Correspondence
Cardiovascular Events during World Cup Soccer
N Engl J Med 2008; 358:2408-2409May 29, 2008
- Article
To the Editor:
The conclusion by Wilbert-Lampen et al. (Jan. 31 issue)1 that World Cup soccer is a risk factor for the occurrence of acute cardiovascular events is weakened considerably by the lack of data on the incidence of such events in the several weeks or months after the German matches. The increased incidence during the German matches may simply reflect a phase shift in events that would have occurred over the next several months under other circumstances — somewhat similar to lead-time bias in disease-screening programs that seem to show prolonged survival but merely reflect the earlier detection of a disease such as cancer that progresses as it would have otherwise. Although the stress of World Cup soccer may precipitate a cardiac event, it may not be changing the inevitable outcome of the underlying coronary artery disease.
1 ReferencesThomas L. Schwenk, M.D.
University of Michigan, Ann Arbor, MI 48103
tschwenk@umich.edu 1
Wilbert-Lampen U ,Leistner D ,Greven S , et al. Cardiovascular events during World Cup soccer. N Engl J Med 2008;358:475-483
Full Text | Web of Science | Medline
To the Editor:
Wilbert-Lampen et al. found an ecologic association between the occurrence of German national team matches and the incidence of cardiovascular events in the greater Munich area during World Cup 2006. Further supporting the authors' conclusions are the results of the matches themselves.
The two highest peaks in cardiac events occurred during the days of the two most emotionally wrenching matches. Germany trailed through much of the quarterfinal against Argentina, winning in the shoot-out after regulation. In the semifinal loss to Italy, Germany trailed throughout the contest.
Conversely, the three lowest peaks in events occurred during fairly easy victories against Ecuador in the initial group play (when Germany had already qualified to advance), against Sweden in the Round of 16, and in the consolation match against Portugal.
It appears that both a decisive victory and a match that is relatively meaningless are protective factors in this association. If that holds up in American football, New England must have been a much more tranquil place than Seattle was for cardiologists on Sundays in the autumn of 2007.
Christopher E. Spitters, M.D., M.P.H.
University of Washington School of Medicine, Seattle, WA 98195To the Editor:
Wilbert-Lampen et al. hypothesize that the increase in cardiovascular events in the Munich area during the World Cup soccer matches was triggered by emotional stress in relation to the matches. However, we believe that some additional causes might have played a role. Lifestyle habits change substantially in association with broadcast sports matches. In particular, postprandial hyperglycemia, hypertriglyceridemia, and increased intake of saturated fat from typical Central European foods, such as french fried potatoes, beef fat, pork, lard, and cheeses, are commonplace among people who are watching sports on television. A large body of epidemiologic evidence attests that these foods can trigger postprandial angina pectoris and acute coronary syndromes, especially in patients with preexisting cardiovascular disease and when accompanied by stress, physical inactivity, alcohol consumption (especially binge drinking), consumption of coffee, and smoking.1,2 Therefore, we agree that both medical and nonmedical treatments might be considered, and we suggest that additional dietary or physical interventions (e.g., walking) should be recommended before and after broadcast sports.
2 ReferencesGiuseppe Lippi, M.D.
Giovanni Targher, M.D.
University of Verona, 37134 Verona, Italy
ulippi@tin.it 1
Goldstein RE ,Redwood DR ,Rosing DR ,Beiser GD ,Epstein SE . Alterations in the circulatory response to exercise following a meal and their relationship to postprandial angina pectoris. Circulation 1971;44:90-100
Web of Science | Medline2
Kolettis TM ,Papathanasiou A ,Tziallas D ,Milionis HJ ,Kastanioti CK ,Achenbach K . Afternoon nap, meal ingestion and circadian variation of acute myocardial infarction. Int J Cardiol 2008;123:338-340
CrossRef | Web of Science | Medline
To the Editor:
In the report by Wilbert-Lampen et al. on the increased incidence of cardiovascular events in association with the World Cup soccer matches involving the German team, the specified events included acute coronary syndromes, symptomatic cardiac arrhythmia, cardiac arrest, and therapeutic discharge of an implantable cardioverter–defibrillator. However, the authors make no mention of stress-induced (takotsubo) cardiomyopathy as an alternative diagnosis that can mimic acute coronary syndromes in this setting.1 Given that cardiovascular events were based on presumptive diagnoses made by emergency room physicians, misclassification bias is likely. Stress-induced cardiomyopathy can be diagnosed only after significant coronary artery disease has been ruled out by angiography.2
2 ReferencesRamin Farzaneh-Far, M.D.
University of California, San Francisco, San Francisco, CA 94143
rfarzanehfar@medicine.ucsf. edu Afshin Farzaneh-Far, M.D.
Duke University Medical Center, Durham, NC 277101
Wittstein IS ,Thiemann DR ,Lima JAC , et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539-548
Full Text | Web of Science | Medline2
Abdulla I ,Ward MR . Tako-tsubo cardiomyopathy: how stress can mimic acute coronary occlusion. Med J Aust 2007;187:357-360
Web of Science | Medline
Author/Editor Response
In response to the comments of Schwenk: no decrease in acute cardiac events was observed for 3 weeks after the final and 4 weeks after the most dramatic match against Italy. Thus, a phase shift did not occur after a period of 4 weeks; the long-term outcome for the patients with cardiac events is not known because of the preclinical study design.
Spitters points out that besides the overall increase in cardiovascular events during the days when the German team played, the association between the magnitude of this increase and the amount of stress presumably imposed by the individual games further supports a causal relationship.
Lippi and Targher comment that — besides stress — certain lifestyle habits may contribute to cardiovascular events in association with broadcast sports matches. Heavy alcohol drinking was ruled out in all our patients who presented to the emergency medicine physicians from May 1 to July 31, 2006. Otherwise, we agree with these comments, as well as the reasonable suggestions for treatment.
R. and A. Farzaneh-Far discuss stress-associated takotsubo cardiomyopathy as an underlying cause of acute coronary syndromes. This disease is diagnosed in about 1 to 2% of all patients presenting with chest pain and ST-segment elevation, and almost exclusively in postmenopausal women without clinically significant coronary heart disease; few cases have been reported in men.1 This rare disease — if it occurred at all — went undetected in our study.
1 ReferencesUte Wilbert-Lampen, M.D.
Gerhard Steinbeck, M.D.
Ludwig-Maximillians-Universität Munich, D-81377 Munich, Germany
ute.wilbert-lampen@med. uni-muenchen. de 1
Prasad A . Apical ballooning syndrome: an important differential diagnosis of acute myocardial infarction. Circulation 2007;115:e56-e59
CrossRef | Web of Science | Medline
