Can Anger or Emotional Upset and Heavy Physical Exertion Trigger Stroke?

Depression Risk in Angina
Depression Risk in Angina
Researchers examined the association between anger, emotional upset, or heavy physical exertion and acute stroke.

A case-control study found the onset of stroke, ischemic stroke, and intracerebral hemorrhage (ICH) were associated with acute anger or emotional upset, and acute heavy physical exertion was only associated with ICH. The findings were published in the European Heart Journal.

INTERSTROKE was a large, international, case-control study conducted at 142 centers in 32 countries. Patients (N=13,462) with acute first stroke responded to a structured questionnaire that assessed for possible stroke triggers. Using a case-crossover approach, the investigators assessed whether a trigger occurred within 1 hour of symptom onset (case) or the same time on the previous day (control).

Patients had a mean age of 62.2±13.6 years, and 59.6% were men.

Anger or emotional upset occurred within 1 hour of symptom onset among 9.2% of study participants and during the previous day among 8.3%. Individuals reporting an emotional trigger during the case time period were younger, more were men, had higher levels of education, body mass index (BMI), stress, had a history of diabetes, hypertension, angina, myocardial infarction, depression, and fewer took cardiovascular prevention medications.

During the case period, anger or emotional upset associated with all stroke (odds ratio [OR], 1.37; 95% CI, 1.15-1.64), ischemic stroke (OR, 1.22; 95% CI, 1.00-1.49), and ICH (OR, 2.05; 95% CI, 1.40-2.99). Stratified by subtype, the association was strongest among those with an “other” etiological classification (OR, 2.53; 95% CI, 1.30-4.90; P <.001).

Significant interactions were observed between depression with all stroke (P <.001), ischemic stroke (P <.001), and ICH (P =.012); education with all stroke (P <.001) and ICH (P =.001); and diabetes with ICH (P =.002).

After removing data from patients who did not respond to the questionnaire themselves, the associations between an emotional trigger and all stroke (OR, 1.40; 95% CI, 1.09-1.81) and ICH (OR, 3.93; 95% CI, 1.62-9.56) were stronger (P =.001).

Heavy physical exertion occurred within 1 hour of symptom onset among 5.3% of study participants and during the previous day among 5.4%. Individuals reporting physical exertion during the case time period were younger, more were men, they were current smokers, did not have diabetes, had higher physical activity, and adjusted systolic blood pressure.

During the case period, heavy physical exertion associated with ICH (OR, 1.62; 95% CI, 1.03-2.55). Similar to emotional triggers, the association between physical exertion and ICH was stronger among patients who responded to the questionnaire themselves (OR, 2.86; 95% CI, 1.00-8.15; P =.009).

Odds of ICH were lowest among individuals with a BMI 25-29.9 kg/m2 (P =.001). A significant gender effect with physical exertion was observed among women who had a stroke (P =.001).

This study may have been limited by recall bias, especially after having a stroke.

“We report that anger or emotional upset is common in the 1 hour before the onset of symptoms of stroke and was associated with all stroke types,” the study authors said. “In contrast, the evidence is less convincing to support heavy physical exertion as an external trigger for stroke.”

Disclosure: An author declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Smyth A, O’Donnell M, Hankey GJ, et al. Anger or emotional upset and heavy physical exertion as triggers of stroke: the INTERSTROKE study Eur Heart J. Published online December 1, 2021. doi:10.1093/eurheartj/ehab738