EURO PEAN SO CIETY O F CARDIOLOGY ®
Original scientific paper
Winning or losing does matter: Acute cardiac admissions in New Zealand during Rugby World Cup tournaments
European Journal of Preventive Cardiology 2015, Vol. 22(10) 1254–1260 ! The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/2047487314539433 ejpc.sagepub.com
P Olsen1, JM Elliott2, C Frampton2 and PS Bradley3
Abstract Aim: The relationship between watching major sporting events and cardiac hospital admissions is contentious. This study is the first to investigate cardiovascular admissions during Rugby World Cup (RWC) tournaments. Methods and results: New Zealand (NZ) public hospital admissions data were analysed for cardiovascular events during the 1999, 2003, 2007 and 2011 RWC tournaments. The exposure period was the day of the NZ All Blacks last match and 2 days post-match. The control period was equivalent days in October or November for 3 years prior to or after each RWC. The NZ 2011 semi-final win and 2000 Olympics opening ceremony were also analysed. There were 281 14 and 3313 379 cardiac admissions in the exposure and control periods. The semi-final loss in 2003 was associated with a 50% (p < 0.01) increase in pooled heart failure admissions and a 20% (p < 0.05) increase in pooled acute coronary syndromes admissions. Increases in heart failure were specific to women with a two-fold increase on match day and 2-days post (p < 0.01). There was no increase in male heart failure admissions but arrhythmias increased 2.6 times (p < 0.01) 1-day after losing the 2003 semi-final. In contrast, admissions were typically lower after the 2011 semi-final win and Olympics opening ceremony. Conclusion: This is the first study to find a relationship between hospital admissions for heart failure in women and a major sporting event. Preventive health measures should be considered in fans with cardiovascular disease or at high risk of cardiovascular events during sporting events. Winning or losing does matter.
Keywords Major sporting events, cardiovascular triggers, cardiovascular disease, heart failure, arrhythmias, spectators, rugby Received: 26 February 2014; accepted: 22 May 2014
Introduction Considerable conflict exists in the literature regarding the relationship between watching major sporting events and the incidence of cardiovascular events in the general population. Reviews by Leeka et al.1 and Culic2 concluded sporting events can increase cardiovascular events and mortality rates with variables such as the importance of the match, intensity of the game and final outcome being important contributing factors. Relationships have been observed between American football Super Bowl matches, soccer matches in the English Premiership, European and World Cup finals, and increased hospital admissions for events such as myocardial infarction and sudden death mortality.3–8 Other researchers9–12 have found no relationships between watching sport and hospital admissions for cardiovascular events.
Winning major sporting events may have either a protective or adverse effect on the incidence of cardiovascular events in the general population.7,8,13,14 Wilbert-Lampen et al.7 observed a three-fold increase in acute cardiovascular events when Germany hosted the 2006 Soccer World Cup irrespective of the outcome of matches for the host team. Kloner et al.8 found 1 Department of Applied Sciences and Allied Health, Christchurch Polytechnic Institute of Technology, New Zealand 2 Department of Medicine, University of Otago, Christchurch, New Zealand 3 Department of Sport and Exercise Sciences, University of Sunderland, UK
Corresponding author: P Olsen, Department of Applied Sciences and Allied Health, Christchurch Polytechnic Institute of Technology, Christchurch 8011, New Zealand. Email: [email protected]
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all-cause mortality and cardiovascular death rates increased in Los Angeles (LA) County when the LA Rams lost the 1980 Super Bowl but mortality decreased when the LA Raiders won the 1984 Super Bowl or when neutral teams played. According to Hoek15 a possible explanation for the conflicting research outcomes is admissions data had not been adjusted for confounding variables such as seasons, temperature and day of the week. While this conclusion is valid for the majority of research in the area, researchers such as WilbertLampen et al.7 used multi-year data and controlled for environmental variables and observed significant relationships while others such as Barone-Adesi et al.9 found negligible relationships. Consequently, more research is needed to explore the relationship between acute cardiovascular events in the general population and watching major sporting events. New Zealand (NZ) hosted the Rugby World Cup (RWC) in 2011. The RWC is one of the world’s largest sporting events with a cumulative TV audience of almost four billion people.16 Rugby and sport in general holds a prominent place in NZ society17 and the Chief Executive of Rugby NZ stated: ‘‘The RWC will be delivered by our stadium of four million’’,16 which is equivalent to the total population of the country. Given the prominence of rugby in NZ, the knock out nature of the RWC, and the fact the NZ All Blacks team had not won the RWC for 24 years despite being perennial favourites, we thought it would be pertinent to investigate cardiovascular events in the NZ population during RWC tournaments. This study is unique as previous research has not examined the relationship between hospital admissions for cardiovascular events in RWC tournaments. Additionally, a comparative analysis of the effect of a large television audience event that would not presumably elicit strong emotions such as the opening ceremony of the 2000 Sydney Olympics has not previously been undertaken. The aim of this study was to investigate cardiovascular events in the NZ population during the 1999, 2003, 2007 and 2011 RWC tournaments, and compare with control years from 1999 to 2011 and the opening ceremony of the 2000 Sydney Summer Olympic games.
Methods We extracted public hospital admissions data from the NZ Ministry of Health statistics database for October and November from 1999 to 2011. The following categories were analysed: acute coronary syndromes (ACS) consisting of myocardial infarction and unstable angina (I21–I25), arrhythmias (I46–I48), heart failure (I50) and stroke (I60–I64). The exposure period was the date of the NZ team’s last match in each RWC and the 2 days after each match in 1999, 2003, 2007 and
2011. The control period was equivalent days of the week for 4 weeks in October or November in each of the 3 years prior to a RWC (i.e. 36 days in total). The exception was the 1999 RWC where data for comparison was November 2000, 2001 and 2003 as the current National database was not introduced until 1999. Admissions related to the 2011 semi-final NZ won against Australia and the opening ceremony of the 2000 Sydney Olympics were also analysed to compare admissions after major public events that might elicit different emotions. Same month comparisons were used to decrease the influence of confounding variables such as variations in temperature and air pollution. Relative ratios (RR) and 95% confidence limits were produced for admissions in exposure days and control periods for grouped gender data and male and female admissions. Day stay cases were excluded from the analyses and public holidays were excluded from the control dataset. The research complies with the Declaration of Helsinki, had institutional ethical approval and all data was anonymous.
Results Cases On average, there were 281 14 hospital admissions for all categories of ACS, arrhythmias, heart failure and stroke on the match days and the 2 days after each game (the exposure periods, see Table 1). The average number of hospital admissions in the corresponding control periods was 3313 379 (Table 1).
Hospital admissions Figure 1 illustrates the pooled ratios when NZ lost the 2003 semi-final against Australia compared to winning the semi-final against Australia in 2011, and the 2000 Olympics opening ceremony. Heart failure admissions increased by 33% and 60% (p ¼ 0.15 and 0.05) on the match day when NZ lost the 1999 and 2003 RWC semi-finals respectively, and 60% (p < 0.01) 2 days after the 2003 match (Table 2). In contrast, there was a 40% reduction in heart failure admissions (p ¼ 0.04) the day after the All Blacks won the 2011 RWC final (Table 2). No significant differences were observed for heart failure after the 2007 RWC loss or 2011 RWC semi-final win against Australia (Table 2). An increase of 20% was observed for pooled ACS data 1 day after the 2003 RWC loss (p < 0.05) but not after other All Black losses or wins. Arrhythmias admissions decreased by 40% (p ¼ 0.04) 1 day after the 1999 RWC loss. No differences were observed for stroke admissions in any RWC tournaments.
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European Journal of Preventive Cardiology 22(10) Table 1. Number of hospital admissions during exposure and control periods.a 2011 (W) Final Exposure period Total ACS Arrhythmias Heart failure Stroke Control period Total ACS Arrhythmias Heart failure Stroke
2011 (W) Semi-final
2007 (L) QF
2003 (L) Semi-final
1999 (L) Semi-final
281 102 62 53 64
282 91 67 57 67
303 103 69 64 67
276 108 53 66 49
264 83 58 63 60
3600 1244 724 816 816
3600 1244 724 816 816
3449 1316 670 735 728
2755 1043 533 529 650
3448 1208 701 731 808
a RWC exposure period: Game day and 2-days post game. Control period: Data for equivalent days in October or November for 3 years preceding 2011, 2007 and 2003 RWC or following 1999 RWC. ACS: acute coronary syndromes; QF: quarter-final.
**
1.5
2011 semi-final (won) 2003 semi-final (lost)
Relative ratios
*
2000 olympics
1.0
0.5
0.0 ACS
Arrhythmias Heart failure
Stroke
Hospital admissions
Figure 1. Pooled ratios for hospital admissions for 2000 Olympics opening ceremony and RWC 2003 and 2011 semi-finals relative to control data. Significantly different (*p < 0.05; **p < 0.01).
The ratios for hospital admissions were lower in the exposure period for the Sydney Olympics opening ceremony compared to control data (Table 2). This trend was significant for stroke admissions 2 days after the event (50% decrease, p ¼ 0.04).
1 day after the 2003 RWC loss (Figure 2). There were no significant differences for other matches or tournaments for the female or male admissions RWC data.
Labour Day holiday Male and female hospital admissions Figure 2 shows ratios for hospital admissions in men and women for the RWC 2003 semi-final loss on match day, 1 day and 2 days post-match. Heart failure admissions increased two-fold on match day and 2 days postmatch after the 2003 RWC loss in women but not men (p < 0.01, see Figure 2). In contrast, arrhythmias increased by 157% in men (p < 0.01) but not women
In response to the observed 40% reduction (p ¼ 0.04) in heart failure admissions the day (Labour day – a public holiday) after the All Blacks won the 2011 RWC final (Table 2), we performed an additional analysis of cardiovascular events on Labour Day Mondays compared to non-Labour Day Mondays in October (2008–2010). Acute cardiovascular hospital admissions were significantly lower (0.59 to 0.73, p < 0.05) on Labour Day
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Table 2. Ratios and confidence intervals for hospital admissions for NZ RWC matches and the Olympic opening ceremony for the day of the event and the two days after the event.a 2011 (W) Final
2011 (W) Semi-final
2007 (L) QF
2003 (L) Semi-final
1999 (L) Semi-final
2000 Olympics
ACS
Event þ1-day þ2-day Pooled
1.1 0.8 1.1 1.0
(0.7–1.6) (0.6–1.2) (0.8–1.4) (0.8–1.2)
0.8 0.9 0.8 0.9
(0.5–1.2) (0.6–1.3) (0.6–1.2) (0.7–1.1)
0.8 1.1 0.8 0.9
(0.5–1.2) (0.8–1.4) (0.6–1.2) (0.8–1.1)
1.3 1.4 1.1 1.2b
(0.8–1.9) (1.0–2.0) (0.8–1.5) (1.0–1.5)
0.8 0.8 0.8 0.8
(0.6–1.2) (0.5–1.2) (0.5–1.2) (0.7–1.0)
0.9 0.7 1.1 0.9
(0.6–1.3) (0.4–1.1) (0.7–1.6) (0.7–1.1)
Arrhythmias
Event þ1-day þ2-day Pooled
0.7 1.1 1.2 1.0
(0.3–1.3) (0.7–1.7) (0.8–1.7) (0.8–1.3)
1.2 1.1 1.0 1.1
(0.7–2.0) (0.7–1.7) (0.6–1.5) (0.9–1.4)
1.4 0.9 1.3 1.2
(0.8–2.3) (0.6–1.4) (0.9–2.0) (1.0–1.6)
1.1 1.5 1.1 1.2
(0.6–1.9) (0.8–2.4) (0.7–1.7) (0.9–1.6)
1.1 0.6b 1.2 1.0
(0.7–1.8) (0.3–1.0) (0.8–1.9) (0.8–1.3)
0.9 0.8 0.9 0.9
(0.5–1.5) (0.4–1.5) (0.4–1.6) (0.6–1.2)
Heart failure
Event þ1-day þ2-day Pooled
0.9 0.6b 0.9 0.8
(0.5–1.6) (0.3–1.0) (0.6–1.4) (0.6–1.0)
0.8 0.9 0.7 0.8
(0.4–1.4) (0.6–1.3) (0.5–1.2) (0.6–1.1)
0.8 1.0 1.1 1.1
(0.4–1.5) (0.6–1.5) (0.7–1.7) (0.8–1.4)
1.6b 1.2 1.6c 1.5c
(0.9–2.6) (0.6–2.0) (1.1–2.4) (1.1–1.9)
1.3 0.8 0.9 1.0
(0.9–2.0) (0.5–1.2) (0.5–1.4) (0.8–1.3)
0.8 1.0 1.0 0.9
(0.5–1.3) (0.5–1.7) (0.5–1.8) (0.7–1.2)
Stroke
Event þ1-day þ2-day Pooled
1.0 0.8 1.1 0.9
(0.6–1.6) (0.5–1.2) (0.7–1.6) (0.7–1.2)
1.0 1.0 0.9 1.0
(0.6–1.6) (0.6–1.5) (0.6–1.4) (0.8–1.3)
1.4 1.3 0.7 1.1
(0.8–2.2) (0.9–1.9) (0.4–1.1) (0.9–1.4)
0.9 1.1 0.8 0.9
(0.5–1.5) (0.6–1.8) (0.5–1.3) (0.7–1.2)
0.7 1.1 0.8 0.9
(0.4–1.2) (0.7–1.6) (0.5–1.3) (0.8–1.0)
1.0 0.7 0.5b 0.8
(0.6–1.5) (0.3–1.3) (0.2–1.0) (0.5–1.0)
a RWC exposure period: Game day and 2 days post game. Control period: Data for equivalent days in October or November for 3 years preceding 2011, 2007 and 2003 RWC or following 1999 RWC. Olympics exposure period: Day of Ceremony (15th September 2000) and 2 days post event. Control period - data for equivalent days in September for 3 years following the Sydney Olympics Opening Ceremony. b p 0.05; cp 0.01. W: won; L: lost; ACS: acute coronary syndromes; QF: Quarter-final. Pooled data is the grouped data for the event and the 2 days post event.
3.0
Relative ratios
2.0
Arrhythmias male
**
2.5
Arrhythmias female
**
**
**
Heart failure male Heart failure female
1.5 1.0 0.5 0.0
Match day
+ 1-day
+ 2-days
Pooled
Figure 2. Ratios for hospital admissions for RWC 2003 semi-final loss, 1-day and 2-day post match relative to control data. Significantly different (**p < 0.01).
Mondays compared to control Mondays except in stroke admissions (0.89, p > 0.05).
Discussion Losing RWC matches This is the first study to find a relationship between national hospital admissions for heart failure and a
major sporting event. New Zealand lost the 2003 RWC semi-final, which coincided with an increase of 60% in heart failure admissions on match day and a persistent increase 1–2 days after the match in 2003. A 20% increase was also observed for pooled ACS data after the 2003 RWC semi-final loss. Culic2 indicated acute emotional stress as a possible cause for increased cardiovascular events and mortality rates in major sporting events. Proposed mechanisms for emotional
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triggers facilitating cardiovascular events include acute physiological changes such as increased heart rate and blood pressure, which could transiently increase the risk of plaque rupture and thrombosis and decrease the threshold for ventricular fibrillation.18 In a separate study by the authors, NZ fans had higher heart rates, increased systolic blood pressure, and elevated anxiety and excitement measures during the semi-final and final of the 2011 RWC compared to control games when the All Blacks were not playing.19 It is likely similar physiological and psychological responses were present in NZ spectators when the All Blacks lost in 2003 and were coupled with acute emotions such as anger. European Guidelines on cardiovascular disease prevention indicate anger and hostility are associated with an increased risk of cardiovascular events in both healthy and cardiovascular disease populations.20 A study by Wilbert-Lampen et al.21 also found stress induced ACS was associated with large increases of inflammatory and vasoconstrictive mediators in patients admitted during the 2006 Soccer World Cup. These physiological mechanisms may have contributed to the increase in heart failure and ACS admissions in the NZ population after the 2003 RWC loss, especially in previous myocardial infarction patients and high risk individuals.2,7 In contrast, arrhythmia admissions significantly decreased by 45% the day after the 1999 semi-final loss to France. The reason for the decrease in arrhythmia admissions is unknown and unusual given heart failure increased by 30% on the day the All Blacks lost in 1999. The decrease could be due to the time and day of the game as it was the only match played early Monday morning (3.00 am NZ time). The 2007 quarter-final loss to France produced no significant differences. As in 1999, the time of the game (9.00 am NZ time) may have had an effect although television audience figures were higher for the 2007 quarterfinal than the 2003 semi-final loss (10.00 pm NZ time). It is unlikely to be the nature of the games as media reports indicated NZ was the favourite to win and both matches against France were remarkable games.22,23 Perhaps the ‘build-up’ to the evening game contributed to increased admissions in 2003. Alternatively, the NZ public might find losing to France less emotionally stressful than losing to their Australian neighbours. It is also pertinent to note a considerable number of statistical tests were performed in this study therefore the possibility of type I errors leading to significant differences cannot be dismissed. However, such an error seems unlikely with regards to heart failure in the 2003 RWC, as the observed trend was consistent across days and specific to female admissions.
Gender and RWC losses Hospital admissions increased two-fold on match day and 2-days post-match for heart failure in women, and
160% for arrhythmias in men the day after the 2003 RWC semi-final loss. Women are more likely to have heart failure due to diastolic impairment or abnormal filling secondary to hypertensive heart disease and ventricular hypertrophy.24 The stress of watching a sporting event may have increased blood pressure or impaired filling and led to increased heart failure in women. Another possibility is Takotsubo syndrome, which occurs predominately in older women and is often preceded by emotional or physical stress.25 Wilbert-Lampen et al.7 suggested that in addition to emotional stress, lack of sleep, overeating, heavy alcohol ingestion, smoking, and failure to comply with medical regimes were possible triggers for increase cardiac events during the 2006 Soccer World Cup in Germany. However, it is unlikely overindulgence in food and alcohol or non-compliance with medical routines was the primary cause of increased cardiovascular events during RWC tournaments as there was not a consistent trend in admissions. For example, the 2003 semi-final loss against Australia increased admissions whereas the 2011 semi-final win against Australia produced minimal change in cardiovascular events. The 2011 RWC was the largest sporting event held in NZ and the semi-final against Australia was the second most watched event in NZ television history and it is likely a large portion of the population over-indulged compared to normal dietary habits. Air pollution is another potential confounding variable in cardiac admissions research.15 However, most high concentrations of PM10 in NZ occur in winter26 not October or November when RWC tournaments were held, and NZ is in the lowest 5% for PM10 world averages.27 Therefore the increase in admissions in 2003 compared to 2011 is likely to be the result of acute emotional triggers produced in NZ fans after the All Blacks lost against Australia in 2003 compared to winning in 2011, rather than variables such as overindulgence, pollution and changes in medical regimes.
Winning RWC matches The RWC 2011 final was the most watched event in NZ television history and attracted a 98% audience share.28 Winning the RWC 2011 final was associated with a 42% decrease in heart failure admissions the day after the game and there was no significant increase in any acute cardiac hospital admissions. Previous research found winning or neutral matches decreased cardiovascular incidents or all-cause mortality, which was attributed to the euphoria of victory and or less overall physical activity in the general population.8,13 A unique aspect of this study was the analysis of hospital admissions during the 2000 Sydney Olympics opening ceremony to determine the effect of a large television
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event that would not be expected to produce acute emotional triggers. Overall, admissions were lower in the opening ceremony exposure period with a significant reduction in stroke admissions 2-days after the event. The lower admissions could be related to less physical activity in the NZ population during the event. A metaanalysis by Culic29 found physical activity was the most frequent external trigger of myocardial infarction in the general population. Consequently, the decreased admissions in studies by Berthier and Boulay,13 along with Kloner et al.8 and our research are probably related to less overall physical activity in the general population rather than the euphoria of victory.
Preventive medical or behavioural measures should be considered in sport fans with existing cardiovascular disease or those at high risk prior to a major sporting event. Future research could attempt to identify the specific emotional triggers for cardiovascular events in major sporting events. Acknowledgements We thank Chris Lewis from Analytical Services, Ministry of Health for providing National cardiac hospital admissions data from 1999 to 2011.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
The effect of a national holiday A potential confounding factor for the RWC 2011 final data is the Monday following winning the Final was an annual national holiday (Labour Day). Research by Kloner et al.30 and Phillips et al.31 found cardiovascular events increased during holidays in the United States. We performed an additional analysis of cardiovascular events on Labour Day Mondays compared to nonLabour Day Mondays in October (2008–2010) and found acute cardiovascular hospital admissions were significantly lower on Labour days compared to control days except in stroke admissions. Consequently, the observation of decreased hospital admissions is probably due to a holiday effect and decreased physical activity levels in the general population rather than emotions associated with winning the 2011 RWC. Future research could determine if the decrease is specific to Labour Day or if there are differences between the Northern and Southern hemispheres in hospital admissions during holiday periods.
Conclusions The 2003 RWC semi-final loss by the All Blacks was associated with increased hospital admissions for cardiovascular causes in the NZ population relative to control years. Increases in heart failure were specific to females while admissions for arrhythmias increased in males. Such trends were less evident during other RWC tournaments. Emotional triggers and changes in physiological parameters such as heart rate were probably responsible for the increase in admissions rather than non-compliance with medical routines or excessive food and alcohol intake, as there was not a consistent trend in admissions between RWC tournaments (i.e. winning or losing mattered). The lower ratios for the Sydney Olympics Opening Ceremony also imply the effect of emotionally charged major sporting events may be larger than reported as large audience non-emotive events may lower admissions.
Conflict of interest None declared.
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Original scientific paper
Winning or losing does matter: Acute cardiac admissions in New Zealand during Rugby World Cup tournaments
European Journal of Preventive Cardiology 2015, Vol. 22(10) 1254–1260 ! The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/2047487314539433 ejpc.sagepub.com
P Olsen1, JM Elliott2, C Frampton2 and PS Bradley3
Abstract Aim: The relationship between watching major sporting events and cardiac hospital admissions is contentious. This study is the first to investigate cardiovascular admissions during Rugby World Cup (RWC) tournaments. Methods and results: New Zealand (NZ) public hospital admissions data were analysed for cardiovascular events during the 1999, 2003, 2007 and 2011 RWC tournaments. The exposure period was the day of the NZ All Blacks last match and 2 days post-match. The control period was equivalent days in October or November for 3 years prior to or after each RWC. The NZ 2011 semi-final win and 2000 Olympics opening ceremony were also analysed. There were 281 14 and 3313 379 cardiac admissions in the exposure and control periods. The semi-final loss in 2003 was associated with a 50% (p < 0.01) increase in pooled heart failure admissions and a 20% (p < 0.05) increase in pooled acute coronary syndromes admissions. Increases in heart failure were specific to women with a two-fold increase on match day and 2-days post (p < 0.01). There was no increase in male heart failure admissions but arrhythmias increased 2.6 times (p < 0.01) 1-day after losing the 2003 semi-final. In contrast, admissions were typically lower after the 2011 semi-final win and Olympics opening ceremony. Conclusion: This is the first study to find a relationship between hospital admissions for heart failure in women and a major sporting event. Preventive health measures should be considered in fans with cardiovascular disease or at high risk of cardiovascular events during sporting events. Winning or losing does matter.
Keywords Major sporting events, cardiovascular triggers, cardiovascular disease, heart failure, arrhythmias, spectators, rugby Received: 26 February 2014; accepted: 22 May 2014
Introduction Considerable conflict exists in the literature regarding the relationship between watching major sporting events and the incidence of cardiovascular events in the general population. Reviews by Leeka et al.1 and Culic2 concluded sporting events can increase cardiovascular events and mortality rates with variables such as the importance of the match, intensity of the game and final outcome being important contributing factors. Relationships have been observed between American football Super Bowl matches, soccer matches in the English Premiership, European and World Cup finals, and increased hospital admissions for events such as myocardial infarction and sudden death mortality.3–8 Other researchers9–12 have found no relationships between watching sport and hospital admissions for cardiovascular events.
Winning major sporting events may have either a protective or adverse effect on the incidence of cardiovascular events in the general population.7,8,13,14 Wilbert-Lampen et al.7 observed a three-fold increase in acute cardiovascular events when Germany hosted the 2006 Soccer World Cup irrespective of the outcome of matches for the host team. Kloner et al.8 found 1 Department of Applied Sciences and Allied Health, Christchurch Polytechnic Institute of Technology, New Zealand 2 Department of Medicine, University of Otago, Christchurch, New Zealand 3 Department of Sport and Exercise Sciences, University of Sunderland, UK
Corresponding author: P Olsen, Department of Applied Sciences and Allied Health, Christchurch Polytechnic Institute of Technology, Christchurch 8011, New Zealand. Email: [email protected]
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all-cause mortality and cardiovascular death rates increased in Los Angeles (LA) County when the LA Rams lost the 1980 Super Bowl but mortality decreased when the LA Raiders won the 1984 Super Bowl or when neutral teams played. According to Hoek15 a possible explanation for the conflicting research outcomes is admissions data had not been adjusted for confounding variables such as seasons, temperature and day of the week. While this conclusion is valid for the majority of research in the area, researchers such as WilbertLampen et al.7 used multi-year data and controlled for environmental variables and observed significant relationships while others such as Barone-Adesi et al.9 found negligible relationships. Consequently, more research is needed to explore the relationship between acute cardiovascular events in the general population and watching major sporting events. New Zealand (NZ) hosted the Rugby World Cup (RWC) in 2011. The RWC is one of the world’s largest sporting events with a cumulative TV audience of almost four billion people.16 Rugby and sport in general holds a prominent place in NZ society17 and the Chief Executive of Rugby NZ stated: ‘‘The RWC will be delivered by our stadium of four million’’,16 which is equivalent to the total population of the country. Given the prominence of rugby in NZ, the knock out nature of the RWC, and the fact the NZ All Blacks team had not won the RWC for 24 years despite being perennial favourites, we thought it would be pertinent to investigate cardiovascular events in the NZ population during RWC tournaments. This study is unique as previous research has not examined the relationship between hospital admissions for cardiovascular events in RWC tournaments. Additionally, a comparative analysis of the effect of a large television audience event that would not presumably elicit strong emotions such as the opening ceremony of the 2000 Sydney Olympics has not previously been undertaken. The aim of this study was to investigate cardiovascular events in the NZ population during the 1999, 2003, 2007 and 2011 RWC tournaments, and compare with control years from 1999 to 2011 and the opening ceremony of the 2000 Sydney Summer Olympic games.
Methods We extracted public hospital admissions data from the NZ Ministry of Health statistics database for October and November from 1999 to 2011. The following categories were analysed: acute coronary syndromes (ACS) consisting of myocardial infarction and unstable angina (I21–I25), arrhythmias (I46–I48), heart failure (I50) and stroke (I60–I64). The exposure period was the date of the NZ team’s last match in each RWC and the 2 days after each match in 1999, 2003, 2007 and
2011. The control period was equivalent days of the week for 4 weeks in October or November in each of the 3 years prior to a RWC (i.e. 36 days in total). The exception was the 1999 RWC where data for comparison was November 2000, 2001 and 2003 as the current National database was not introduced until 1999. Admissions related to the 2011 semi-final NZ won against Australia and the opening ceremony of the 2000 Sydney Olympics were also analysed to compare admissions after major public events that might elicit different emotions. Same month comparisons were used to decrease the influence of confounding variables such as variations in temperature and air pollution. Relative ratios (RR) and 95% confidence limits were produced for admissions in exposure days and control periods for grouped gender data and male and female admissions. Day stay cases were excluded from the analyses and public holidays were excluded from the control dataset. The research complies with the Declaration of Helsinki, had institutional ethical approval and all data was anonymous.
Results Cases On average, there were 281 14 hospital admissions for all categories of ACS, arrhythmias, heart failure and stroke on the match days and the 2 days after each game (the exposure periods, see Table 1). The average number of hospital admissions in the corresponding control periods was 3313 379 (Table 1).
Hospital admissions Figure 1 illustrates the pooled ratios when NZ lost the 2003 semi-final against Australia compared to winning the semi-final against Australia in 2011, and the 2000 Olympics opening ceremony. Heart failure admissions increased by 33% and 60% (p ¼ 0.15 and 0.05) on the match day when NZ lost the 1999 and 2003 RWC semi-finals respectively, and 60% (p < 0.01) 2 days after the 2003 match (Table 2). In contrast, there was a 40% reduction in heart failure admissions (p ¼ 0.04) the day after the All Blacks won the 2011 RWC final (Table 2). No significant differences were observed for heart failure after the 2007 RWC loss or 2011 RWC semi-final win against Australia (Table 2). An increase of 20% was observed for pooled ACS data 1 day after the 2003 RWC loss (p < 0.05) but not after other All Black losses or wins. Arrhythmias admissions decreased by 40% (p ¼ 0.04) 1 day after the 1999 RWC loss. No differences were observed for stroke admissions in any RWC tournaments.
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European Journal of Preventive Cardiology 22(10) Table 1. Number of hospital admissions during exposure and control periods.a 2011 (W) Final Exposure period Total ACS Arrhythmias Heart failure Stroke Control period Total ACS Arrhythmias Heart failure Stroke
2011 (W) Semi-final
2007 (L) QF
2003 (L) Semi-final
1999 (L) Semi-final
281 102 62 53 64
282 91 67 57 67
303 103 69 64 67
276 108 53 66 49
264 83 58 63 60
3600 1244 724 816 816
3600 1244 724 816 816
3449 1316 670 735 728
2755 1043 533 529 650
3448 1208 701 731 808
a RWC exposure period: Game day and 2-days post game. Control period: Data for equivalent days in October or November for 3 years preceding 2011, 2007 and 2003 RWC or following 1999 RWC. ACS: acute coronary syndromes; QF: quarter-final.
**
1.5
2011 semi-final (won) 2003 semi-final (lost)
Relative ratios
*
2000 olympics
1.0
0.5
0.0 ACS
Arrhythmias Heart failure
Stroke
Hospital admissions
Figure 1. Pooled ratios for hospital admissions for 2000 Olympics opening ceremony and RWC 2003 and 2011 semi-finals relative to control data. Significantly different (*p < 0.05; **p < 0.01).
The ratios for hospital admissions were lower in the exposure period for the Sydney Olympics opening ceremony compared to control data (Table 2). This trend was significant for stroke admissions 2 days after the event (50% decrease, p ¼ 0.04).
1 day after the 2003 RWC loss (Figure 2). There were no significant differences for other matches or tournaments for the female or male admissions RWC data.
Labour Day holiday Male and female hospital admissions Figure 2 shows ratios for hospital admissions in men and women for the RWC 2003 semi-final loss on match day, 1 day and 2 days post-match. Heart failure admissions increased two-fold on match day and 2 days postmatch after the 2003 RWC loss in women but not men (p < 0.01, see Figure 2). In contrast, arrhythmias increased by 157% in men (p < 0.01) but not women
In response to the observed 40% reduction (p ¼ 0.04) in heart failure admissions the day (Labour day – a public holiday) after the All Blacks won the 2011 RWC final (Table 2), we performed an additional analysis of cardiovascular events on Labour Day Mondays compared to non-Labour Day Mondays in October (2008–2010). Acute cardiovascular hospital admissions were significantly lower (0.59 to 0.73, p < 0.05) on Labour Day
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Table 2. Ratios and confidence intervals for hospital admissions for NZ RWC matches and the Olympic opening ceremony for the day of the event and the two days after the event.a 2011 (W) Final
2011 (W) Semi-final
2007 (L) QF
2003 (L) Semi-final
1999 (L) Semi-final
2000 Olympics
ACS
Event þ1-day þ2-day Pooled
1.1 0.8 1.1 1.0
(0.7–1.6) (0.6–1.2) (0.8–1.4) (0.8–1.2)
0.8 0.9 0.8 0.9
(0.5–1.2) (0.6–1.3) (0.6–1.2) (0.7–1.1)
0.8 1.1 0.8 0.9
(0.5–1.2) (0.8–1.4) (0.6–1.2) (0.8–1.1)
1.3 1.4 1.1 1.2b
(0.8–1.9) (1.0–2.0) (0.8–1.5) (1.0–1.5)
0.8 0.8 0.8 0.8
(0.6–1.2) (0.5–1.2) (0.5–1.2) (0.7–1.0)
0.9 0.7 1.1 0.9
(0.6–1.3) (0.4–1.1) (0.7–1.6) (0.7–1.1)
Arrhythmias
Event þ1-day þ2-day Pooled
0.7 1.1 1.2 1.0
(0.3–1.3) (0.7–1.7) (0.8–1.7) (0.8–1.3)
1.2 1.1 1.0 1.1
(0.7–2.0) (0.7–1.7) (0.6–1.5) (0.9–1.4)
1.4 0.9 1.3 1.2
(0.8–2.3) (0.6–1.4) (0.9–2.0) (1.0–1.6)
1.1 1.5 1.1 1.2
(0.6–1.9) (0.8–2.4) (0.7–1.7) (0.9–1.6)
1.1 0.6b 1.2 1.0
(0.7–1.8) (0.3–1.0) (0.8–1.9) (0.8–1.3)
0.9 0.8 0.9 0.9
(0.5–1.5) (0.4–1.5) (0.4–1.6) (0.6–1.2)
Heart failure
Event þ1-day þ2-day Pooled
0.9 0.6b 0.9 0.8
(0.5–1.6) (0.3–1.0) (0.6–1.4) (0.6–1.0)
0.8 0.9 0.7 0.8
(0.4–1.4) (0.6–1.3) (0.5–1.2) (0.6–1.1)
0.8 1.0 1.1 1.1
(0.4–1.5) (0.6–1.5) (0.7–1.7) (0.8–1.4)
1.6b 1.2 1.6c 1.5c
(0.9–2.6) (0.6–2.0) (1.1–2.4) (1.1–1.9)
1.3 0.8 0.9 1.0
(0.9–2.0) (0.5–1.2) (0.5–1.4) (0.8–1.3)
0.8 1.0 1.0 0.9
(0.5–1.3) (0.5–1.7) (0.5–1.8) (0.7–1.2)
Stroke
Event þ1-day þ2-day Pooled
1.0 0.8 1.1 0.9
(0.6–1.6) (0.5–1.2) (0.7–1.6) (0.7–1.2)
1.0 1.0 0.9 1.0
(0.6–1.6) (0.6–1.5) (0.6–1.4) (0.8–1.3)
1.4 1.3 0.7 1.1
(0.8–2.2) (0.9–1.9) (0.4–1.1) (0.9–1.4)
0.9 1.1 0.8 0.9
(0.5–1.5) (0.6–1.8) (0.5–1.3) (0.7–1.2)
0.7 1.1 0.8 0.9
(0.4–1.2) (0.7–1.6) (0.5–1.3) (0.8–1.0)
1.0 0.7 0.5b 0.8
(0.6–1.5) (0.3–1.3) (0.2–1.0) (0.5–1.0)
a RWC exposure period: Game day and 2 days post game. Control period: Data for equivalent days in October or November for 3 years preceding 2011, 2007 and 2003 RWC or following 1999 RWC. Olympics exposure period: Day of Ceremony (15th September 2000) and 2 days post event. Control period - data for equivalent days in September for 3 years following the Sydney Olympics Opening Ceremony. b p 0.05; cp 0.01. W: won; L: lost; ACS: acute coronary syndromes; QF: Quarter-final. Pooled data is the grouped data for the event and the 2 days post event.
3.0
Relative ratios
2.0
Arrhythmias male
**
2.5
Arrhythmias female
**
**
**
Heart failure male Heart failure female
1.5 1.0 0.5 0.0
Match day
+ 1-day
+ 2-days
Pooled
Figure 2. Ratios for hospital admissions for RWC 2003 semi-final loss, 1-day and 2-day post match relative to control data. Significantly different (**p < 0.01).
Mondays compared to control Mondays except in stroke admissions (0.89, p > 0.05).
Discussion Losing RWC matches This is the first study to find a relationship between national hospital admissions for heart failure and a
major sporting event. New Zealand lost the 2003 RWC semi-final, which coincided with an increase of 60% in heart failure admissions on match day and a persistent increase 1–2 days after the match in 2003. A 20% increase was also observed for pooled ACS data after the 2003 RWC semi-final loss. Culic2 indicated acute emotional stress as a possible cause for increased cardiovascular events and mortality rates in major sporting events. Proposed mechanisms for emotional
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triggers facilitating cardiovascular events include acute physiological changes such as increased heart rate and blood pressure, which could transiently increase the risk of plaque rupture and thrombosis and decrease the threshold for ventricular fibrillation.18 In a separate study by the authors, NZ fans had higher heart rates, increased systolic blood pressure, and elevated anxiety and excitement measures during the semi-final and final of the 2011 RWC compared to control games when the All Blacks were not playing.19 It is likely similar physiological and psychological responses were present in NZ spectators when the All Blacks lost in 2003 and were coupled with acute emotions such as anger. European Guidelines on cardiovascular disease prevention indicate anger and hostility are associated with an increased risk of cardiovascular events in both healthy and cardiovascular disease populations.20 A study by Wilbert-Lampen et al.21 also found stress induced ACS was associated with large increases of inflammatory and vasoconstrictive mediators in patients admitted during the 2006 Soccer World Cup. These physiological mechanisms may have contributed to the increase in heart failure and ACS admissions in the NZ population after the 2003 RWC loss, especially in previous myocardial infarction patients and high risk individuals.2,7 In contrast, arrhythmia admissions significantly decreased by 45% the day after the 1999 semi-final loss to France. The reason for the decrease in arrhythmia admissions is unknown and unusual given heart failure increased by 30% on the day the All Blacks lost in 1999. The decrease could be due to the time and day of the game as it was the only match played early Monday morning (3.00 am NZ time). The 2007 quarter-final loss to France produced no significant differences. As in 1999, the time of the game (9.00 am NZ time) may have had an effect although television audience figures were higher for the 2007 quarterfinal than the 2003 semi-final loss (10.00 pm NZ time). It is unlikely to be the nature of the games as media reports indicated NZ was the favourite to win and both matches against France were remarkable games.22,23 Perhaps the ‘build-up’ to the evening game contributed to increased admissions in 2003. Alternatively, the NZ public might find losing to France less emotionally stressful than losing to their Australian neighbours. It is also pertinent to note a considerable number of statistical tests were performed in this study therefore the possibility of type I errors leading to significant differences cannot be dismissed. However, such an error seems unlikely with regards to heart failure in the 2003 RWC, as the observed trend was consistent across days and specific to female admissions.
Gender and RWC losses Hospital admissions increased two-fold on match day and 2-days post-match for heart failure in women, and
160% for arrhythmias in men the day after the 2003 RWC semi-final loss. Women are more likely to have heart failure due to diastolic impairment or abnormal filling secondary to hypertensive heart disease and ventricular hypertrophy.24 The stress of watching a sporting event may have increased blood pressure or impaired filling and led to increased heart failure in women. Another possibility is Takotsubo syndrome, which occurs predominately in older women and is often preceded by emotional or physical stress.25 Wilbert-Lampen et al.7 suggested that in addition to emotional stress, lack of sleep, overeating, heavy alcohol ingestion, smoking, and failure to comply with medical regimes were possible triggers for increase cardiac events during the 2006 Soccer World Cup in Germany. However, it is unlikely overindulgence in food and alcohol or non-compliance with medical routines was the primary cause of increased cardiovascular events during RWC tournaments as there was not a consistent trend in admissions. For example, the 2003 semi-final loss against Australia increased admissions whereas the 2011 semi-final win against Australia produced minimal change in cardiovascular events. The 2011 RWC was the largest sporting event held in NZ and the semi-final against Australia was the second most watched event in NZ television history and it is likely a large portion of the population over-indulged compared to normal dietary habits. Air pollution is another potential confounding variable in cardiac admissions research.15 However, most high concentrations of PM10 in NZ occur in winter26 not October or November when RWC tournaments were held, and NZ is in the lowest 5% for PM10 world averages.27 Therefore the increase in admissions in 2003 compared to 2011 is likely to be the result of acute emotional triggers produced in NZ fans after the All Blacks lost against Australia in 2003 compared to winning in 2011, rather than variables such as overindulgence, pollution and changes in medical regimes.
Winning RWC matches The RWC 2011 final was the most watched event in NZ television history and attracted a 98% audience share.28 Winning the RWC 2011 final was associated with a 42% decrease in heart failure admissions the day after the game and there was no significant increase in any acute cardiac hospital admissions. Previous research found winning or neutral matches decreased cardiovascular incidents or all-cause mortality, which was attributed to the euphoria of victory and or less overall physical activity in the general population.8,13 A unique aspect of this study was the analysis of hospital admissions during the 2000 Sydney Olympics opening ceremony to determine the effect of a large television
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event that would not be expected to produce acute emotional triggers. Overall, admissions were lower in the opening ceremony exposure period with a significant reduction in stroke admissions 2-days after the event. The lower admissions could be related to less physical activity in the NZ population during the event. A metaanalysis by Culic29 found physical activity was the most frequent external trigger of myocardial infarction in the general population. Consequently, the decreased admissions in studies by Berthier and Boulay,13 along with Kloner et al.8 and our research are probably related to less overall physical activity in the general population rather than the euphoria of victory.
Preventive medical or behavioural measures should be considered in sport fans with existing cardiovascular disease or those at high risk prior to a major sporting event. Future research could attempt to identify the specific emotional triggers for cardiovascular events in major sporting events. Acknowledgements We thank Chris Lewis from Analytical Services, Ministry of Health for providing National cardiac hospital admissions data from 1999 to 2011.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
The effect of a national holiday A potential confounding factor for the RWC 2011 final data is the Monday following winning the Final was an annual national holiday (Labour Day). Research by Kloner et al.30 and Phillips et al.31 found cardiovascular events increased during holidays in the United States. We performed an additional analysis of cardiovascular events on Labour Day Mondays compared to nonLabour Day Mondays in October (2008–2010) and found acute cardiovascular hospital admissions were significantly lower on Labour days compared to control days except in stroke admissions. Consequently, the observation of decreased hospital admissions is probably due to a holiday effect and decreased physical activity levels in the general population rather than emotions associated with winning the 2011 RWC. Future research could determine if the decrease is specific to Labour Day or if there are differences between the Northern and Southern hemispheres in hospital admissions during holiday periods.
Conclusions The 2003 RWC semi-final loss by the All Blacks was associated with increased hospital admissions for cardiovascular causes in the NZ population relative to control years. Increases in heart failure were specific to females while admissions for arrhythmias increased in males. Such trends were less evident during other RWC tournaments. Emotional triggers and changes in physiological parameters such as heart rate were probably responsible for the increase in admissions rather than non-compliance with medical routines or excessive food and alcohol intake, as there was not a consistent trend in admissions between RWC tournaments (i.e. winning or losing mattered). The lower ratios for the Sydney Olympics Opening Ceremony also imply the effect of emotionally charged major sporting events may be larger than reported as large audience non-emotive events may lower admissions.
Conflict of interest None declared.
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