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Acute coronary syndromes
The effects of cold and exercise on the cardiovascular system
  1. Vasiliki Manou-Stathopoulou1,2,
  2. Christopher D Goodwin1,
  3. Tiffany Patterson1,2,
  4. Simon R Redwood1,2,
  5. Michael S Marber1,2,
  6. Rupert P Williams1,2
  1. 1King's College London British Heart Foundation Centre of Research Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, UK
  2. 2National Institute for Health Research Biomedical Research Centre at Guy's and St. Thomas’ NHS Foundation Trust, London, UK
  1. Correspondence to Dr Rupert P Williams, SpR Cardiology & British Heart Foundation Clinical Research Training Fellow Cardiovascular Division, Rayne Institute, St Thomas’ Hospital, London SE1 7EH, UK; rupert.williams{at}

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Learning objectives

  • 1. Coronary physiology

  • 2. Exercise physiology

  • 3. Events that precipitate acute coronary syndrome and angina

Curriculum topic

Acute coronary syndromes


Decreased exercise tolerance and worsening of angina symptoms during the winter months is a well-documented phenomenon among patients with coronary artery disease (CAD).1 There is a significant increased risk of acute myocardial infarction (AMI) with cold temperatures,2 even when taking into account confounding factors such as altered glucose and cholesterol levels and higher incidence of respiratory infections.3 ,4 When comparing seasonal differences in the northern and southern hemispheres, a higher incidence of AMI correlates with periods of cold weather in both hemispheres (figure 1).5 ,6 The risk of AMI in cold temperatures is further increased if exercise is being performed. Notable examples are shovelling snow7 and downhill skiing,8 which involve significant isometric exercise and dynamic exercise components. While epidemiological studies suggest a strong link between exercising in the cold and AMI, a causal relationship is yet to be demonstrated.

Figure 1

Seasonal differences in the incidence of myocardial infarction in the northern and southern hemispheres. This figure represents data from two observational studies investigating the incidence of myocardial infarction in the northern (the USA) and southern (Australia) hemispheres. The figure demonstrates the percentage change in the incidence of myocardial infarction compared with their respective winters. Of note the average temperatures in the summer months for the northern and southern hemispheres were 21°C and 22°C, whereas the winters were significantly colder in the northern hemispheres, 2°C vs 10°C. This might explain the greater seasonal variation in the northern hemisphere. Adapted from Loughnan et al5 and Spencer et al6.

The exact mechanism by which cold increases the risk of AMI remains unclear. Proposed mechanisms include a myocardial oxygen supply and demand mismatch or an …

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  • Contributors VM-S, RPW and CDG were involved in the writing and initial critical review of the manuscript. MSM, SRR and TP were involved in subsequent critical review.

  • Funding British Heart Foundation Clinical Training Fellowship awarded to Dr Williams grant number FS/11/90/29087. National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas’ National Health Service Foundation Trust and King's College London.

  • Competing interests None.

  • Provenance and peer review Commissioned; externally peer reviewed.

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