It's well known that some activities can act as the final straw for someone prone to a heart attack. For instance, heavy physical work (like shoveling snow), unusual emotional stress, and binging (alcohol, food or tobacco) have all been shown to provoke heart attacks. Sometimes events beyond our control can do this, too - earthquakes, war and revolution, for instance. Up to now, you've probably thought that sitting in front of a TV set was a pretty harmless occupation. It depends, however, what you are watching.

In June 1996 the national Dutch football (soccer) team was matched against France in the quarterfinals of the European football championship held in England. The game was obviously an exciting one; it was drawn at full-time, and went into extra time. The result was finally decided by alternating penalty kicks (France won). Over 60% of the Dutch population watched the game on TV. Scientists at Utrecht University in the Netherlands have now analyzed the numbers and causes of deaths that occurred on the day of the game, and compared them with those on the five days before and the five days after the game. They also looked at the numbers of deaths for similar dates in the previous and the next years (1995 and 12997). Results for men and women were analyzed separately.

The numbers of deaths in people aged 45 and over - totals, and those for heart attacks (myocardial infarction, or MI) or strokes - are given in the table below for June 22 (the day of the game) and as an average daily rate for the 5 days on each side of this day:

	Number of deaths on game day	Average number of daily deaths on the 5 days on either side
All causes, men	173	150.1
All causes, women	146	164.1
MI or stroke, men	41	27.2
MI or stroke, women	38	34.1

It can be seen that there was roughly 1½ times as many deaths from heart attacks or strokes on game day, compared with the other days. There was no increased risk in women, and there were no changes in the death rates in 1995 and 1997 for the same dates.

For men, watching the football game on TV may have been responsible for an increase of about 14 deaths in the Netherlands on the day of the match. However, before we conclude that the game was directly responsible, we must remember that watching a major sports event is often accompanied by other 'risky' activities such as excessive drinking, eating and smoking. It was interesting to see that the actual numbers of heart attack or stroke deaths in men the day after the game were below the average (132). Perhaps an effect of watching the game was to accelerate death in people who were destined to die the following day anyway.

This study raises more questions than it answers. For instance, why didn't women show the same increased risk? Probably fewer women actually watched the game or were as interested in the result as men. Or, perhaps, they ate and drank less. Still, it's tempting to think that women are less likely to respond to emotional stress than men by having a heart attack.

What are the mechanisms of the effect? Is it really emotional stress, or another, associated risky behavior (e.g. binging). If it's emotional stress, what would have happened if the Netherlands had finally won the game - would the stress have been sufficiently different to produce a different result?

How does stress (or the associated effect of watching a game like this) actually cause a heart attack or stroke? Could it be that a vulnerable artery develops a thrombosis (blood clot) as a result of over-stimulation of the sympathetic nervous system (the 'fight-or-flight' system) or an increase in the clotting status of the blood?

Finally, what are the practical consequences? Until we know more, it isn't possible to pinpoint the actual physical changes associated with watching a sports event. However, it makes good sense to check excessive eating and drinking. Men who are known to be at risk for a heart attack or stroke should check with their physicians about whether to take some protective medication if they are really likely to get involved with game, however indirectly. And, always remember, it's only a game, not a war!

The findings in this study were confirmed in a similar study reported in the British Medical Journal. Hospital admissions for MIs (myocardial infarction) were increased by 25% on the day England was eliminated from the 1998 World Cup (soccer) by Argentina in a penalty shoot-out, as well as on the next two days. It would be interesting if someone did the same sort of study in the USA for a big closely-fought game e.g. US football's SuperBowl. (Carroll C, et al. Admissions for myocardial infarction and World Cup football: database survey. BMJ 2002; 325:1435-1449).