title: Triggering of acute coronary syndromes by physical exertion and anger: clinical and sociodemographic characteristics.
abstract: OBJECTIVE
  To investigate the role of vigorous physical exertion and anger as triggers of acute coronary syndromes (ACS) and to identify the clinical and sociodemographic correlates of triggering.
  
  
  METHODS
  Prospective observational clinical cohort study.
  
  
  METHODS
  Four coronary care units in the London area.
  
  
  METHODS
  295 men and women with electrocardiographically and biochemically verified ACS.
  
  
  METHODS
  Physical exertion in the 1 h and anger in the 2 h before symptom onset were assessed with structured interviews. Control periods were the equivalent hours one day earlier and usual rates over the past six months. Data were analysed by case-crossover methods.
  
  
  RESULTS
  Physical exertion was reported by 10% and anger by 17.4% of patients in the hazard period. The risk of ACS onset after physical exertion compared with light or no activity was 3.50 (95% confidence interval (CI) 1.37 to 10.6). The risk of onset with anger was 2.06 (95% CI 1.12 to 3.92). Physical exertion during the hazard period was related to an absence of premonitory symptoms, presentation with an ST elevation myocardial infarction (STEMI), low socioeconomic deprivation and higher future cardiovascular risk. Anger during the hazard period was more common in younger, socioeconomically deprived patients who presented with a STEMI.
  
  
  CONCLUSIONS
  Triggers are relevant across the spectrum of ACS. The distinct clinical and sociodemographic factors associated with physical exertion and anger suggest that different pathophysiological processes may be involved.
authors.affiliation: Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK.
authors.forename: P C
authors.initials: PC
authors.lastname: Strike
authors.forename: L
authors.initials: L
authors.lastname: Perkins-Porras
authors.forename: D L
authors.initials: DL
authors.lastname: Whitehead
authors.forename: J
authors.initials: J
authors.lastname: McEwan
authors.forename: A
authors.initials: A
authors.lastname: Steptoe
mesh_terms: D000367:Age Factors; D000368:Aged; D000786:Anger / Q000502:physiology*; D000789:Angina, Unstable / Q000209:etiology*; D004812:Epidemiologic Methods; D015444:Exercise / Q000502:physiology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology*; D012737:Sex Factors; D013577:Syndrome; D013997:Time Factors