Anger, Physical Exertion May Up Risk of Acute MI for Some—but Not All

The old adage “calm down or you’ll have a heart attack” appears to be true for some but not all patients who go on to have an acute MI. A new analysis of a large global cohort suggests that one in seven patients report some type of emotional upset and/or heavy exertion in the hour prior to having a first occurrence of MI. 

“The main thing physicians can do is to increase awareness of the potential for these triggers, as our results did not identify any specific groups that were particularly high risk,” lead author Andrew Smyth, PhD (National University of Ireland Galway), told TCTMD in an email.

Smyth and colleagues’ study, published online October 10, 2016, in Circulation, found similar self-reported rates of emotional upset, anger, and exertion prior to acute MI regardless of gender, country of origin, or age and among those with or without previous cardiovascular disease, as well as those with or without significant risk factors for acute MI. The use of preventive therapies such as aspirin, ACE inhibitors, beta-blockers, and statins also did not modify the association, Smyth noted.

Emotion, Exertion Together Triple Risk

The data come from the INTERHEART study, which looked at risk factors for acute MI in patients from 52 countries. The current subanalysis focused on how patients in that study answered a questionnaire regarding whether they were angry or upset or were engaged in heavy physical exertion in the hour before the onset of symptoms. These answers were compared in a case-crossover approach in which each patient was compared with themselves during the same hour on the previous day.

Among the 12,461 patients with acute MI, 13.6% reported heavy physical exertion and 14.4% reported anger or emotional upset in the hour prior to onset of symptoms. Performing an activity of heavy exertion—but not physical exercise—on the day of symptoms as opposed to the same time the previous day doubled the risk of acute MI (adjusted OR 2.31; 99% CI 1.96-2.72), as did being emotionally upset or angry (adjusted OR 2.44; 99% CI 2.06-2.89). Having both triggers tripled the risk (adjusted OR 3.05; 99% CI 2.29-4.07).

Although most acute MIs in the study occurred between 6 am and 6 pm, patients who reported either of the triggers were more likely to experience symptom onset between 6 pm and midnight.

Smyth and colleagues say the findings highlight “difficulties with primary prevention of AMI associated with external triggering events.” They also acknowledge that since not every person who is exposed to the same triggers has an acute MI, in those who do, the triggering events may “precipitate AMI only in the setting of biologically active plaques that may be particularly vulnerable to plaque erosion, which vary significantly between individuals.”

Potential for Subjective Impressions

The “heavy exertion” reported in the study was unique to each individual and the authors did not give examples of what it may constitute. In an interview with TCTMD, Barry Jacobs, PsyD, (Crozer-Keystone Family Medicine Residency Program, Springfield, PA), who was not involved in the study, said that element is one weakness of the paper, since participants defined for themselves what they considered strenuous or emotionally upsetting.

“It leaves open the possibility that people have their own subjective impressions that are different from one person to another,” Jacobs said.

Smyth told TCTMD that although there may have been some differences in the interpretation of events and activities between participants, “it is unlikely that there were significant differences within the same participant. As such, differences in interpretation are not likely to have significantly influenced our results,” he noted.

Interestingly, the study also found no differences in baseline physical activity, supporting their hypothesis that heavy exertion itself, not any specific physical activity or exercise, increases risk.

To TCTMD, Jacobs said the uniformity of the triggers across age groups, gender, and cultures is an important finding and signifies “that there’s something not just in our physiology, but in our emotional function as well . . . that makes humans in general prone to these events.”

He added that the basic message for patients is to learn to regulate emotions and curb anger, possibly through outlets such as regular exercise and meditation. 

“We also know that when people feel supported by others [it] often provides validation that enables them to contain their anger better,” said Jacobs, who works with the American Heart Association to provide online support for cardiac survivors and their caregivers. “For many people, being able to talk with others is important and a far more adaptive way of managing their feelings than throwing a fit, which could ultimately be a danger to them.”  






  • Smyth and Jacobs report no relevant conflicts of interest. 


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  • Smyth A, O’Donnell M, Lamelas P, et al. Physical activity and anger or emotional upset as triggers of acute MI: the INTERHEART study. Circulation. 2016;Epub ahead of print.