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original article
A bs t r ac t
Background
The Fédération Internationale de Football Association (FIFA) World Cup, held in From Medizinische Klinik und Poliklinik I,
Germany from June 9 to July 9, 2006, provided an opportunity to examine the rela- Campus Grosshadern (U.W.-L., D.L., T.P.,
S.S., C.V., A.P., A.K., G.S.), and Statis
tion between emotional stress and the incidence of cardiovascular events. tisches Beratungslabor, Institut für Statis-
tik (S.G., D.G., H.K.), Ludwig-Maximilians-
Methods Universität, Munich, Germany. Address
reprint requests to Dr. Wilbert-Lampen at
Cardiovascular events occurring in patients in the greater Munich area were pro- Med. Klinik und Poliklinik I, Campus Gross
spectively assessed by emergency physicians during the World Cup. We compared hadern, Marchioninistr. 15, D-81377 Mu-
those events with events that occurred during the control period: May 1 to June 8 nich, Germany, or at ute.wilbert-lampen@
med.uni-muenchen.de.
and July 10 to July 31, 2006, and May 1 to July 31 in 2003 and 2005.
Drs. Wilbert-Lampen and Leistner con-
Results tributed equally to this article.
Acute cardiovascular events were assessed in 4279 patients. On days of matches N Engl J Med 2008;358:475-83.
involving the German team, the incidence of cardiac emergencies was 2.66 times Copyright © 2008 Massachusetts Medical Society.
that during the control period (95% confidence interval [CI], 2.33 to 3.04; P<0.001);
for men, the incidence was 3.26 times that during the control period (95% CI, 2.78
to 3.84; P<0.001), and for women, it was 1.82 times that during the control period
(95% CI, 1.44 to 2.31; P<0.001). Among patients with coronary events on days when
the German team played, the proportion with known coronary heart disease was
47.0%, as compared with 29.1% of patients with events during the control period.
On those days, the highest average incidence of events was observed during the first
2 hours after the beginning of each match. A subanalysis of serious events during
that period, as compared with the control period, showed an increase in the inci-
dence of myocardial infarction with ST-segment elevation by a factor of 2.49 (95%
CI, 1.47 to 4.23), of myocardial infarction without ST-segment elevation or unstable
angina by a factor of 2.61 (95% CI, 2.22 to 3.08), and of cardiac arrhythmia causing
major symptoms by a factor of 3.07 (95% CI, 2.32 to 4.06) (P<0.001 for all com-
parisons).
Conclusions
Viewing a stressful soccer match more than doubles the risk of an acute cardiovas-
cular event. In view of this excess risk, particularly in men with known coronary
heart disease, preventive measures are urgently needed.
E
vents that induce environmental included only those patients who had had an
stress in a large number of people in de- event in their officially registered place of resi-
fined areas — such as earthquakes, war, dence or within a 500-m radius of that residence.
and sporting events — may increase the risk of Thus, cardiac events were analyzed for local Ger-
cardiovascular events.1-3 Reports of the associa- man residents only, not for visitors from inside
tion between soccer matches and rates of illness or outside Germany.
or death from cardiac causes have been contro- We analyzed the emergency medicine doctors’
versial.4-9 records of the German Interdisciplinary Asso-
The Fédération Internationale de Football As- ciation for Intensive and Emergency Medicine
sociation (FIFA) World Cup was held in Germany (DIVI).10 From the records, the following data
from June 9 to July 9, 2006. It provided the op- were collected: date and location of the event,
portunity to investigate the relation of emotional time of the emergency call, time of the onset of
stress, experienced simultaneously in a predefined symptoms, details of the initial findings (i.e.,
population during the soccer matches, and car- blood pressure, heart rate, a brief medical his-
diovascular events, as prospectively assessed by tory, and results on the electrocardiogram), the
experienced emergency medicine physicians. We final diagnosis, and the patient’s age and sex.
hypothesized that in a country such as Germany Weather data were obtained from Germany’s
— where soccer is particularly popular — World national meteorologic service. Air-pollution data
Cup matches involving the national team might were collected from the Environmental Authority
be a trigger strong enough to cause an increase of the State of Bavaria.
in the incidence of cardiac emergencies. The study protocol was approved by the ethics
committee of the Medical Faculty of the Ludwig-
Me thods Maximilians Universität and the Bavarian Medi-
cal Association. The requirement for informed
Acquisition of Data consent was waived.
The study sites were all in Bavaria: emergency
services in 15 locations, including the city of Statistical Analysis
Munich, the conurbation of Munich, and a rural We used Poisson regression with a log link to
area, as well as 6 air rescue services and 3 inten- model the number of cardiovascular emergencies
sive care vehicles. The prospectively assessed study per day.11 A day was defined as a 24-hour period
period was June 9 to July 9, 2006. The periods of beginning at noon. We compared events occur-
May 1 to July 31 in 2005 and in 2003, as well as ring during three different periods: the 7 days of
May 1 to June 8 and July 10 to July 31, 2006, made World Cup matches played by the German team,
up the control period. The year 2004 was exclud- the 24 days of the World Cup without German
ed on the basis of possible effects of the Euro- matches, and 242 control days (May 1 to June 8
pean Soccer Championship in Portugal that year. and July 10 to July 31, 2006, and May 1 to July 31
We studied patients who had contacted emer- in 2003 and 2005).
gency services and had been treated by an emer- We calculated incidence ratios for the 7 days
gency medicine physician and given one of the of matches played by the German team and the
following final preclinical diagnoses: prolonged 24 days of matches not involving the German
acute chest pain due to myocardial infarction with team as compared with the control period, using
ST-segment elevation, myocardial infarction with- indicator variables. We then calculated incidence
out ST-segment elevation or unstable angina, ratios for subgroups of patients, according to
symptomatic cardiac arrhythmia, cardiac arrest their region of residence or their final diagnosis,
leading to cardiopulmonary resuscitation, or and compared them, assuming asymptotic nor-
therapeutic discharge of an implantable cardio- mality of parameter estimates and independence
verter–defibrillator. All patients included in the of events between subgroups.
study were admitted to a hospital for further In order to avoid confounding, we included in
evaluation. our model the mean daily measurements for
In order to rule out a possible increase in the temperature, barometric pressure, and levels of
incidence of cardiovascular events caused by particulate matter with a diameter smaller than
shifts in population within the study area, we 10 μm per cubic meter. All weather and air-pol-
and Sunday. 1
An autocorrelation plot of the Pearson residu- 40 4
Table 1. Incidence Ratios for Cardiovascular Events on Days during the World Cup, as Compared with Days during
the Control Period, in the Overall Group and in Subgroups.*
* Incidence ratios were calculated as the mean number of cardiovascular events per day for days during the World Cup
divided by the mean number per day for days during the control period. Data were adjusted for environmental and tem-
poral variables.
cardiovascular events was observed during the the German team, the proportion of patients who
hours or days after the games with German par- were men was much higher (71.5%) than during
ticipation. the control period (56.7%). For men, the inci-
Analysis of the regional subgroups indicated a dence of cardiovascular events during the days
significant increase in the number of events dur- of matches involving the German team was 3.26
ing days on which Germany played in a match, times that in the control period; for women, the
as compared with the control period, for patients incidence was 1.82 times that in the control
who lived in the city (incidence ratio, 2.63), those period; both effects were significant (P<0.001).
who lived in the suburbs (3.11), and those who During the 7 days of matches played by the
lived in the countryside (1.99). The incidence of German team, as compared with the control pe-
events that led to interhospital transfer for fur- riod, patients tended to be younger (mean age,
ther evaluation increased as well (incidence ratio, 65.4 vs. 68.5 years), the average heart rate and
3.39). All effects were significant (P<0.001), al- systolic blood pressure were slightly lower, and
though there were no significant differences more patients had known coronary artery disease
among the incidence ratios between the regional (47.0% vs. 29.1%). In order to assess the effect of
subgroups (P = 0.13). In contrast, we could not stress in relation to the presence or absence of
demonstrate a significant increase in the num- known coronary artery disease, we calculated the
ber of events on the 24 days of the World Cup incidence ratios for patients with a history of
without German participation. coronary artery disease, and for those without,
Table 2 shows descriptive characteristics of pa during the 7 days of matches played by the Ger-
tients who had a cardiovascular event, based on man team. The number of events in patients with
the history taken by the emergency medicine phy- known coronary artery disease increased by a
sician. During the 7 days of matches played by factor of 4.03, and in those without known coro-
Table 2. Characteristics of the Patients Who Had an Acute Cardiovascular Event on Days during the World Cup
as Compared with Days during the Control Period.*
* Plus–minus values are means ±SD. Incidence ratios were calculated as the mean number of cardiovascular events per
day for days during the World Cup divided by the mean number per day for days during the control period. Data were
adjusted for environmental and temporal variables.
nary artery disease by a factor of 2.05, as com- All increases were significant, but the effects
pared with the number of events during the were similar among the four diagnostic catego-
control period. Both increases were significant ries (P = 0.62).
(P<0.001). The difference between the incidence Figure 2 shows the numbers of events on days
ratios of the two groups was also significant of German matches relative to the start of the
(P<0.001). game. There was a clear association between the
For prespecified subgroup analyses, we grouped start of the match and the onset of cardiac symp-
the emergency medicine doctor’s final diagnosis toms. The highest number of events was observed
into four categories (Table 3). During the 7 days within the 2 hours after the start of the match,
of games with German participation, there were with numbers that were higher than the average
6.1 myocardial infarctions with ST-segment eleva- (12.6 events) for several hours before and after
tion per day, as compared with 2.6 per day dur- the match.
ing the control period, corresponding to an adjust
ed incidence ratio of 2.49. During the 7 days, the Dis cus sion
incidence ratio for chest pain, classified as myo-
cardial infarction without ST-segment elevation Our results show a strong and significant in-
or unstable angina, was 2.61; for the composite crease in the incidence of cardiovascular events
of cardiac arrhythmias causing major symptoms, (including the acute coronary syndrome and
the incidence ratio was 3.07, and for cardiac ar- symptomatic cardiac arrhythmia), in a defined
rhythmias causing minor symptoms, it was 2.13. sample of the German population, in association
Table 3. Incidence Ratios for Cardiovascular Events on Days during the World Cup, as Compared with Days during
the Control Period, According to the Final Diagnosis.*
* Cardiac arrhythmias causing major symptoms were defined as those characterized by atrial fibrillation with rapid conduc-
tion (>100 beats per minute), ventricular tachycardia, cardiac arrest, or discharge of an implantable cardioverter–defibril-
lator. The composite of cardiac arrhythmias causing minor symptoms were defined as those characterized by sinus
tachycardia, sinus bradycardia, atrial fibrillation with normal conduction, or premature beats. Incidence ratios were calcu-
lated as the mean number of cardiovascular events per day for days during the World Cup divided by the mean number
per day for days during the control period. Data were adjusted for environmental and temporal variables. NSTEMI de-
notes myocardial infarction without ST-segment elevation, and STEMI myocardial infarction with ST-segment elevation.
with matches involving the German team during An association between soccer matches and
the FIFA World Cup held in Germany in 2006. In rates of illness or death from cardiovascular
contrast, the average daily number of cardiac causes has been previously investigated in six
emergencies during soccer matches involving retrospective epidemiologic studies.4-9 Four as-
foreign teams was well within the range of val- sessed mortality due to myocardial infarction and
ues obtained during the control period. Since the stroke,4,5,7,8 one assessed hospital admission due
incidence ratios were close to 1 for the days around to myocardial infarction and stroke,6 and the last
the German matches, it is clear that watching an involved a combined end point of cardiac and
important soccer match, which can be associated extracardiac diseases.9 Data were collected by
with intense emotional stress, triggers the acute central bureaus for statistics. The results are
coronary syndrome and symptomatic cardiac ar- inconsistent: two studies showed an increase in
rhythmia. the relative risk of an event on the day of a
match,4,5 another showed an increase but did Averaged over all seven games involving Germa-
not evaluate it statistically,6 two did not show an ny, the incidence of events increased during the
increase,7,8 and one showed a decrease.9 In con- several hours before the match, the highest inci-
trast, the conceptual design of the present study dence was observed during the 2 hours after the
was to prospectively evaluate clinical end points start of the match, and the incidence remained
(myocardial infarction with ST-segment elevation, increased for several hours after the end of the
myocardial infarction without ST-segment eleva- match. Trigger studies typically assess activities
tion or unstable angina, and symptomatic cardiac that are regarded as acute trigger mechanisms
arrhythmia) in a predefined population before, during the period of 1 or 2 hours before cardiac
during, and after an entire soccer tournament, symptoms occur.15,16 Thus, our findings with re-
with assessments by a team of experienced emer- spect to the relationship between the timing of
gency physicians. Using this study design, we the trigger and the cardiovascular event fully con-
found that the risk of an acute cardiovascular cur with those in other trigger studies.
event on days on which matches were played by In accordance with other studies,3-6 we found
the German team was considerably increased that most of the additional cardiac emergencies
overall, by a factor of 2.7; similar results were occurred in men. This phenomenon may be ex-
also found for all diagnostic subgroups. plained by sex-specific pathophysiological differ-
Carroll et al.6 found a significant increase in ences17 or by differences in the degree of interest
the incidence of acute myocardial infarction after in soccer matches or vulnerability to emotional
the national team lost a penalty shoot-out, and triggers.18
we have documented an increase in the incidence A trigger can be defined as a stimulus that
of cardiac events after the German team won a produces pathophysiological changes leading
penalty shoot-out. Apparently, of prime impor- directly to disease — in this case, cardiovascu-
tance for triggering a stress-induced event is not lar diseases.18 Although various mechanisms of
the outcome of a game — a win or a loss — but stress-induced cardiac arrhythmias have been
rather the intense strain and excitement experi- described,19‑21 those underlying the induction of
enced during the viewing of a dramatic match, acute coronary syndromes are less clear. As pre-
such as one with a penalty shoot-out. viously reported, stress hormones may directly
Several studies have indicated that triggering influence endothelial and monocytic function.22‑24
is more common in patients with known coro- Thus, future evaluations of endothelial and mono-
nary artery disease than in those without it.1,15,16 cytic mediators in patients with stress-induced
Our results are consistent with these findings: cardiovascular events might clarify the mecha-
cardiovascular events on days of soccer matches nisms of emotional triggering.
with German participation were associated with The excess risk of cardiovascular events associ-
an increased rate of known coronary heart dis- ated with viewing stressful soccer matches (and
ease. More specifically, events occurred in all pa probably other sporting events) is considerable,
tients more frequently during the 7 days of match and evaluation of preventive measures is needed,
es played by the German team than during the particularly in patients with preexisting coronary
control period, and the increase was greater artery disease. Interventions that might be con-
among those with a history of coronary artery sidered include the administration or the increase
disease than among those without such a history in dose of beta-adrenergic-blocking drugs, anti-
(incidence ratio, 4.03 vs. 2.05). We assume that inflammatory agents such as statins, or anti-
patients with preexisting coronary artery disease platelet drugs such as aspirin, as well as the
had, on average, more extensive underlying dis- blockade of stress-mediating receptors. In addi-
ease (more vulnerable plaques), leading to more tion, nonmedical strategies, such as behavioral
frequent acute coronary syndromes, than did pa- therapy for coping with stress, should be con
tients who were considered to be healthy before sidered.
the event. Our study has several limitations. The differ-
The emergency records enabled us to analyze entiation of myocardial infarction without ST-seg-
the exact temporal relationship between the emo- ment elevation from unstable angina was impos-
tional trigger (the soccer match) and the onset sible because of the limited prehospital diagnosis.
of symptoms prompting the emergency call. However, all patients with these diagnoses were
References
1. Leor J, Poole WK, Kloner RA. Sudden acute myocardial infarction and sudden nary events among spectators in a soccer
cardiac death triggered by an earthquake. death in Israeli civilians. Lancet 1991;338: stadium. Rev Esp Cardiol 2005;58:587-91.
N Engl J Med 1996;334:413-9. 660-1. (In Spanish.)
2. Meisel SR, Kutz I, Dayan KI, et al. Ef- 3. Serra Grima R, Carreño MJ, Tomás 4. Witte DR, Bots ML, Hoes AW, Grob-
fect of Iraqi missile war on incidence of AL, Brossa V, Ligero C, Pons J. Acute coro- bee DE. Cardiovascular mortality in Dutch
men during 1996 European football cham- Theory. Budapest: Akadémiai Kiadó, 1973: Circadian rhythms of frequency domain
pionship: longitudinal population study. 267-81. measures of heart rate variability in healthy
BMJ 2000;321:1552-4. 13. Wood SN. Generalized additive mod- subjects and patients with coronary artery
5. Kirkup W, Merrick DW. A matter of els: an introduction with R. London: Chap- disease: effects of arousal and upright
life and death: population mortality and man & Hall, 2006. posture. Circulation 1994;90:121-6.
football results. J Epidemiol Community 14. R: a language and environment for 21. Hemingway H, Malik M, Marmot M.
Health 2003;57:429-32. statistical computing: reference index. Ver- Social and psychosocial influences on sud-
6. Carroll D, Ebrahim S, Tilling K, Mac sion 2.4.0 (2007-04-23). Vienna: R Foun- den cardiac death, ventricular arrhythmia
leod J, Smith GD. Admissions for myocar- dation for Statistical Computing, 2007. and cardiac autonomic function. Eur Heart
dial infarction and World Cup football: 15. Strike PC, Perkins-Porras L, White- J 2001;22:1082-101.
database survey. BMJ 2002;325:1439-42. head DL, McEwan J, Steptoe A. Triggering 22. Wilbert-Lampen U, Trapp A, Modrzik
7. Toubiana L, Hanslik T, Letrilliart L. of acute coronary syndromes by physical M, Fiedler B, Straube F, Plasse A. Effects
French cardiovascular mortality did not exertion and anger: clinical and sociode- of corticotropin-releasing hormone (CRH)
increase during 1996 European football mographic characteristics. Heart 2006;92: on endothelin-1 and NO release, mediated
championship. BMJ 2001;322:1306. 1035-40. by CRH receptor subtype R2: a potential
8. Brunekreef B, Hoek G. No association 16. Tofler GH, Muller JE. Triggering of link between stress and endothelial dys-
between major football games and cardio- acute cardiovascular disease and potential function? J Psychosom Res 2006;61:453-
vascular mortality. Epidemiology 2002;13: preventive strategies. Circulation 2006;114: 60.
491-2. 1863-72. 23. Wilbert-Lampen U, Trapp A, Barth S,
9. Berthier F, Boulay F. Lower myocar- 17. Culić V, Mirić D, Jukić I. Acute myo- Plasse A, Leistner D. Effects of beta-
dial infarction mortality in French men cardial infarction: differing preinfarction endorphin on endothelial/monocytic endo
the day France won the 1998 World Cup of and clinical features according to infarct thelin-1 and nitric oxide release mediated
football. Heart 2003;89:555-6. site and gender. Int J Cardiol 2003;90:189- by mu1-opioid receptors: a potential link
10. Moecke H, Dirks B, Friedrich HJ, et al. 96. between stress and endothelial dysfunc-
DIVI emergency medicine protocol, ver- 18. Tofler GH, Stone PH, Maclure M, et al. tion? Endothelium 2007;14:65-71.
sion 4.0. Anaesthesist 2000;49:211-3. (In Analysis of possible triggers of acute 24. Wilbert-Lampen U, Straube F, Trapp A,
German.) myocardial infarction (the MILIS study). Deutschmann A, Plasse A, Steinbeck G.
11. Schwartz J. Air pollution and hospital Am J Cardiol 1990;66:22-7. Effects of corticotropin-releasing hormone
admissions for heart disease in eight U.S. 19. Lampert R, Joska T, Burg MM, Bats- (CRH) on monocyte function, mediated by
counties. Epidemiology 1999;10:17-22. ford WP, McPherson CA, Jain D. Emotion- CRH-receptor subtype R1 and R2: a poten-
12. Akaike H. Information theory and an al and physical precipitants of ventricular tial link between mood disorders and en-
extension of the maximum likelihood arrhythmia. Circulation 2002;106:1800-5. dothelial dysfunction? J Cardiovasc Phar-
principle. In: Petrov BN, Csaki F, eds. 2nd 20. Huikuri HV, Niemelä MJ, Ojala S, macol 2006;47:110-6.
International Symposium on Information Rantala A, Ikäheimo MJ, Airaksinen KE. Copyright © 2008 Massachusetts Medical Society.