Physical Activity and Anger or Emotional Upset as Triggers of Acute Myocardial Infarction

Abstract

On behalf of the INTER-HEART InvestigatorsOriginal research article BACKGROUND: Physical exertion, anger, and emotional upset are reported to trigger acute myocardial infarction (AMI). In the INTERHEART study, we explored the triggering association of acute physical activity and anger or emotional upset with AMI to quantify the importance of these potential triggers in a large, international population. METHODS:INTERHEART was a case-control study of first AMI in 52 countries. In this analysis, we included only cases of AMI and used a casecrossover approach to estimate odds ratios for AMI occurring within 1 hour of triggers. RESULTS:Of 12 461 cases of AMI 13.6% (n=1650) engaged in physical activity and 14.4% (n=1752) were angry or emotionally upset in the case period (1 hour before symptom onset). Physical activity in the case period was associated with increased odds of AMI (odds ratio, 2.31; 99% confidence interval [CI], 1.96-2.72) with a population-attributable risk of 7.7% (99% CI,). Anger or emotional upset in the case period was associated with an increased odds of AMI (odds ratio, 2.44; 99% CI, 2.06-2.89) with a population-attributable risk of 8.5% (99% CI, 7.0-9.6). There was no effect modification by geographical region, prior cardiovascular disease, cardiovascular risk factor burden, cardiovascular prevention medications, or time of day or day of onset of AMI. Both physical activity and anger or emotional upset in the case period were associated with a further increase in the odds of AMI (odds ratio, 3.05; 99% CI, 2.29-4.07; P for interaction <0.001).CONCLUSIONS: Physical exertion and anger or emotional upset are triggers associated with first AMI in all regions of the world, in men and women, and in all age groups, with no significant effect modifiers. 1 The INTERHEART study reported that >90% of the risk of myocardial infarction was attributable to long-term exposure to 9 risk factors.2 Most longterm exposures (eg, lipids, obesity) are mediated through an intermediate phenotype (atherosclerotic change) rather than trigger acute rupture of atherosclerotic plaque, precipitating an acute myocardial infarction (AMI). Observational studies identified potential external triggers for AMI, including physical exertion and anger or emotional upset.3,4 However, with few exceptions, the included studies had small sample sizes (n<2000) and were completed primarily in 1 country or geographical region (predominantly Western countries). As with long-term exposure to cardiovascular risk factors, the prevalence of potential triggers of AMI may also vary by geographical region; triggers important in 1 region or ethnic group may be different in others. Large, international studies using standardized methodology are required to determine whether there are variations in the importance of triggering risk factors and to determine other factors that may modify the association. The INTERHEART study provides an opportunity to study the association between these potential external triggers of AMI and effect modifiers in a large,...

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