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Canadian Journal of Cardiology

Taking Hockey to Heart: Potential Coronary Risks of Watching Exciting Games

  • David D. Waters
    Correspondence
    Corresponding author: Dr David D. Waters, Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, 5G1, San Francisco, California 94110, USA. Tel.: +1-415-420-6646.
    Affiliations
    Division of Cardiology, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
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  • Stanley Nattel
    Affiliations
    Department of Medicine, Montréal Heart Institute and Université de Montréal, and Department of Pharmacology, McGill University, Montréal, Québec, Canada
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Published:October 04, 2017DOI:https://doi.org/10.1016/j.cjca.2017.08.020
      Arguably, the greatest hockey game ever was played on New Year's Eve 1975 at the old Montreal Forum, between the Stanley Cup champion Montreal Canadiens and the Soviet Central Red Army team. This might have been the best Canadiens team ever, and the Red Army team had all the great Soviet stars from the 1972 Summit Series, led by the lightening-fast Valeri Kharlamov. The game ended in a 3-3 tie, but the Canadiens played an inspired game, checking ferociously all over the ice and outshooting Red Army by 38-13. Only spectacular goaltending by Vladislav Tretiak kept Red Army in the game as he stood down wave after wave of attackers. We wonder what the peak heart rate and blood pressure of the average fan was during that game.
      In this issue of the Canadian Journal of Cardiology, Khairy et al.
      • Khairy L.T.
      • Barin R.
      • Demonière F.
      • et al.
      Heart rate response in spectators of the Montreal Canadiens hockey team.
      report on the heart rate response of spectators during more ordinary Montreal Canadiens games.
      • Khairy L.T.
      • Barin R.
      • Demonière F.
      • et al.
      Heart rate response in spectators of the Montreal Canadiens hockey team.
      Heart rate increased from 60 (interquartile range [IQR], 54-65) bpm at rest to 114 (IQR, 103-129) bpm during the game (P < 0.001). Heart rates were higher in those watching live vs those watching televised games. A fan passion score did not correlate significantly with heart rate response. Peak heart rates most commonly occurred during overtime and scoring opportunities and were comparable to heart rate increases during significant exercise.
      As the authors note, the heart rate responses of hockey spectators has not previously been reported. However, more data are available from other sports, particularly World Cup football (soccer). In a small series of German fans, watching a World Cup match with Germany participating, compared with a match involving other teams, was associated with not only higher heart rates but also higher central and peripheral blood pressure, cardiac output, and peripheral resistance.
      • Reppel M.
      • Franzen K.
      • Bode F.
      • et al.
      Central hemodynamics and arterial stiffness during the finals of the world cup soccer championship 2010.
      These changes were attributed to an increase in adrenaline release and persisted for hours after a match.

      Cardiovascular Events in Sports Spectators

      Increases in heart rate and blood pressure increase cardiac work, but do these hemodynamic changes also increase the risk of myocardial infarction (MI) or cardiovascular (CV) death? Although not all studies are concordant, the consensus is that they do. For example, during the 2006 World Cup, emergency department physicians prospectively assessed acute coronary events in 4279 patients in the Greater Munich area.
      • Wilbert-Lampen U.
      • Leistner D.
      • Greven S.
      • et al.
      Cardiovascular events during World Cup soccer.
      On days of matches involving the German team, the incidence of cardiac events for men was 2.66 times that during the control period (95% CI, 2.33-3.04; P < 0.001) and there was a 1.82 times increase for women (95% CI, 1.44-2.31; P < 0.001). The highest average incidence of events was observed during the first 2 hours after the beginning of each match. Known coronary disease was present in 47.0% of patients with events on the days that the German team played compared with 29.1% of patients with events during the control period.
      Is acute coronary syndrome (ACS) that occurs during spectator stress different in any way from other ACS events? When patients with ACS during the aforementioned 2006 World Cup were compared with other patients with ACS, higher levels of inflammatory and vasoconstrictive mediators were found, specifically, soluble CD40L, soluble vascular cell adhesion molecule-1, monocyte chemoattractant protein-1, tumor necrosis factor-α, and endothelin-1.
      • Wilbert-Lampen U.
      • Nickel T.
      • Leistner D.
      • et al.
      Modified serum profiles of inflammatory and vasoconstrictive factors in patients with emotional stress-induced acute coronary syndrome during World Cup Soccer 2006.

      Triggers of Myocardial Infarction

      Watching a stressful sporting event is just one of many triggers of MI and coronary death that have been identified. Some are external, such as earthquakes,
      • Suzuki S.
      • Sakamoto S.
      • Miki T.
      • Matsuo T.
      Hanshin-Awaji earthquake and acute myocardial infarction.
      Iraqi missile strikes,
      • Meisel S.R.
      • Kutz I.
      • Dayan K.I.
      • et al.
      Effect of Iraqi missile war on incidence of acute myocardial infarction and sudden death in Israeli civilians.
      blizzards,
      • Glass R.I.
      • Zack Jr., M.M.
      Increase in deaths from ischaemic heart-disease after blizzards.
      hot weather,
      • Heyer H.E.
      • Teng H.C.
      • Barris B.
      The increased frequency of acute myocardial infarction during summer months in a warm climate; a study of 1,386 cases from Dallas, Texas.
      and holidays.
      • Phillips D.P.
      • Jarvinen J.R.
      • Abramson I.S.
      • Phillips R.R.
      Cardiac mortality is higher around Christmas and New Year's than at any other time: the holidays as a risk factor for death.
      Others are optional and behavioral, such as exercise,
      • Giri S.
      • Thompson P.D.
      • Kiernan F.
      • et al.
      Clinical and angiographic characteristics of exertion-related acute myocardial infarction.
      sexual activity,
      • Muller J.E.
      • Mittleman M.A.
      • Maclure M.
      • Sherwood J.B.
      • Tofler G.H.
      Triggering myocardial infarction by sexual activity. Low absolute risk and prevention by regular physical exertion. Determinants of Myocardial Infarction Onset Study Investigators.
      or cocaine use.
      • Mittleman M.A.
      • Mintzer D.
      • Maclure M.
      • et al.
      Triggering of myocardial infarction by cocaine.
      In a prospective survey, 48% of patients identified a trigger for their MI.
      • Tofler G.H.
      • Stone P.H.
      • Maclure M.
      • et al.
      Analysis of possible triggers of acute myocardial infarction (the MILIS study).
      Stressors that extend over longer periods, such as bereavement, unemployment, or social isolation, also increase the risk of CV events.
      • Waters D.D.
      The rise and fall of tuberculosis and atherosclerosis: first there is a mountain….
      An interesting feature reported in some of these studies is that after the initial trigger and spike in CV events, the event rate becomes depressed for approximately 2 weeks, with the number of CV events caused by the trigger being much less than the number that appear to be “prevented” during the aftermath. This pattern was clearly seen after the 1994 Northridge earthquake in Southern Califorina.
      • Kloner R.A.
      • Leor J.
      • Poole W.K.
      • et al.
      Population-based analysis of the effect of the Northridge earthquake on cardiac death in Los Angeles County, California.
      It is possible that triggers precipitate CV events that are about to occur soon anyway. If so, preventive strategies directed specifically at triggers would not be particularly helpful.

      Coronary Risk Factors in Hockey Fans

      Ardent hockey fans can be found across all levels of Canadian society—from grade schools to nursing homes. Nevertheless, the archetypical hockey fan is perceived as being laden with CV risk factors. For example, “Dart Guy,” the Toronto Maple Leaf super fan who shot to Twitter stardom during the 2016 playoffs, is addicted to cigarettes and looks rather overweight.
      Fox Sports. The Maple Leafs are embracing ‘Dart Guy’ and not everyone is happy about it.
      One could speculate that he might also have some combination of hypertension, prediabetes, hypertriglyceridemia, and low high-density lipoprotein cholesterol.
      Dart Guy obviously deserves a CV risk factor assessment from his physician and strong encouragement to quit smoking. Should his medical management be influenced in any way by his relationship to hockey? News reports suggest that he is extremely stressed while watching playoff games, although his heart rate, blood pressure, and catecholamine levels at that time are not known. Would a β-blocker or aspirin reduce his risk of a CV event? Should he be encouraged to diversify his interests and perhaps to embark on an exercise program?

      How Should We Advise At-Risk Fans About the Risks of Watching Hockey?

      As already discussed, watching an exciting hockey game might trigger a CV event in an individual at risk. The danger is particularly high in the arena and at dramatic moments such as overtime. The underlying substrate, a vulnerable plaque for type 1 MI or severe diffuse coronary disease for type 2 MI, will still be present if a CV event does not occur and will be susceptible to the next trigger that comes along. However, life must go on. Watching hockey is only one of several activities that are important for quality of life but are associated with some risk of a CV event. Life is full of triggers, large and small, good and bad. Avoiding all triggers equates to avoiding life itself and is not a viable strategy.
      At-risk patients should be warned about potential CV symptoms. They should be instructed to seek medical attention promptly if such symptoms occur (and not wait for the end of the period). At events where triggering might occur, appropriate precautions should be in place, including the availability of defibrillators and personnel trained in their use. Standard procedures should exist for getting individuals with symptoms to medical attention, and staff training should be updated regularly. Such readiness will save lives.

      Conclusions

      The Montreal Canadiens have won the Stanley Cup more often than any other team—24 times—but not since 1993. The Toronto Maple Leafs have won the Stanley Cup 13 times but not since 1967. A Stanley Cup victory for either team would trigger a frenzied celebration and undoubtedly cause a spike in CV events among that team's fans. Unfortunately, that risk does not seem imminent. In fact, no Canadian-based team has won the Stanley Cup since 1993. Despite this sad circumstance, we should continue to work hard to reduce the CV risk of our patients who are fans (and nonfans too).

      Disclosures

      The authors have no conflicts of interest to disclose.

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      1. Fox Sports. The Maple Leafs are embracing ‘Dart Guy’ and not everyone is happy about it.
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