circadian variation is found on all days of the week including weekends' when the morning peak is less obvious.
I haven't looked at the methodology of the cited studies but they include 6 references for your perusal.
[0]https://onlinelibrary.wiley.com/doi/abs/10.1002/clc.22 [1]https://onlinelibrary.wiley.com/doi/epdf/10.1002/clc.4960261... [2]https://europepmc.org/article/med/12061302
Honestly, when I have an ICU nurse providing procedural sedation for me I essentially just defer to their expertise on the rhythms and if they're worried I activate the mobile response team.
The EKG, as far as I know, doesn't really tell you much other than whether it thinks you have a normal sinus rhythm, or something it doesn't recognize. Too fast, too slow, or whatever. It's also on demand, not continuous. You have to touch a finger from your opposite hand to the crown, while the EKG app is running.
Also, that Kardia advertising is borderline scam. It's a 1 lead EKG just like the Apple Watch. Six lead my ass, they make that claim because you can contort your body in enough ways to take readings from each standard EKG location. You can sorta do the same thing with an apple watch, though it's not physically as large so it wouldn't be as easy. What rubs me the wrong way about calling the Kardia a 6-lead EKG is that it cannot do 6-leads simultaneously, and I think that is a critical detail.
I had a Kardia myself before the first Apple Watch with EKG came out.
That matches with my impression about a lot of things in her job. I'm always a little surprised when she talks about calling the doctor saying I need X, Y and Z and the doctor just being like cool I'll put in the order. Obviously, not all doctors are like that but it seems like the vast majority defer to the nurses in a lot of situations. This is completely different than the conception I had of healthcare before I met her.
> I'm always a little surprised when she talks about calling the doctor saying I need X, Y and Z and the doctor just being like cool I'll put in the order.
This is the best part. A lot of decisions like sleeping aids, antipsychotics, antiemetics don't have evidence to choose from the various options so it's a bit of trial and error. An ICU nurse typically covers 1-2 patients and knows them very well, so if the recommend/ask for something it's usually the right decision and reduces the cognitive burden on the physician. We obviously still do a safety/sanity check but ballpark estimate I'd say I disagree or order something else < 5% of the time.
Similarly I'd say the proportion of bullshit overnight pages (e.g. I fondly remember a 4am call that a patient has leg cramps) I've received from ICU nurses are even less than that.
General ward nurses on the other hand... A very heterogeneous bunch with high turnover (worse in academia, at my last hospital average career length was ~2 years before they leave for greener pastures) so the relationship is very different.
Not that I don't appreciate them or their work, but far less trust in decision making and they need more oversight.
I disagree. It's not that the symptoms aren't there, but that they have become normalized due to obesity, smoking, etc. being commonplace. Shortness of breath, sleep apnea, feeling weak, upper body tension/pain, etc. are usually present for quite a while in most people before it finally happens. People don't check their blood pressure often enough despite it being so cheap and easy to do.
We already had evidence that the time shift increases heart attacks.
I’m planning to just ignore DST this year. I’ll show up a little early for work half the year, and a little late for the rest.
So many people must get quite close to a heart attack only to live a long life and die of something else.
These were synchronized wired clocks ( https://www.natsco.net/industries-served/industries-served-o... /// https://blog.american-time.com/wireless-master-time-clock-vs... ).
> Schools traditionally used wired clock systems for two basic reasons: rock solid reliability and the ability to synchronize school bells to the rest of the system. The wired synchronized system ensured that clocks would all read the same time and bells would ring at the same time every day, no matter what classroom you were in, and that students would arrive to class on time — something teachers could only dream of before installing a synchronized system.
I suppose it’s a nice problem to have but still uncomfortable. Congratulations on your retirement and hope you get to figure it out and find a new mountain to climb.
Walker's book—and his accompanying Ted talks and podcasts—instilled a deep sense of sleep anxiety in me, which led to episodes of chronic insomnia (still occurs today). I had never experienced these issues before reading the book. Unfortunately, his message ensures that the insomnia is self-exacerbating, causing a vicious cycle.
Essentially, I find it very wrong for Walker to focus on and overhype the negative aspects of sleep loss as much as he does. Guzey's article [0], also linked above, goes through much of this. Why We Sleep turns into a horror book if you aren't able to sleep for whatever reason. It implies that, from just one bad night's sleep,
1. your immune system will deteriorate significantly
2. the chance that you develop a cancer will increase
3. your mental health will suffer
4. you are more likely to develop anxiety or depression
5. the probability you hurt yourself will increase
6. your mental faculties will be destroyed, you will be unable to reason well
7. you are at higher risk of mortality (!)
8. you are literally closer to death, which the book supports by mentioning fatal familial insomnia (FFI)... a flawed analogy
I was initially ok after reading the book, but the problems really started after I had a bad nights' sleep. I was absolutely terrified the following night, remembering all the awful things that will happen to my body and mind if I do not recuperate the next night. And we all know how easy it is to lose sleep when you are worried. I stayed up until 6 AM that night. Every passing hour made it harder to sleep.
Naturally, this started a cycle. Grumpy and even more anxious the next day ("two days? wow, am I now DOUBLE the chance of cancer and depression?"), sleep began evading me more and more often. The bed became a place of anxiety. Every minute I spent awake, I remembered Walker's book and the terrible things he told me was happening to my body due to the insomnia. This caused an infernal, unending loop of insomnia. Morning birdsong became hell to my ears.
I still sometimes suffer from it to this day, but Guzey's essay really helped. I think some quotes can do my point more justice:
> Your essay on Why we sleep - I can’t thank you enough. I’m a sleep doctor in Oregon and have seen many many patients who have developed severe sleep anxiety and insomnia. Two friends in the sleep field and myself weekly have talked about people that slept well until reading this book.
> I wanted to drop you a line to thank you for all the time and effort involved in debunking Matthew Walker’s book. As someone who works with individuals with insomnia on a daily basis, I know from firsthand experience the harm that Walker’s book is causing. I have many stories of people who slept well on less than eight hours of sleep, read Walker’s book, tried to get more sleep and this led to more time awake, frustration, worry, sleep-related anxiety, and insomnia.
> My patients are coming to me after reading this alarmist book, with insomnia that they did not have before, and worse, harder to treat because although the book has caused these anxieties - they can’t shake their newly built alarmist beliefs they learnt from the very same book.
> Scott slept well his entire life until he listened to a podcast that led him to worry about how much sleep he was getting and the health consequences of insufficient sleep. That night, Scott had a terrible night of sleep and this triggered a vicious cycle of ever-increasing worry about sleep and increasingly worse sleep that lasted for ten months.
- “on the cusp of death already”
- Normalized ill-health
There are some things in between those two.
The point of the guidelines is to help reduce low value comments and on that note - mentioning voting is against the guidelines https://news.ycombinator.com/newsguidelines.html for the same reason “Please don't comment about the voting on comments. It never does any good, and it makes boring reading.”
Other weekday numbers will also have delayed presentations included so you can't just "subtract 3.1" from one day and declare statistical insignificance.
What you can do is subtract it from every day as we know that 97% of STEMIs present within 12 hours.
As this is just an abstract we don't know what the authors did in this particular example but it's not the first study to suggest Mondays have the highest ACS rates.
I think many people do the same sort of thing, and then monday -- they have to cut their sleep short to get up early and sync with the rest of the world.
I can see how this would be the stressor you allude to.
What's really normalized is metabolic syndrome. 88% of adult americans have some degree of metabolic dysfunction. High blood pressure, obesity and other ailments are very often a direct result of that. So much so, that the 'normal' range of indicators such as uric acid has been revised and adjusted over the years, because "normal" people had higher levels and still appeared to be fine. Thankfully, we are starting to question that (eg. https://pubmed.ncbi.nlm.nih.gov/24867507/)
First order of business for anyone watching their blood pressure creeping up over the years (even more so if A1C, triglycerides, liver enzymes and uric acid are rising too): cut sugar in all forms. Not just the sugar you personally add to food, not only what's specified as 'added sugar', but all food containing sugar - which is basically all ultra processed foods. It does include sliced bread which is easily broken down into sugar( and is often laced with additional sugar, check ingredients). Leave your sugar 'allowance' to be used by a reasonable amount of fruits.
That may not reverse the problem (although, in my case, it did) but should help tremendously.
Anxiety due the the looming work week?
After a year of this, a therapist pointed out that you can have bad days on good sleep and good days on bad sleep. That finally made it click that it wasn't logical to worry about bad sleep so much. I just stopped caring and that mostly got me over it, but I still have more bad nights than I ever used to.
If I see people reading the book, I warn them about it even though it feels a bit rude to tell someone not to read something.
They don’t break it down by age which might help show if it’s work related.
Heart attacks are also clearly elevated on Sundays, and not depressed on Saturdays, which might suggest this is related to alcohol.
More than once a relative has been admitted on a Saturday and is just observed until Monday when the full diagnostics are available (eg MRI).
The only problem is it's often incompatible with a social life when you're in your 20s, but thankfully I'm not in my 20s anymore.
Everyone knows it, I don't need to list it: eating clean, getting good sleep, plenty of exercise, etc.
And furthermore, though our healthcare system seems only configured to deal with things once they become emergencies, metabolic disorder takes your whole life to take root. The time to start making positive changes is now.
There is no proof of this as to why. Only that it happens. For example:
* the hour of lost sleep does not happen on Monday, but on Sunday morning
* people could sleep in on Monday, then get hyper stressed that they are late
* type A personalities could get mad at an office of sluggish people
* people could get upset at everyone complaining about DST again, my blood pressure went up at your post!
Cholesterol, Fasting Insulin levels, and (if male) free Testosterone are other good ones. Cholesterol and Insulin should be checked by all adults annually, and BP should be checked at least annually. T isn't checked as routinely, but it's worth knowing where you fit and has an impact on your metabolics and the test isn't a big deal.
"Heart attack rates go up 24% after daylight savings changes" is not the same thing as "There are 24% more heart attacks due to daylight savings". You can't really know the weight of magnitude vs distribution without actually stopping daylight savings.
Also, resting heart rate is very easy to measure, especially if you have any kind of fitness/smart watch, and that's a good marker of health too.
I'm a fan of getting lab work done, but it's definitely more of a hassle.
It was once I lost 100lb that it became apparent just how bad condition I was in even though at the time I thought I felt fine. It doesn't help when you mention a lack of energy, or poor sleep to the doctor and they just say "Everyone is tired!".
No, first order of business is consulting your doctor and/or a nutritionist and otherwise adhering to common sense of having a reasonably balanced nutritional diet.
If your first order of business is taking random advice from the intertubez, you have bigger problems than high blood pressure.
I maintain enough competence to know when it looks like it could be critical so I can call for help, but realistically that's happening anyway as soon as someone gets unstable as I haven't resuscitated someone in years.
I haven't looked at a real patient's ECG in probably 7 years now. If you were the patient, would you even want me to? I'd rather just do the smart and safe thing, call for help.
No subspecialist (or even specialist) can maintain competence in all areas of medicine, it's hard enough keeping up my general radiology skills. It's a good thing none of us practice in silos by definition.
You have basically agreed with me. I made no statements about subspecialisation or attempt to reconcile the breadth of medical knowledge that is required as you progress through medical training into consultant status with that original knowledge, or implied that we're expected to be able to definitively diagnose and manage a patient with a ECG that implies an imminent threat to life.
Frankly I think that everyone should still be able to recognise a STEMI - it's pretty characteristic; the more severe or subtle AV blocks definitely take some familiarity; but the bedrock principle of ACLS is calling for help, and medicine is certainly a team sport
True but checking your blood pressure is painless, basically free and so easy that one can do it at home with no loss of precision.
Speaking as someone with mild high blood pressure, I see people obsess over diets, physical activity, looks, that never go to the doctor or check for their health conditions and "cure" every discomfort/pain with painkillers or ibuprofen.
And they of course all have some advice to give to me to improve my condition based, of course, on some diet they read online or to try yoga or acupuncture (or whatever is fashionable at the moment) and totally ignore the fact that I've been checking my blood pressure for over 20 years, I know a thing or two about it, because doctors. Yeah... I am that crazy! I see doctors!
Once a year is more than enough for people that have never been diagnosed with anything and yet very few people regularly do it, even here in my Country where medical checkups are virtually free.
IMO the real silent killer is indolence.
I dont know about bulging but when I experienced my first break up in the 20s, I literally felt a hole in my heart for many days. It was a surreal experience, for some reason my mind was just telling me that there is nothing there where my heart should be.