Do Patients With Acute Coronary Syndrome Face Higher Mortality on Weekends Versus Weekdays? A Comprehensive Analysis of Demographic, Geographic, and Temporal Trends in the United States

Abstract

Background

The impact of a “weekend effect” on US acute coronary syndrome (ACS) mortality remains uncertain. We compared weekend and weekday age-adjusted mortality rates (AAMRs) and analyzed demographic, geographic, and temporal trends from 1999 to 2020.

Methods

We conducted a national analysis of ACS deaths (age ≥ 25 years) using CDC WONDER (ICD-10: I20.0; I21.0–I21.4; I21.9; I22.0–I22.9; I24.8; I24.9). Crude and AAMRs (per 100 000; 2000 U.S. standard) were calculated, and trends were assessed by joinpoint regression to estimate annual percent changes (APCs) and average APCs (AAPCs).

Results

From 1999 to 2020, there were 3, 101, 451 ACS deaths: 2, 222, 468 on weekdays (AAMR 46.4; 95% CI 46.39–46.51) and 878, 983 on weekends (AAMR 18.4), a 2.5:1 ratio. Both periods saw two-phase declines—APCs of ≈ –6.4%/year before 2009–2010 and –3.3 to –3.7%/year thereafter (all p <  0.001). Disparities persisted: Black adults had the highest AAMRs (20.9 weekend; 53.2 weekday), rural rates exceeded urban (28.7 vs. 15.8; 72.0 vs. 40.2), men exceeded women (23.8 vs. 14.0; 60.2 vs. 35.4), and rates rose steeply with age (weekend 0.3–223.0; weekday 0.7–561.0). After 2009, declines slowed, and weekday deaths in Black adults rose after 2018.

Conclusions

The weekend effect on ACS mortality is minimal, with weekday deaths far outnumbering weekend deaths. Persistent—and sometimes widening—disparities by race, rurality, sex, and age highlight the need for equity-focused interventions, strengthened rural cardiac care, and targeted prevention.