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From Epidemiology and Preventive Medicine (Drs. Koton, Tanne, and Green), Sackler Faculty of Medicine (Dr. Bornstein), Tel-Aviv University; Israel Center for Disease Control (Drs. Koton and Green); Stroke Unit (Dr. Tanne), Neurology Department, Chaim Sheba Medical Center; and Neurology Department and Stroke Unit (Dr. Bornstein), Tel Aviv Sourasky Medical Center, Israel.
Address correspondence and reprint requests to Dr. Silvia Koton, The Israel Center for Disease Control, Gertner Institute, Tel Hashomer, 52621 Israel; e-mail: silvia.k{at}icdc.health.gov.il
Background: While vascular risk factors for stroke are well established, little is known about factors that may precipitate the acute event. In this study the authors investigated the association between exposure to seven potential triggers during waking hours and acute onset of ischemic stroke.
Methods: In a case-crossover study, 200 consecutive stroke patients were interviewed 1 to 4 days after the event using a validated questionnaire. Reported exposure to potential triggers including negative and positive emotions, anger, sudden posture changes as response to a startling event, heavy physical exertion, heavy eating, and sudden temperature changes during a 2-hour hazard period prior to stroke onset were compared to the same period during the preceding day and to average exposures in the last year.
Results: Seventy-six patients (38%) reported exposure to at least one of the study triggers during the 2-hour hazard period. For all factors combined, the OR was 8.4 (95% CI 4.5 to 18.1). The OR for negative emotions was 14.0 (95% CI 4.4 to 89.7), for anger 14.0 (95% CI 2.8 to 253.6), and for sudden changes in body posture in response to a startling event 24.0 (95% CI 5.1 to 428.9). It is important to interpret the reported ORs as estimates of a short-term 2-hour period relative risk and not as cumulative risks.
Conclusions: Negative emotions, anger, and sudden changes in body posture in response to a startling event appear to be independent triggers for ischemic stroke.
Received June 3, 2004. Accepted in final form August 16, 2004.
This work was performed in partial fulfillment of the requirements for a PhD degree of Silvia Koton, Sackler Faculty of Medicine, Tel Aviv University, Israel.
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