World Cup games more than doubled heart emergencies, and stress training helped in two trials

Key takeaways

• On days Germany played in the 2006 World Cup, cardiac emergencies among Munich-area residents ran at 2.66 times the usual rate, and more than three times for men¹.
• In the two hours after an angry outburst, heart attack risk rose nearly fivefold, yet one outburst a month adds only about 1 extra heart attack a year per 10,000 low-risk people⁴.
• In a Duke University trial, 18% of heart patients who added stress management training to cardiac rehab had another clinical event over about three years, versus 33% with rehab alone¹⁴.
• Stress hormones can push blood sugar up or down in people with diabetes, and the American Diabetes Association’s 2026 Standards include guidance on screening for diabetes distress and anxiety¹¹¹².
• Call 911 for chest pain or other heart attack signs, and call or text 988 if stress comes with thoughts of harming yourself⁷¹³.

In 2006, Germany hosted soccer’s World Cup, and a research team used the tournament to answer a question about the heart.

Led by Wilbert-Lampen, the team counted cardiac emergencies among people living in the Munich area: heart attacks and related crises, rhythm problems that caused symptoms, cardiac arrests and shocks from implanted defibrillators¹. Then they compared the World Cup weeks with the same weeks in earlier years¹.

On days the German team played, emergencies ran at 2.66 times the usual rate¹. For men the rate was 3.26 times higher, and for women 1.82 times¹. People who already had heart disease saw about four times the usual rate, while others saw about twice¹. Matches without Germany brought no rise at all¹.

The study appeared in the New England Journal of Medicine in 2008. Reviewing it, cardiologist Harlan Krumholz noted how little is known about preventing heart events set off by emotion¹.

That’s the sobering part. The more hopeful part is that, in two trials, heart patients who learned to handle stress had fewer repeat heart events. This article separates sudden triggers from long-running stress, looks at what has been tested, and ends with a plan.

A sudden shock can tip a heart that’s already at risk

At 4:31 a.m. on January 17, 1994, the Northridge earthquake struck the Los Angeles area². Researchers later counted sudden deaths from heart disease in Los Angeles County.

In the week before, there had been an average of 4.6 a day. On the day of the quake there were 24². Sixteen of those people died or had warning symptoms, usually chest pain, within an hour of the first tremor². Only three deaths came during or right after unusual physical effort².

In the six days after the quake, sudden cardiac deaths fell below normal, to 2.7 a day².

A broader look at all county death certificates found the same pattern. Deaths from artery disease of the heart averaged 73 a day in early January, jumped to 125 on the quake day and averaged 57 a day for the rest of the month³. The 14 days after the quake had 144 fewer deaths than expected, more than offsetting the 55 extra deaths on the day itself³.

The researchers offered two explanations: the quake hastened deaths among the most vulnerable, leaving a hardier group behind, or it somehow toughened survivors’ hearts³. Either way, it fits the World Cup finding that people with known heart disease were hit hardest¹. A sudden shock is rarely the whole story. It is often the last push on arteries that were already in trouble.

Anger’s two-hour window, in absolute numbers

Fear is one trigger. Anger is another.

In 2014, a team led by Murray Mittleman pooled nine studies of people who had heart attacks, strokes or dangerous heart rhythms⁴. The studies compared each person’s anger in the hours before the event with other times in their own lives⁴.

In the two hours after an angry outburst, heart attack risk rose nearly fivefold and stroke risk more than tripled⁴. The risk of a dangerous rhythm in the heart’s lower chambers rose, too⁴.

That sounds alarming. The absolute numbers put it in proportion⁴:

Outbursts	Extra heart attacks per 10,000 lower-risk people a year	Extra heart attacks per 10,000 higher-risk people a year
One a month	About 1	About 4
Five a day	About 158	About 657

A single outburst carries a small risk. Frequent anger, in someone with existing heart disease or risk factors, adds up⁴. The studies showed a link, not proof that anger causes the events, and they differed in methods⁴.

A 2024 lab trial suggests one way anger could do harm. Researchers led by Daichi Shimbo assigned 280 healthy adults to spend eight minutes recalling an angry, anxious or sad memory, or doing a neutral task⁵.

Then they tested how well blood vessels widened, a sign of a healthy vessel lining. The anger group lagged: from before the task to 40 minutes after, its score changed by 0.20, versus 0.50 in the neutral group⁵. By our math, that’s less than half. Anxiety’s effect was borderline, and sadness had no significant effect⁵.

Broken heart syndrome: when stress stuns the heart muscle

Sometimes stress strikes the heart muscle itself. In broken heart syndrome, also called takotsubo syndrome, physical or emotional stress makes the heart’s main pumping chamber enlarge for a time and pump poorly⁶.

A 2021 study in the Journal of the American Heart Association counted 135,463 cases in U.S. hospital records from 2006 to 2017⁶. Cases climbed year after year, and 88.3% were women. Women ages 50 to 74 had by far the highest rates, six to 12 times or more those of men or younger women⁶.

People who survive the first phase often recover within days or weeks⁶. MedlinePlus, the National Library of Medicine’s health site, says most people recover fully¹⁰. Some studies suggest a higher risk of later heart problems, even after the heart seems to recover⁶.

Its chest pain and shortness of breath mimic a heart attack⁶, so don’t try to tell them apart at home. The CDC says to call 911 right away for heart attack symptoms⁷. Our mind-body connection article has more on this syndrome.

Long-running stress works through the brain, bone marrow and daily habits

Sudden triggers get headlines. Stress that drags on for months may matter as much.

Ahmed Tawakol of Massachusetts General Hospital and Harvard has traced one path using brain and body scans. When stress activates the amygdala, a brain area that reacts to threat, nerve signals rev up immune activity in the bone marrow⁸. That activity tracks with inflamed arteries and plaque, the raw material of heart attacks and strokes⁸.

Higher amygdala activity has shown up in people facing money worries, chronic noise, ongoing anxiety or depression⁸. In Tawakol’s studies, it predicted the risk and timing of heart events⁸. His earlier study scanned almost 300 people without known heart disease⁹.

A follow-up found that people in the lowest-income neighborhoods had about four times the five-year risk of a major heart event as those in the highest-income areas⁹. The brain-to-inflammation pathway could account for about 28% of poverty’s effect, though the method couldn’t prove cause⁹. These are small imaging studies, so the chain is still being tested.

Stress also works through ordinary routes. MedlinePlus notes that it raises blood pressure, can make the heart beat fast or irregularly, and can raise inflammation, cholesterol and triglycerides¹⁰. It can steer people toward smoking, heavy drinking and salty, sugary or fatty food¹⁰.

The most harmful kinds, it says, include chronic stress, feeling helpless, loneliness, anger and the shock of very bad news¹⁰. Our articles on chronic stress and on work stress cover allostatic load and job strain in depth.

Stress and blood sugar: why diabetes adds a layer

The CDC says stress hormones can make blood sugar rise or fall in ways that are hard to predict, and the stress of illness or injury can raise it¹¹. Anxiety can feel like low blood sugar, and the reverse is true too, so the CDC advises checking your sugar when you feel anxious and treating a low¹¹.

Mood and diabetes travel together. People with diabetes are two to three times as likely to have depression, yet only 25% to 50% of those with depression are diagnosed and treated¹¹. They are also 20% more likely to have anxiety¹¹.

There’s a third problem with its own name. Diabetes distress means feeling overwhelmed, discouraged or worn out by daily diabetes care. In any 18-month period, 33% to 50% of people with diabetes have it, the CDC says, and medicine alone doesn’t fix it¹¹.

The American Diabetes Association (ADA) addresses this in its guidance. Its Standards of Care in Diabetes 2026, released in December 2025, include guidance on screening for diabetes distress and anxiety and referring people for help¹².

Distress can lead people to drop healthy habits, stop checking their blood sugar or even skip doctor visits, the CDC notes¹¹. Tell your care team if that’s happening. If stress or low mood ever brings thoughts of harming yourself, call or text 988 to reach the 988 Suicide & Crisis Lifeline, which is open 24/7¹³.

If you use insulin or another medicine that can cause lows, any big change in your routine can shift your sugar patterns. Bring your readings to your care team rather than changing a dose on your own.

Stress training added to heart care cut repeat events in two trials

Can learning to manage stress protect a heart that has already been damaged? Two randomized trials, where patients were assigned by chance, tested that.

At Duke University, Blumenthal and colleagues enrolled 151 outpatients with coronary heart disease, ages 36 to 84¹⁴. All got 12 weeks of full cardiac rehabilitation, the supervised exercise and education program offered after heart events. Half also got stress management training¹⁴.

The stress training group’s anxiety, distress and perceived stress fell more¹⁴. Over a median of 3.2 years, 18% of that group had a further clinical event, versus 33% of the rehab-only group¹⁴. By our math, that’s about 15 fewer people per 100, or roughly one event prevented for every seven people trained.

A separate group of eligible patients who skipped rehab did worst, at 47%¹⁴. They weren’t assigned by chance, so that comparison is weaker. Both rehab groups improved about equally on standard heart risk markers¹⁴.

In Sweden, the SUPRIM trial followed 362 people within a year of a heart event¹⁵. Those assigned to the program met in small groups, separated by sex, for 20 two-hour sessions over a year¹⁵. Sessions covered education, self-monitoring, skills training, rethinking stressful thoughts and spiritual development, aiming at daily stress, time pressure and hostility¹⁵.

Over an average of 94 months, nonfatal heart and blood vessel events struck 35.9% of the program group and 45.3% of the usual-care group¹⁵. By our math, that’s about nine fewer people per 100. Nonfatal heart attacks were 21.4% versus 30%¹⁵.

Deaths, 23 versus 25, didn’t differ significantly¹⁵. People who attended more sessions did better¹⁵.

Both trials were modest in size, but they point the same way. Our articles on meditation traditions, the relaxation response and blood pressure habits cover how heart groups have graded meditation and other calming methods.

Depression and anxiety deserve treatment, too

Low mood after a heart attack isn’t harmless. Depression raises the risk of another heart attack, and stress can slow rehab, MedlinePlus says¹⁰. Depression is a medical illness, and therapy, medicine or both usually work very well, the CDC says¹¹.

If stress or depression makes daily life hard, tell your clinician¹⁰. If you ever think about harming yourself, call or text 988¹³. Our article on how stress reaches the heart covers why the American Heart Association urges doctors to ask heart patients about mood.

What the evidence shows

Claim	Rating	What it rests on
Sudden emotional stress can trigger heart attacks and cardiac deaths in people at risk	Strong evidence	A World Cup study, an earthquake study and a review of nine trigger studies14
Letting anger out in outbursts is good for the heart	Evidence says no, or unsafe	Heart attack risk rose nearly fivefold in the two hours after an outburst, though one outburst adds little absolute risk4
Brief anger impairs blood vessel function	Promising but early	One randomized lab study of 280 healthy adults5
Chronic stress raises heart risk through brain-driven inflammation	Promising but early	Imaging studies of a few hundred people89
Stress training added to cardiac rehab cuts repeat heart events	Promising but early	Two trials of 151 and 362 patients1415
Stress training lowers death rates after a heart event	Not enough evidence	No significant difference in deaths in SUPRIM15
Stress hormones can move blood sugar in diabetes	Strong evidence	CDC guidance11
Avoiding big stressful events prevents heart attacks	Not enough evidence	Untested; little is known about prevention1

The heart-stress plan

This plan is our own, built from the sources above. Pick the rows that fit your life.

Trigger or pattern	In the moment	Long-term habit	When to get help
A big game or tense event, and you have heart disease	Keep your usual routine and treatment; be with someone who knows the warning signs7	Make a plan with your clinician ahead of time	Heart attack signs: call 9117
An anger flare	Pause, sit quietly and focus on your breathing10	Practice 10 minutes of quiet breathing daily, or take a stress class10	If frequent anger is hurting your health or relationships, talk with a professional410
Shocking news or grief	Call a friend who will listen11	Make regular time for friends and the outdoors10	Chest pain or breathlessness: call 9117
The daily grind	Take a short, quiet break	Regular exercise, yoga or meditation, time in nature10	Stress or low mood makes daily life hard: see your clinician10
Diabetes stress	If you feel anxious, check your blood sugar and treat a low11	Work with a diabetes educator on one or two small goals; ask about distress screening1112	Skipping sugar checks or visits: tell your team11; thoughts of self-harm: call or text 98813
After a heart attack or heart procedure	Rest and follow your discharge plan	Ask whether your cardiac rehab includes stress management1415	Low mood that won’t lift: tell your clinician10

Mind and heart were never separate

Many natural-health traditions have long taught that grief, rage and worry live in the body. Cardiology now has numbers for that idea, from soccer stadiums to earthquake zones.

The tools that helped in trials were human ones: small groups, skills practice and, in the Swedish trial, spiritual development¹⁵. Most steps in the plan above cost nothing.

They worked as additions, not replacements. In the Duke trial, both randomized groups got full cardiac rehab, and stress training was added on top¹⁴. Keep taking the treatments your clinician prescribed, and talk with them before changing any medicine.

Questions readers ask

The bottom line

Sudden fear, anger and shock can trigger heart attacks within hours, mostly in people whose arteries are already diseased. Long-running stress works more slowly, through the brain, inflammation, blood pressure, blood sugar and daily habits.

The encouraging news is that stress skills, learned in groups and added to standard heart care, cut repeat heart events in two trials. Know the warning signs, build a daily calming habit, ask for stress support in cardiac rehab, and reach for help early when mood sinks.

Related reading

• Stress reaches your heart, skin and pain nerves, and that doesn’t make symptoms imaginary
• Chronic stress adds up in the body, and two famous studies need a second look
• Venting on a punching bag fed anger in a lab, and calmer skills work better
• Work stress has two classic recipes, and both show up in heart studies
• Blood pressure should fall while you sleep, and high nighttime readings are a warning

Sources

1. Krumholz HM. Journal Watch summary of Wilbert-Lampen U, et al., “Cardiovascular Events During World Cup Soccer,” New England Journal of Medicine, 2008;358:475–483. NEJM Journal Watch, January 30, 2008. clinician.nejm.org
2. Leor J, Poole WK, Kloner RA. “Sudden Cardiac Death Triggered by an Earthquake.” New England Journal of Medicine, 1996;334:413–419 (abstract reproduced in JCI reference list).
3. Kloner RA, Leor J, Poole WK, Perritt R. “Population-based analysis of the effect of the Northridge earthquake on cardiac death in Los Angeles County, California.” Journal of the American College of Cardiology, 1997;30(5):1174–1180 (abstract). pubmed.ncbi.nlm.nih.gov
4. European Society of Cardiology. News release on Mostofsky E, Penner EA, Mittleman MA, “Outbursts of anger as a trigger of acute cardiovascular events: a systematic review and meta-analysis,” European Heart Journal, 2014. ScienceDaily, March 3, 2014. sciencedaily.com
5. Shimbo D, Cohen MT, McGoldrick M, et al. “Translational Research of the Acute Effects of Negative Emotions on Vascular Endothelial Health: Findings From a Randomized Controlled Study.” Journal of the American Heart Association, 2024;13(9) (DOAJ record). pubmed.ncbi.nlm.nih.gov
6. American Heart Association News. “Broken heart syndrome is on the rise, especially among older women.” October 13, 2021. heart.org
7. Centers for Disease Control and Prevention. “Heart Attack Symptoms, Risk, and Recovery.” October 24, 2024. cdc.gov
8. NIH Intramural Research Program. “This Is Your Heart on Stress” (on Ahmed Tawakol’s Stephen E. Straus lecture). The NIH Catalyst, 2024;32(1). irp.nih.gov
9. National Institutes of Health. “Stress links poverty to inflammation and heart disease” (on Tawakol A, Osborne MT, et al., Journal of the American College of Cardiology, 2019). NIH Research Matters, July 9, 2019. nih.gov
10. MedlinePlus. “Stress and your heart.” National Library of Medicine, reviewed February 9, 2026. medlineplus.gov
11. Centers for Disease Control and Prevention. “Diabetes and Mental Health.” May 15, 2024. cdc.gov
12. American Diabetes Association. “American Diabetes Association Releases Standards of Care in Diabetes—2026.” News release, December 8, 2025. diabetes.org
13. Substance Abuse and Mental Health Services Administration. “In Crisis” (988 Suicide & Crisis Lifeline). SAMHSA, updated June 3, 2026. samhsa.gov
14. Blumenthal JA, Sherwood A, Smith PJ, et al. “Enhancing Cardiac Rehabilitation With Stress Management Training: A Randomized, Clinical Efficacy Trial.” Circulation, 2016;133(14):1341–1350 (Duke Scholars record). scholars.duke.edu
15. JAMA and Archives Journals. News release on Gulliksson M, et al., “Randomized Controlled Trial of Cognitive Behavioral Therapy vs Standard Treatment to Prevent Recurrent Cardiovascular Events in Patients With Coronary Heart Disease (SUPRIM),” Archives of Internal Medicine, 2011;171(2):134. ScienceDaily, January 24, 2011. sciencedaily.com