Can a fan be so caught up in World Cup soccer that they have a heart attack? Can watching your football team in a tough, hard-fought, closely contested Super Bowl lead to sudden cardiac arrest? There are well known triggers to major cardiac events, but are sporting events one of them?

Many studies have shown that there is an increased risk for a cardiac event immediately after a trigger or stressor occurs. Triggers can be physical, chemical, psychosocial or environmental. Stressors typically will increase the heart rate and blood pressure, increasing the oxygen demand of the heart and leading to a heart attack. Stressors can cause the heart arteries to spasm (the artery closes down, reducing blood flow to the heart). A trigger will result in the release of several stress hormones including catecholamines (adrenaline) and cortisol, in addition to inflammatory proteins and procoagulants (substances which increase blood clotting in a heart artery). In addition, stress reactions destabilize the electrical activity of the heart, which can lead to deadly irregular rhythms and sudden cardiac arrest.

One trigger is physical activity. In general, physical activity protects against heart disease. However in patients who are sedentary, a sudden burst of physical activity can lead to acute cardiac events. For example, consider someone who doesn’t exercise and who has to suddenly run for a bus on a hot humid day or who is out shoveling snow on a cold winter day. That person is at a higher risk for a heart attack than someone who exercises regularly. In fact, studies have shown that the risk for a heart attack is 6 times higher in patients who exercise less than once per week, compared to patients who exercise 5 or more times per week. Many studies have documented that specific physical activities, such as skiing, snow shoveling and sexual activity, can trigger acute heart events.

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Caffeine, alcohol, cocaine and cigarette smoke are all chemical triggers which can cause an acute heart attack, sudden cardiac arrest and stroke. Caffeine and alcohol can cause these events if consumed in excess, or in greater than usual quantities, for example binge drinking. Patients who don’t regularly use these beverages are more susceptible than those whose consume moderate amounts. Cocaine and cigarette smoke may cause spasm of the heart arteries, cutting off oxygen to the heart muscle leading to heart attacks or malignant irregular heart rhythms. As opposed to caffeine and alcohol, even a single cigarette or snort of cocaine can lead to an acute cardiac event.

Environmental triggers include pollution and changes in temperature. Many studies have shown an increased risk for acute cardiac events in areas of high pollution. Heart patients are very susceptible to changes in temperature. Usually the extremes of temperature, very cold or very hot, are a stressor for heart patients and can trigger an event, especially if combined with physical activity.

Psychosocial triggers include anger, depression, anxiety, work stress, natural disasters, war and terrorist attacks. Fits of anger result in the same bad physiological responses as a physical stressor. Patients who were angry, enraged or furious face a two to nine times higher risk for a heart attack within hours of the episode. Acute episodes of anxiety or depression may trigger events as well. In patients who experienced an episode of severe emotional upset, the risk for a heart attack was 2.5 times higher within 24 hours. Work stress is well known to cause heart attacks. For example, there is a six-fold increase in the risk for a heart attack within 24 hours of having a high-pressure deadline at work.

Natural disasters are certainly triggers which can precipitate an acute cardiac event. This was first described in a study that showed an excess of cardiac deaths in the days surrounding a major earthquake which struck Athens Greece in 1981. There were no excess deaths from cancer or from other causes in the days after the earthquake.  These findings were confirmed in a study examining deaths after the Northridge earthquake, which struck the Los Angeles area in January 1994. There was an excess of cardiac deaths in the six days following the earthquake with the death rate returning to baseline levels after one week. Most of the victims died or had chest pain within one hour of the initial tremor. Japanese researchers looked at heart attacks after the major earthquake and tsunami which struck in March 2011. They found that heart attacks increased from 9 per week before the disaster to 22 in the week following the catastrophe. The heart attack rate slowly declined to the baseline rate over the subsequent 6 weeks. Similar to earthquakes or tsunamis, a war or terrorist attack exposes an entire population to a stressful environment. Studies done after the September 11, 2001 terrorist attack on the World Trade Center showed an increase in heart attacks and arrhythmias. In addition, it was shown that there was an increase in cardiac events far from New York City. All of these studies suggest that psychosocial stress, rather than the living conditions at the site of the disaster, precipitated these cardiac events in those who are vulnerable.  

Can watching a sporting match trigger an acute cardiac event? The two arenas where this issue has been studied, World Cup soccer and the Super Bowl, involve football. A study was published in the New England Journal of Medicine comparing heart attacks among German fans during the 2006 World Cup tournament with cardiac emergencies in Germany at other times the same year. The study showed that when the German team played, acute cardiac events were 2.6 times more likely to occur (3.2 times more likely in men, 1.8 times more likely in women). Interestingly, 47 percent of the victims had underlying heart disease and the risk rose during the knockout stage (when the stakes and the pressure are higher). Similarly, the risk for hospital admission for heart attack increased 25 percent in England on the day in 1998 that England lost to Argentina on a penalty shoot out. No excess admissions occurred for other diagnoses or on the days of England's other matches.

Is the Super Bowl a trigger for acute cardiac events? To answer this question, researchers examined death certificates in Los Angeles County for two weeks after the Rams Super Bowl loss in 1980. They found that heart-related deaths increased 15 percent in men and 27 percent in women during that period. A more recent study showed that cardiac deaths increased by 20 percent in Massachusetts following the Patriots loss to the Giants in the 2008 Super Bowl, as dramatic and intense a game as there has been in recent memory.

It seems that the psychosocial stress of watching a high stakes match can trigger an acute cardiac event. In addition, watching sporting matches is associated with adverse behaviors, such as cigarette smoking and binge drinking, which are triggers unto themselves. Clearly fans can get excited and succumb while watching their favorite sporting event, especially if they are male, have underlying heart disease, engaging in risky behavior and if it is a high-stress, pressure-packed event. So sit back and enjoy the game, but don't smoke, don't let the emotions of the game overwhelm you and take it easy on the beer.