Heart 92:1035-1040 doi:10.1136/hrt.2005.077362
  • Cardiovascular medicine

Triggering of acute coronary syndromes by physical exertion and anger: clinical and sociodemographic characteristics

  1. P C Strike1,
  2. L Perkins-Porras1,
  3. D L Whitehead1,
  4. J McEwan2,
  5. A Steptoe1
  1. 1Department of Epidemiology and Public Health, University College London, London, UK
  2. 2Department of Medicine, University College London, London, UK
  1. Correspondence to:
    Professor Andrew Steptoe
    Department of Epidemiology and Public Health, University College London, 1–19 Torrington Place, London WC1E 6BT, UK; a.steptoe{at}
  • Accepted 20 December 2005
  • Published Online First 6 January 2006


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.

Design: Prospective observational clinical cohort study.

Setting: Four coronary care units in the London area.

Patients: 295 men and women with electrocardiographically and biochemically verified ACS.

Main outcome measures: 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.


  • Published Online First 6 January 2006

  • This research was supported by the British Heart Foundation. The funding source has not been involved in the submission of the manuscript or in the decision to publish the data.

  • Competing interests: None declared.

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