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Previous Volume 329:1684-1690 December 2, 1993 Number 23 Next

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ABSTRACT

Background It is controversial whether the onset of myocardial infarction occurs randomly or is precipitated by identifiable stimuli. Previous studies have suggested a higher risk of cardiac events in association with exertion.

Methods Consecutive patients with acute myocardial infarction were identified by recording all admissions to our hospital in Berlin and by monitoring a general population of 330,000 residents in Augsburg, Germany. Information on the circumstances of each infarction was obtained by means of standardized interviews. The data analysis included a comparison of patients with matched controls and a case-crossover comparison (one in which each patient serves as his or her own control) of the patient's usual frequency of exertion with the last episode of exertion before the onset of myocardial infarction.

Results From January 1989 through December 1991, 1194 patients (74 percent of whom were men; mean age [±SD], 61 ±9 years) completed the interview 13 ±6 days after infarction. We found that 7.1 percent of the case patients had engaged in physical exertion ( 6 metabolic equivalents) at the onset of infarction, as compared with 3.9 percent of the controls at the onset of the control event. For the patients as compared with the matched controls, the adjusted relative risk of having engaged in strenuous physical activity at the onset of infarction or the control event was 2.1 (95 percent confidence interval, 1.1 to 3.6). The case-crossover comparison yielded a similar relative risk of 2.1 (95 percent confidence interval, 1.6 to 3.1) for having engaged in strenuous physical activity within one hour before myocardial infarction. Patients whose frequency of regular exercise was less than four and four or more times per week had relative risks of 6.9 and 1.3, respectively (P<0.01).

Conclusions A period of strenuous physical activity is associated with a temporary increase in the risk of having a myocardial infarction, particularly among patients who exercise infrequently. These findings should aid in the identification of the triggering mechanisms for myocardial infarction and improve prevention of this common and serious disorder.

Source Information

From the Cardiopulmonary Division, Department of Medicine, Klinikum Steglitz, Free University of Berlin, Berlin (S.N.W., H.-R.A., F.S., R.S.), and Zentralklinikum Augsburg, Augsburg (M.L., H.L.) -- both in Germany.

Address reprint requests to Dr. Willich at the Department of Medicine, Klinikum Steglitz, Free University of Berlin, Hindenburgdamm 30, D-12200 Berlin, Germany.

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• Strike, P C, Perkins-Porras, L, Whitehead, D L, McEwan, J, Steptoe, A (2006). Triggering of acute coronary syndromes by physical exertion and anger: clinical and sociodemographic characteristics. Heart 92: 1035-1040 [Abstract] [Full Text]  
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• Kokkinos, P., Chrysohoou, C., Panagiotakos, D., Narayan, P., Greenberg, M., Singh, S. (2006). Beta-Blockade Mitigates Exercise Blood Pressure in Hypertensive Male Patients. J Am Coll Cardiol 47: 794-798 [Abstract] [Full Text]  
• Domenech, R. J. (2006). Preconditioning: A New Concept About the Benefit of Exercise. Circulation 113: e1-e3 [Full Text]  
• Thompson, P. D., Balady, G. J., Chaitman, B. R., Clark, L. T., Levine, B. D., Myerburg, R. J. (2005). Task Force 6: Coronary artery disease. J Am Coll Cardiol 45: 1348-1353 [Full Text]  
• Coppola, A., Coppola, L., dalla Mora, L., Limongelli, F. M., Grassia, A., Mastrolorenzo, L., Gombos, G., Lucivero, G. (2005). Vigorous exercise acutely changes platelet and B-lymphocyte CD39 expression. J. Appl. Physiol. 98: 1414-1419 [Abstract] [Full Text]  
• Strike, P. C., Steptoe, A. (2005). Behavioral and Emotional Triggers of Acute Coronary Syndromes: A Systematic Review and Critique. Psychosom. Med. 67: 179-186 [Abstract] [Full Text]  
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• Koton, S., Tanne, D., Bornstein, N. M., Green, M. S. (2004). Triggering risk factors for ischemic stroke: A case-crossover study. Neurology 63: 2006-2010 [Abstract] [Full Text]  
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• Maron, B. J. (2000). The Paradox of Exercise. NEJM 343: 1409-1411 [Full Text]  
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• Williams, M J A, Low, C J S, Wilkins, G T, Stewart, R A H (2000). Randomised comparison of the effects of nicardipine and esmolol on coronary artery wall stress: implications for the risk of plaque rupture. Heart 84: 377-382 [Abstract] [Full Text]  
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• Gill, T. M., DiPietro, L., Krumholz, H. M. (2000). Role of Exercise Stress Testing and Safety Monitoring for Older Persons Starting an Exercise Program. JAMA 284: 342-349 [Abstract] [Full Text]  
• Rankinen, T., Gagnon, J., Perusse, L., Chagnon, Y. C., Rice, T., Leon, A. S., Skinner, J. S., Wilmore, J. H., Rao, D. C., Bouchard, C. (2000). AGT M235T and ACE ID polymorphisms and exercise blood pressure in the HERITAGE Family Study. Am. J. Physiol. Heart Circ. Physiol. 279: H368-H374 [Abstract] [Full Text]  
• van den Burg, P. J. M., Hospers, J. E. H., Mosterd, W. L., Bouma, B. N., Huisveld, I. A. (2000). Aging, physical conditioning, and exercise-induced changes in hemostatic factors and reaction products. J. Appl. Physiol. 88: 1558-1564 [Abstract] [Full Text]  
• Arntz, H.-R, Willich, S.N, Schreiber, C, Bruggemann, T, Stern, R, Schultheiss, H.-P (2000). Diurnal, weekly and seasonal variation of sudden death. Population-based analysis of 24061 consecutive cases. Eur Heart J 21: 315-320 [Abstract]  
• Kay, P, Kittelson, J, Stewart, R A H (2000). Relation between duration and intensity of first exercise and "warm up" in ischaemic heart disease. Heart 83: 17-21 [Abstract] [Full Text]  
• Giri, S., Thompson, P. D., Kiernan, F. J., Clive, J., Fram, D. B., Mitchel, J. F., Hirst, J. A., McKay, R. G., Waters, D. D. (1999). Clinical and Angiographic Characteristics of Exertion-Related Acute Myocardial Infarction. JAMA 282: 1731-1736 [Abstract] [Full Text]  
• Moller, J., Hallqvist, J., Diderichsen, F., Theorell, T., Reuterwall, C., Ahlbom, A. (1999). Do Episodes of Anger Trigger Myocardial Infarction? A Case-Crossover Analysis in the Stockholm Heart Epidemiology Program (SHEEP). Psychosom. Med. 61: 842-849 [Abstract] [Full Text]  
• Li, N., Wallen, N. H., Hjemdahl, P. (1999). Evidence for Prothrombotic Effects of Exercise and Limited Protection by Aspirin. Circulation 100: 1374-1379 [Abstract] [Full Text]  
• Mittleman, M. A., Mintzer, D., Maclure, M., Tofler, G. H., Sherwood, J. B., Muller, J. E. (1999). Triggering of Myocardial Infarction by Cocaine. Circulation 99: 2737-2741 [Abstract] [Full Text]  
• Shephard, R. J., Balady, G. J. (1999). Exercise as Cardiovascular Therapy. Circulation 99: 963-972 [Full Text]  
• Willich, S. N (1999). Circadian variation and triggering of cardiovascular events. Vasc Med 4: 41-49 [Abstract]  
• Pereira, M. A., Kriska, A. M., Day, R. D., Cauley, J. A., LaPorte, R. E., Kuller, L. H. (1998). A Randomized Walking Trial in Postmenopausal Women: Effects on Physical Activity and Health 10 Years Later. Arch Intern Med 158: 1695-1701 [Abstract] [Full Text]  
• Shah, P. K (1998). Role of inflammation and metalloproteinases in plaque disruption and thrombosis. Vasc Med 3: 199-206 [Abstract]  
• Balady, G. J., Chaitman, B., Driscoll, D., Foster, C., Froelicher, E., Gordon, N., Pate, R., Rippe, J., Bazzarre, T. (1998). Recommendations for Cardiovascular Screening, Staffing, and Emergency Policies at Health/Fitness Facilities. Circulation 97: 2283-2293 [Full Text]  
• Lavery, C. E., Mittleman, M. A., Cohen, M. C., Muller, J. E., Verrier, R. L. (1997). Nonuniform Nighttime Distribution of Acute Cardiac Events : A Possible Effect of Sleep States. Circulation 96: 3321-3327 [Abstract] [Full Text]  
• PARRATT, J. R, VEGH, A. (1997). Delayed protection against ventricular arrhythmias by cardiac pacing. Heart 78: 423-425 [Full Text]  
• Niebauer, J., Hambrecht, R., Velich, T., Hauer, K., Marburger, C., Kalberer, B., Weiss, C., von Hodenberg, E., Schlierf, G., Schuler, G., Zimmermann, R., Kubler, W. (1997). Attenuated Progression of Coronary Artery Disease After 6 Years of Multifactorial Risk Intervention : Role of Physical Exercise. Circulation 96: 2534-2541 [Abstract] [Full Text]  
• Siegel, A. J. (1997). Relative Risk of Sudden Cardiac Death During Marathon Running. Arch Intern Med 157: 1269-1269 [Abstract]  
• Desouza, C. A., Dengel, D. R., Rogers, M. A., Cox, K., Macko, R. F. (1997). Fibrinolytic responses to acute physical activity in older hypertensive men. J. Appl. Physiol. 82: 1765-1770 [Abstract] [Full Text]  
• Mittleman, M. A., Maclure, M. (1997). Mental Stress During Daily Life Triggers Myocardial Ischemia. JAMA 277: 1558-1559 [Abstract]  
• Held, C., Hjemdahl, P., Rehnqvist, N., Wallen, N. H., Bjorkander, I., Eriksson, S. V., Forslund, L., Wiman, B. (1997). Fibrinolytic Variables and Cardiovascular Prognosisin Patients With Stable Angina Pectoris Treated With Verapamil or Metoprolol: Results From the Angina Prognosis Study in Stockholm. Circulation 95: 2380-2386 [Abstract] [Full Text]  
• Thompson, P. D. (1996). The Cardiovascular Complications of Vigorous Physical Activity. Arch Intern Med 156: 2297-2302 [Abstract]  
• Haapaniemi, H., Hillbom, M., Juvela, S. (1996). Weekend and Holiday Increase in the Onset of Ischemic Stroke in Young Women. Stroke 27: 1023-1027 [Abstract] [Full Text]  
• Krantz, D. S., Kop, W. J., Gabbay, F. H., Rozanski, A., Barnard, M., Klein, J., Pardo, Y., Gottdiener, J. S. (1996). Circadian Variation of Ambulatory Myocardial Ischemia : Triggering by Daily Activities and Evidence for an Endogenous Circadian Component. Circulation 93: 1364-1371 [Abstract] [Full Text]  
• Montgomery, H. E., Clarkson, P., Nwose, O.M., Mikailidis, D.P., Jagroop, I.A., Dollery, C., Moult, J., Benhizia, F., Deanfield, J., Jubb, M., World, M., McEwan, J. R., Winder, A., Humphries, S. (1996). The Acute Rise in Plasma Fibrinogen Concentration With Exercise Is Influenced by the G-453-A Polymorphism of the ß-Fibrinogen Gene. Arterioscler. Thromb. Vasc. Bio. 16: 386-391 [Abstract] [Full Text]  
• Petch, M C (1996). Triggering a heart attack. BMJ 312: 459-460 [Full Text]  
• Glenister, D. (1996). Exercise and mental health: a review. The Journal of the Royal Society for the Promotion of Health 116: 7-13 [Abstract]  
• Mittleman, M. A., Maclure, M., Sherwood, J. B., Mulry, R. P., Tofler, G. H., Jacobs, S. C., Friedman, R., Benson, H., Muller, J. E. (1995). Triggering of Acute Myocardial Infarction Onset by Episodes of Anger. Circulation 92: 1720-1725 [Abstract] [Full Text]  
• Falk, E., Shah, P. K., Fuster, V. (1995). Coronary Plaque Disruption. Circulation 92: 657-671 [Full Text]  
• Wight, J. N Jr, Salem, D. (1995). Sudden Cardiac Death and the `Athlete's Heart'. Arch Intern Med 155: 1473-1480 [Abstract]  
• O'Rourke, M. (1995). Mechanical Principles in Arterial Disease. Hypertension 26: 2-9 [Full Text]  
• Capezzuto, A., Achilli, A., Pontillo, D., Sassara, M., De Spirito, S., Guerra, R. (1995). Acute Myocardial Infarction Shortly After a Normal Exercise Stress Test: Case Reports. ANGIOLOGY 46: 521-526 [Abstract]  
• Vinson, D. C., Mabe, N., Leonard, L. L., Alexander, J., Becker, J., Boyer, J., Moll, J. (1995). Alcohol and Injury: A Case-Crossover Study. Arch Fam Med 4: 505-511 [Abstract]  
• Franklin, B. A., Hogan, P., Bonzheim, K., Bakalyar, D., Terrien, E., Gordon, S., Timmis, G. C. (1995). Cardiac Demands of Heavy Snow Shoveling. JAMA 273: 880-882 [Abstract]  
• Esler, M. D., Thompson, J. M., Kaye, D. M., Turner, A. G., Jennings, G. L., Cox, H. S., Lambert, G. W., Seals, D. R. (1995). Effects of Aging on the Responsiveness of the Human Cardiac Sympathetic Nerves to Stressors. Circulation 91: 351-358 [Abstract] [Full Text]  
• Broijersen, A., Eriksson, M., Angelin, B., Hjemdahl, P. (1995). Gemfibrozil Enhances Platelet Activity in Patients With Combined Hyperlipoproteinemia. Arterioscler. Thromb. Vasc. Bio. 15: 121-127 [Abstract] [Full Text]  
• Simon, H. B. (1994). Patient-Directed, Nonprescription Approaches to Cardiovascular Disease. Arch Intern Med 154: 2283-2296 [Abstract]  
• Angell, M., Kassirer, J. P. (1994). Clinical Research -- What Should the Public Believe?. NEJM 331: 189-190 [Full Text]  
• Roberts, J. A., Goble, A. J., O'Connor, P. J., Mittleman, M. A., Tofler, G. H., Muller, J. E., Willich, S. N., Lewis, M. (1994). Triggering of Acute Myocardial Infarction by Exercise. NEJM 330: 1156-1157 [Full Text]  
• (1993). EXERCISE CAN TRIGGER MI IN THE PHYSICALLY UNFIT. JWatch General 1993: 2-2 [Full Text]  
• Mittleman, M. A., Maclure, M., Tofler, G. H., Sherwood, J. B., Goldberg, R. J., Muller, J. E., The Determinants of Myocardial Infarction Onset St, (1993). Triggering of Acute Myocardial Infarction by Heavy Physical Exertion -- Protection against Triggering by Regular Exertion. NEJM 329: 1677-1683 [Abstract] [Full Text]  
• Curfman, G. D. (1993). Is Exercise Beneficial -- or Hazardous -- to Your Heart?. NEJM 329: 1730-1731 [Full Text]