Heart attacks at Christmas: why the risk rises and how to protect your heart

Christmas is meant to be restful, but for the heart it often is not. A large Swedish registry study found that heart attacks are more common over Christmas than at almost any other time of year, with a peak on the evening of Christmas Eve. The likely reasons are ordinary ones: salty food, more alcohol, stress, cold weather and a habit of ignoring symptoms until the holidays are over. Most of them are within your control.

What the Swedish Christmas study found

Researchers used SWEDEHEART, the Swedish national registry of coronary care, to look at 283,014 heart attacks between 1998 and 2013. The study, published in the Christmas issue of The BMJ in 2018, compared holidays with the two weeks before and after them.

• Christmas Eve: a 37% higher risk than in the control period, the highest of any day studied, with a peak at around 10 pm.
• The Christmas holiday as a whole: a 15% higher risk.
• New Year's Day: a higher risk, while New Year's Eve showed no increase.
• Easter and major sporting events: no increase.

The people most affected were those over 75 and people who already had diabetes or heart disease. The study was observational, so it cannot prove what caused the rise. The authors pointed to strong emotions and stress around the main celebration day, and suggested that on New Year's Day alcohol may lead people to overlook or mask their symptoms.

Salt, rich food and blood pressure

A Swedish julbord, like a British Christmas dinner, leans heavily on cured and salted food: ham, pickled herring, sausages, gravlax, cheese and gravy. Salt raises blood pressure in many people, and the World Health Organization recommends that adults eat less than 5 grams a day, roughly a level teaspoon. A few days of buffets and leftovers can push intake well past that.

A very large meal also makes the heart work harder while the body digests it. For most healthy people this is harmless, but for someone with narrowed coronary arteries it adds strain at a time when they may also be tired, stressed or have been drinking.

Practical ways to keep the balance without skipping the food you look forward to:

• Start with vegetables, red cabbage, salads and potatoes, then add the cured meats and fish.
• Take smaller portions of the saltiest dishes rather than cutting them out completely.
• Keep a glass of water next to your plate and refill it.
• Go for a walk after the main meal instead of moving straight to the sofa.

If you have been told your blood pressure is high, keep taking your medicines as usual over the holidays. Our article on high blood pressure as a silent risk factor explains why it matters even when you feel perfectly well.

Alcohol and holiday heart syndrome

Doctors have a name for a heart rhythm problem that appears after heavy drinking: holiday heart syndrome. The term was introduced by Philip Ettinger and colleagues in 1978 to describe rhythm disturbances in people with no known heart disease after episodes of binge drinking. The most common disturbance is atrial fibrillation, in which the upper chambers of the heart beat fast and irregularly. People often notice a racing or fluttering heartbeat, breathlessness or dizziness.

In people without other heart disease, the rhythm usually returns to normal once they stop drinking. It tends to come back with the next binge, though, and atrial fibrillation is not harmless: it raises the risk of stroke and should always be assessed by a doctor. Our guide to atrial fibrillation symptoms and when to seek care describes what it feels like and how it is treated.

In the UK, the NHS advises adults not to drink more than 14 units a week on a regular basis, spread over three or more days. Over the holidays, it helps to eat before you drink, to alternate glögg, wine or beer with water or alcohol-free versions, and to decide in advance how much you will have.

Stress, travel and broken routines

Hosting, travelling, family tension, money worries and missing people who are no longer there can all make December heavy. Stress raises heart rate and blood pressure in the short term, and it also changes habits: less sleep, less exercise, more alcohol and comfort food. We look at this in more detail in the role of stress management in heart health.

Broken routines also make it easy to miss doses of medicine. If you take medicines for your heart or blood pressure:

1. Check before the holidays that you have enough to last until well after New Year, and renew prescriptions in good time.
2. Pack medicines in your hand luggage when you travel, with a list of what you take.
3. Check the holiday opening hours of your nearest pharmacy, as many open for fewer hours over Christmas and New Year.
4. Ask a pharmacist before taking cold and flu remedies, as some are not suitable with heart conditions or with other medicines.

Cold weather and clearing snow

According to the British Heart Foundation, cold makes the small blood vessels in the skin, fingers and toes narrow to save heat. That raises blood pressure and makes the heart work harder, and blood can become stickier and more likely to clot. Research summarised by the foundation found that heart attacks and strokes in people over 60 were more than twice as likely during cold spells lasting at least four days, and that a sudden drop in temperature seemed to matter more than the cold itself.

Shovelling snow combines cold air with heavy work for the arms, which can briefly push up blood pressure. The American Heart Association advises:

• Push the snow rather than lifting it, and lift small loads with a small shovel when you must.
• Take frequent breaks and stop if you feel unwell.
• Avoid heavy meals and alcohol just before or straight after shovelling.
• Dress in layers with a hat and gloves, and cover your mouth and nose in very cold air.

If you have heart disease or several risk factors, let someone else clear the snow. Indoors, UK health advice is to keep the rooms you use heated to at least 18°C.

Warning signs you should not wait out

Part of the Christmas peak may come from people delaying help because they do not want to spoil the celebration. Call 112 (the emergency number in Sweden, across the EU and in the UK, where 999 also works) straight away if you or someone with you has:

• chest discomfort, pressure, squeezing or pain that lasts more than a few minutes, or goes away and comes back
• discomfort in one or both arms, the back, neck, jaw or stomach
• shortness of breath, with or without chest pain
• a cold sweat, nausea or light-headedness

Women are somewhat more likely than men to have breathlessness, nausea and back or jaw pain rather than classic chest pain. Do not drive yourself to hospital. For a new irregular or racing heartbeat without these warning signs, contact healthcare the same day: 1177 in Sweden or NHS 111 in the UK.

Before the holidays start

Take ten minutes this week to check your medicine supplies, note the holiday opening hours of your pharmacy and agree who will clear the snow if it falls. Then enjoy the food: a smaller plate, a walk after dinner and water between drinks do more for your heart than skipping Christmas altogether.

This article is general information and does not replace advice from a doctor. If you have a heart condition or questions about your own risk over the holidays, talk to your doctor or pharmacist. In an emergency, call 112.