Mortality from acute myocardial infarction and stroke was increased in Dutch men on the day of an important football match compared with the preceding and following days. Compared with the average mortality in the preceding and following days, about 14 additional fatal events occurred; this is an increase of around 50%. Our findings indicate that watching an important football match may be stressful. It further supports the view that the mental and other stressors of such an event may trigger acute myocardial infarction or stroke.
No corresponding increase in mortality occurred in women. This could mean that fewer women were exposed to the triggers (for example, because of less interest in football or lower alcohol consumption) or that they are less vulnerable to their effect. Less exposure seems the more likely explanation, although Tofler et al found that men were more likely to report triggers before myocardial infarction than women.1
The exact mechanism behind this difference is still unclear.
The role of triggering factors has received increased attention since the recognition of a marked circadian, weekly, and seasonal variation in the occurrence of cardiovascular disease and most notably myocardial infarction,15–19
with clear peaks during morning hours, on Mondays, and in winter. A conceptual framework for the underlying pathophysiological mechanism for triggering both myocardial infarction and stroke has been proposed.2,3
The first step would be the transition of a non-vulnerable atherosclerotic plaque into a vulnerable state by unknown mechanisms. This would make the plaque susceptible to disruption by acute risk factors such as increased sympathetic nervous activity (leading to a surge in arterial pressure and vasoconstriction) and increased coagulability. A disrupted plaque could then provide a thrombogenic stimulus, at which point triggers causing further vasoconstriction or increased coagulability could aggravate the situation, eventually leading to embolisation, occlusion, and infarction.
For acute myocardial infarction and stroke, the lowest mortality was found on the day after the match, although this difference was not significant. Stress induced by the football match possibly resulted in an acceleration of mortality—that is, vulnerable men had their fatal myocardial infarction or stroke a day earlier than they would have otherwise.
The proposed acute risk factors could result from activities or situations that occur frequently in daily life: emotional upset or mental stress,1,2,5,17
lack of sleep,1
heavy alcohol ingestion or smoking,1,4,7,19
and sexual activity.1,20,21
The role of emotional or mental stress, physical activity, and heavy alcohol ingestion has been established mainly by retrospective questioning of people who have had non-fatal cardiovascular events. The finding of increased risks of cardiovascular events during earthquakes and wars8–13
has provided strong support for a triggering role of emotional and mental stress. Our findings show that an important football match can similarly provide sufficient triggers to cause a rise in mortality from myocardial infarction and stroke.
What is already known on this topic
Factors such as heavy physical exercise, unusual mental or emotional stress, and high alcohol consumption have been proposed as trigger factors for myocardial infarction and stroke
Events that induce stress on a large number of people in a defined area, such as earthquakes and war, have been reported to increase the incidence of fatal and non-fatal myocardial infarction
What this study adds
Male mortality from myocardial infarction and stroke was increased on the day of an important football match of the Dutch national team, probably because of increased stress
Mortality in women was unaffected
The effect of a single match is detectable in national mortality data
The role of national vital statistics in studies on causes of mortality has been disputed because of the limited validity and accuracy of these routinely collected data. It is, however, unlikely that changes in coding behaviour over days can explain our finding. Furthermore, all cause mortality showed the same trends as mortality from myocardial infarction and stroke.
Our results add prospective evidence for the role of triggering factors, including mental and emotional stress, in cardiovascular deaths in men. We also observed a clear sex difference that merits further investigation. The triggers induced by a critical football match may not be due solely to mental or emotional stress. Notably, heavy alcohol use, overeating, and excessive smoking may also play a part.
The role of trigger factors in cardiovascular disease illustrates that prevention of cardiovascular events goes beyond management of risk factors for atherosclerosis. Increased awareness of the impact of stressors in vulnerable subjects seems crucial. In addition, aspirin or β blockers may prevent acute cardiovascular events being triggered in high risk subjects.22,23