Physical Activity, Anger, Emotional Upset as Triggers of AMI

Study Questions:

Are acute episodes of physical exertion, anger, and/or emotional upset associated with risk for acute myocardial infarction (AMI)?


The INTERHEART study was a case-control study of first AMI conducted in 52 countries (262 centers). Cases of AMI were matched with controls on age and sex. Controls had no prior history of heart disease or exertional chest pain. Participants were asked if they were physically active (heavy physical exertion), were angry, and/or emotionally upset in the 1 hour prior to symptom onset.


A total of 12,461 cases of AMI (mean age 58.1 years, 75.9% males) were identified. Of the cases, 13.6% (n = 1,650) reported engaging in physical activity, and 14.4% (n = 1,752) reported being angry or emotionally upset in the 1 hour prior to AMI symptom onset. Physical activity was associated with an increased odds of AMI (odds ratio [OR], 2.31; 99% confidence interval [CI], 1.96-2.72) and a population-attributable risk of 7.7% (99% CI, 6.3–8.8) compared to controls. Report of anger or being emotionally upset 1 hour prior to symptoms was associated with an increased odds of AMI (OR, 2.44; 99% CI, 2.06–2.89) and a population-attributable risk of 8.5% (99% CI, 7.0–9.6) compared to controls. No evidence of 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 was observed. Reports of both physical activity and anger or emotional upset 1 hour prior to AMI symptoms were associated with the highest risk for AMI (OR, 3.05; 99% CI, 2.29–4.07).


The investigators concluded that 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.


These data suggest that stress reduction and anger management may be important for cardiovascular prevention. In regard to physical activity, regular activity is associated with cardiovascular benefits; rather than warning patients away from physical activity, perhaps the trigger is related to the ‘weekend warrior’ who is sedentary most of the time with intermittent bouts of exertion. Prior work by others has suggested that the risk for vigorous exertion among deconditioned adults is greater than among those who are regularly active.

Clinical Topics: Acute Coronary Syndromes, Diabetes and Cardiometabolic Disease, Prevention, Exercise

Keywords: Acute Coronary Syndrome, Anger, Chest Pain, Exercise, Motor Activity, Myocardial Infarction, Physical Exertion, Precipitating Factors, Primary Prevention, Risk Factors

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