Key result
Acute anger or emotional upset is linked to ~37% higher odds of stroke.
Why the study?
To determine the importance of anger or emotional upset and heavy physical exertion as acute stroke triggers in a large, international population.
Does exposure to acute anger, emotional upset, or heavy physical exertion trigger the onset of acute stroke?
Case-Control (n=13,462)
Yes
Does exposure to acute anger, emotional upset, or heavy physical exertion trigger the onset of acute stroke?
Acute anger or emotional upset is a potential trigger for all types of stroke, whereas heavy physical exertion specifically triggers intracerebral hemorrhage.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Stroke prevention is a priority for physicians, and despite advances it remains difficult to predict when a stroke will occur. Many studies have focused on medium to long-term exposures, such as hypertension, obesity or smoking. Our study aimed to look at acute exposures that may act as triggers.”
“Whilst we cannot eliminate our exposure to anger or emotional upset, we suggest that everyone minimise their and to develop strategies to reduce the reaction of the body to these stressful experiences. For some, this may include breathing exercises; for others it may include meditation, mindfulness, or going for a walk to get some fresh air. What's most important is that everyone has a strategy that works for themselves.”
“Our message is for people to practice mental and physical wellness at all ages. But it is also important for some people to avoid heavy physical exertion, particularly if they are high-risk of cardiovascular, while also adopting a healthy lifestyle of regular exercise.”
Acute emotional triggers merit awareness in stroke-prone patients; hypothesis-generating for prevention trials targeting anger management.
AIMS: In INTERSTROKE, we explored the association of anger or emotional upset and heavy physical exertion with acute stroke, to determine the importance of triggers in a large, international population. METHODS AND RESULTS: INTERSTROKE was a case-control study of first stroke in 32 countries. Using 13 462 cases of acute stroke we adopted a case-crossover approach to determine whether a trigger within 1 hour of symptom onset (case period), vs. the same time on the previous day (control period), was associated with acute stroke. A total of 9.2% (n = 1233) were angry or emotional upset and 5.3% (n = 708) engaged in heavy physical exertion 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. CONCLUSION: Acute anger or emotional upset was associated with the onset of all stroke, ischaemic stroke, and ICH, while acute heavy physical exertion was associated with ICH only.
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Smyth et al. (2021) conducted a case-control in Acute first stroke (n=13,462). Anger or emotional upset vs. Same 1-hour period on the previous day was evaluated on All stroke (OR 1.37, 95% CI 1.15-1.64). Acute anger or emotional upset in the hour before symptom onset was associated with a 37% increased odds of all stroke (OR 1.37, 99% CI 1.15-1.64).
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