OBJECTIVE Nearly four decades ago, a circadian pattern of acute myocardial infarction (AMI) with a peak in the early morning waking hours was described. The goal of the present study was to determine whether major changes in lifestyle and significant advances in medical therapy have altered this pattern in the intervening years. METHODS Retrospective chart review. METHODS Tertiary care hospital in central Wisconsin. METHODS We examined circadian patterns of ST elevation myocardial infarction (STEMI) in 519 patients diagnosed with STEMI over a 5-year period. Time of symptom onset was obtained from patient self-reports in the medical record and was recorded over 24 hours. RESULTS We observed a circadian pattern of STEMI occurrence with a morning peak at approximately 11:30 AM. This pattern was highly significant in patients who were not using beta-blockers (P <0.0001) and had no history of diabetes (P <0.0001), but was otherwise absent. The circadian pattern appeared to be attenuated in patients of a younger age, female gender, or who used statins or aspirin. Peak STEMI occurrence was earlier in smokers than non-smokers. CONCLUSIONS Despite significant lifestyle changes and medical advances in the nearly four decades since a circadian pattern of AMI occurrence was first described, patients with STEMI had a circadian pattern of symptom onset with a morning peak. Use of beta-blockers and a history of diabetes mellitus abolished this pattern. Other modifying factors, including medications, age, and gender attenuated, but did not abolish, the circadian pattern.