Anger or emotional upset and heavy physical exertion as triggers of stroke based on the INTERSTROKE study

As stroke is a leading global cause of death and disability, stroke prevention is a global health priority. The well-known INTERSTROKE study reported that 10 potentially modifiable chronic risk factors are collectively associated with ∼90% of the population-attributable risk of stroke, but despite multiple approaches to measuring cardiovascular risk burden, it remains difficult to predict when a stroke will occur. Importantly, this risk burden predominantly reflects medium- to long-term exposures (including hyperlipidaemia, obesity, and smoking) rather than acute exposures with transient effects that may act as triggers of stroke. A new analysis of the INTERSTROKE data focused on potential stroke triggers such as anger or emotional upset and heave physical exertion was published in the European Heart Journal in December 2021.

INTERSTROKE is a large international case-control study, conducted at 142 centers in 32 countries. Cases were patients with acute first stroke (within 5 days of symptom onset and subsequently confirmed neuroimaging within 1 week of presentation) who were recruited into the study and completed questionnaires within 72 hours of hospital admission. Research study staff performed a standardized physical examination on participants and administered a structured questionnaire. Participants with acute stroke were asked dichotomous questions, ‘Were you angry or emotionally upset?’ and ‘Were you engaged in heavy physical exertion?’ in 1 hour before the onset of symptoms and during the corresponding 1 hour period on the previous day. Data were also collected for age, sex, smoking, usual physical activity, stress, education, medication use, and cardiovascular risk factors.

Based on 13 462 stroke cases, a total of 9.2% (n = 1233) were emotionally upset and 5.3% (n = 708) had heavy physical activity during the case period. Anger or emotional upset in the case period was associated with increased odds of all stroke [odds ratio (OR) 1.37, 99% confidence interval (CI), 1.15–1.64], ischaemic stroke (OR 1.22, 99% CI, 1.00–1.49), and intracerebral haemorrhage (ICH) (OR 2.05, 99% CI 1.40–2.99). Heavy physical exertion in the case period was associated with increased odds of ICH (OR 1.62, 99% CI 1.03–2.55) but not with all stroke or ischaemic stroke. There was no modifying effect by region, prior cardiovascular disease, risk factors, cardiovascular medications, time, or day of symptom onset. Compared with exposure to neither trigger during the control period, the odds of stroke associated with exposure to both triggers were not additive.


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