Psychosomatics 45:477-482, December 2004
© 2004 The Academy of Psychosomatic Medicine
The 1999 Ji-Ji (Taiwan) Earthquake as a Trigger for Acute Myocardial Infarction
Ching-Hong Tsai, M.D., M.Sc.,
For-Wey Lung, M.D., Sc.D., and
Shing-Yaw Wang, M.D., M.P.H.
Received June 23, 2003; revision received Jan. 13, 2004; accepted Jan. 30, 2004. From the Department of Psychiatry, Military Kaohsiung General Hospital, and the Department of Psychiatry, Kaohsiung Medical University. Address reprint requests to Dr. Wang, Department of Psychiatry, Kaohsiung Medical University, Shin-Chuan 1st Rd., Kaohsiung, Taiwan; sywang{at}kmu.edu.tw (e-mail).
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ABSTRACT
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The authors evaluated the effect of stress due to the Ji-Ji, Taiwan, earthquake, which occurred at 1:47 a.m. on September 21, 1999, on the onset of acute myocardial infarction in six counties near the earthquake epicenter. The rate of hospitalization due to acute myocardial infarction increased during the 6 weeks after the earthquake, and a significantly higher number of patients were hospitalized with acute myocardial infarction during that period, compared with the same 6-week period in the previous year (99 and 65 patients, respectively). The findings suggest that extreme emotional stress due to the natural disaster, superimposed on the stress of awakening, increased the incidence of acute myocardial infarction in this population.
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INTRODUCTION
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The 1999 earthquake centered near Ji-Ji, Taiwan, which occurred at 1:47 a.m. on September 21 and measured 7.3 on the Richter scale, was Taiwan's most serious natural disaster in the past 100 years and caused the victims and rescuers great mental and physical stress. Most people were awakened from sleep by the earthquake, there was a sudden increase of activity, and more than 12,000 aftershocks occurred. The earthquake was linked to more than 11,000 deaths and injuries (2,321 deaths), and hundreds of thousands of people were left homeless.
Acute myocardial infarction has circadian variation,1 and higher rates of onset after awakening and in the morning hours up to noon have been noted.2,3 Acute myocardial infarction is probably caused primarily by physiological factors such as unstable blood pressure, heartbeat, speed of blood flow, platelet coagulation, and endocrine function, but other factors, such as stimulation associated with waking up, getting angry, or performing intense physical activity, may trigger acute myocardial infarction.4–8
Natural disasters, such as great earthquakes, not only cause damage to the topography and surface features of the region but also have psychological and physical effects on the residents.9,10 Fear and stress due to changes in the environment are likely to enhance deterioration of the cardiovascular system in persons who are at risk and may trigger acute myocardial infarction. For example, an increase in the number of acute myocardial infarction patients and psychogenic sudden deaths was associated with the Iraqi missile attacks in Israel during the Persian Gulf War of 1991.11
The relationship between earthquakes and acute myocardial infarction has been examined in a few previous studies.
- On Nov. 27, 1980, an earthquake in southern Italy measuring 6.6 on the Richter scale caused 4,441 deaths and 50,000 injuries. Follow-up research found that after the earthquake there was a significant increase in risk factors for coronary heart disease, such as higher heart rates and higher levels of serum cholesterol and triglycerides.12 It was concluded that earthquakes were a risk factor for coronary heart disease.
- At 10:53 p.m. on February 24, 1981, an earthquake measuring 6.7 on the Richter scale, occurred in Athens, Greece. A few days later, a 2.5-fold increase in cardiac deaths, compared with the number of deaths from other diseases, was noted.13
- At 10:27 a.m. on December 28, 1989, an earthquake measuring 5.6 on the Richter scale occurred in the Newcastle area of New South Wales, Australia. Although 12 people died, no increase in acute myocardial infarction onset due to psychological and physical stress was noted in association with the earthquake.14
- At 5:04 p.m. on October 17, 1989, an earthquake measuring 7.0 on the Richter scale occurred in San Francisco, California. In the 20-second earthquake, 63 people died. There was no significant increase in the number of acute myocardial infarction patients on the day of the earthquake, compared with the week before or 6 days after the earthquake or compared with the same day in 1990.15
- The earthquake that struck the Northridge area near Los Angeles, California, at 4:31 a.m. on January 17, 1994, measured 6.7 on the Richter scale and was one of the strongest earthquakes ever recorded in a major North American city. Fifty-seven people died. Leor et al.16 found that on the day of the earthquake, there was a sharp increase in the number of sudden deaths from cardiac causes related to atherosclerotic cardiovascular disease, from a daily average of 4.6 (SD=2.1) in the preceding week to 24 on the day of the earthquake (z=4.41, p<0.001). Brown15 found a >80% increased risk of admission for acute myocardial infarction on the day of the earthquake, compared with the same date a year later (relative risk=1.828).
- At 5:46 a.m. on January 17, 1995, an earthquake measuring 7.2 on the Richter scale occurred in Kobe, Japan. Approximately 6,000 people died, and 25,000 were injured. Suzuki et al.17 found that during the 4 weeks after the earthquake, there was a 3.5-fold increase in acute myocardial infarction cases, compared with the same period in 1994. Ogawa et al.18 found that there was a significant increase in the number of deaths due to myocardial infarction during the 8 weeks after the earthquake, compared with the same period in the previous year. Kario et al.19,20 found a significant increase in the number of deaths due to myocardial infarction during the 12 weeks after the earthquake, compared with the same period in the previous year. Saito21 and Kario22 observed an increase in blood pressure in patients with hypertension during the first few weeks after the earthquake, compared to measurements before the earthquake.
The differences in these findings on the influence of earthquakes on cardiovascular diseases are probably due to the differences between studies in the size of the earthquakes, time of day when the earthquakes occurred, the length of the observation periods, the region in which the earthquakes occurred, the number of deaths and injuries, and the rate of recognition of cases.
Studies of the relationship between earthquakes and acute myocardial infarction have found a significant increase in the number of acute myocardial infarction cases after two earthquakes (one that occurred at 4:31 a.m. on January 17, 1994, in Los Angeles and one that occurred at 5:46 a.m. on January 17, 1995, in Kobe, Japan). However, after another two earthquakes (one at 10:27 a.m. on December 28, 1989, in Australia, and the other at 5:04 p.m. on October 17, 1989, in San Francisco), no such increase was found. These findings suggest that the sudden physical and psychological stress due to the earthquake together with the stress of getting up in haste may trigger acute myocardial infarction in at-risk subjects. The 1999 Ji-Ji earthquake in Taiwan, which measured 7.3 on the Richter scale, occurred at 1:47 a.m., when most people were sleeping. Based on previous findings, we expected that the double stresses of the earthquake and early morning awakening would trigger an increased incidence of acute myocardial infarction.
This study evaluated the effect on onset of acute myocardial infarction of the physical and psychological stress caused by the Ji-Ji earthquake. We investigated whether this environmental factor was a trigger factor for acute myocardial infarction and anticipated that the results could be used in planning postdisaster health care.
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METHOD
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We reviewed data for admissions due to acute myocardial infarction after the earthquake in six different counties near the epicenter. The data were mainly abstracted from the records of the Bureau of National Health Insurance, the only health insurance provider in Taiwan. The subjects were patients with the main diagnosis of acute myocardial infarction (ICD-9-CM code 410) who were admitted to a hospital with facilities for treatment of acute myocardial infarction in the counties/cities closest to the epicenter (Taichung city, Taichung county, Chiayi city and county, Changhua city and county, and Yunlin county). ICD-9-CM code 410 includes anterolateral, anterior, inferolateral, inferoposterior, inferior, lateral, posterior, and subendocardial infarctions, as well as unspecified varieties of infarctions. Eligible subjects were patients with acute myocardial infarction who were hospitalized during the 6 weeks after the 1999 Ji-Ji earthquake (September 21 to October 31). The number of acute myocardial infarction patients in the same 6-week period in 1998 was also checked, and characteristics of cases in the two periods were compared. In addition, the incidence of acute myocardial infarction was analyzed in terms of selected risk factors, such as age and the presence of diabetes or hypertension, to determine whether patients with acute myocardial infarction associated with the earthquake were more likely to have those risk factors.
The data were analyzed by using SPSS for Windows 10.0 (SPSS, Inc., Chicago). Pearson chi-square analysis with 2 x 2 contingency tables and odds ratios were used to compare the incidence of acute myocardial infarction between the two 6-week study periods and to determine the effects of risk factors such as comorbid disorders and age on differences in incidence
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RESULTS
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Incidence of Acute Myocardial Infarction in the Earthquake Region
Table 1 shows the number of hospital admissions for acute myocardial infarction in the counties/cities near the earthquake epicenter during the 6-week period after the earthquake (September 21, 1999, through October 31, 1999) and during the same period in the previous year.
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TABLE 1. Hospital Admissions With Acute Myocardial Infarction in Counties and Cities Close to the Epicenter of the 1999 Ji-Ji (Taiwan) Earthquake During Two 6-Week Periods Before and After the Earthquakea
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A significant difference in the risk of acute myocardial infarction was found for Taichung city, Taichung county, and Chiayi city/county. The Richter scale measurements for the earthquake were above 6 in all three of those areas. In contrast, the measurements were 6 or below in Changhua county and Yunlin county. Thus, the incidence of acute myocardial infarction was comparatively higher in regions with higher Richter scale measurements.
In the overall region near the earthquake epicenter, a total of 99 admissions for acute myocardial infarction occurred during the 6-week period after the earthquake, compared with 65 admissions during the same period of the previous year, a significant difference ( 2=6.81, df=1, p=0.009; odds ratio=1.51) (Table 1). For the 3-day period after the earthquake, a total of 11 acute myocardial infarction admissions occurred in the earthquake region, compared to three acute myocardial infarction admissions during the same 3-day period in 1998, also a significant difference (2=4.52, df=1, p=0.03; odds ratio=3.52).
Figure 1 shows the number of acute myocardial infarction admissions during each week of the 6-week period after the earthquake and during each week of the same 6-week period in the previous year. For each of the first three weeks after the earthquake, the number of admissions was significantly higher than during each of the same three weeks in the previous year (p<0.01, Pearson chi-square tests with odds ratios). The magnitude of the difference in incidence of acute myocardial infarction gradually subsided after week 3.
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FIGURE 1. Hospital Admissions With Acute Myocardial Infarction in Counties and Cities Close to the Epicenter of the 1999 Ji-Ji (Taiwan) Earthquake During Each Week of Two 6-Week Periods Before and After the Earthquakea
aThe Ji-Ji earthquake occurred on September 21, 1999. The 6-week study periods were from September 21–October 31, 1998 (before the earthquake), and September 21–October 31, 1999 (after the earthquake). The number of admissions with acute myocardial infarction was significantly greater during first 3 weeks after the earthquake (1999) than during the same 3 weeks in 1998 (p<0.01).
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Prevalence of Other Diagnoses in Patients With Acute Myocardial Infarction
Several risk factors, such as hypertension and diabetes, probably contribute to the incidence of acute myocardial infarction. We evaluated whether the increased incidence of acute myocardial infarction associated with the earthquake could be accounted for by the presence of these disorders. We found that 48 of the 99 patients admitted with acute myocardial infarction during the 6 weeks after the earthquake had comorbid hypertension or diabetes or both, compared with 24 of the 65 patients admitted with acute myocardial infarction during the same 6-week period in the previous year, not a significant difference (2=2.13, df=1, p=0.14; odds ratio=1.61). This finding suggests that the physical and psychological stress caused by a natural disaster such as an earthquake does not increase the incidence of acute myocardial infarction in patients with hypertension and diabetes.
Age and Incidence of Acute Myocardial Infarction
We considered whether age could account for the increased incidence of acute myocardial infarction associated with the earthquake. A total of 70 of the 99 patients admitted with acute myocardial infarction during the 6 weeks after the earthquake were age 65 years or older, compared with 33 of the 65 patients admitted with acute myocardial infarction during the same 6-week period in the previous year. This difference was not significant (2=0.38, df=1, p=0.54; odds ratio=0.68).
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DISCUSSION
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In this study, we examined acute myocardial infarction admissions in most of the region that received structural damage from the 1999 Ji-Ji (Taiwan) earthquake. A significantly higher number of acute myocardial infarction admissions occurred in the area near the epicenter during the 6 weeks after the earthquake, compared with the same 6-week period in the previous year (odds ratio=1.51). The results are similar to those obtained in studies of the 1994 earthquake in Los Angeles15 and the 1995 earthquake in Kobe, Japan,17,18 but different from those in a study of the 1989 earthquake in San Francisco,15 although all three of those earthquakes were similar in magnitude to the Ji-Ji earthquake. The pattern of findings appears to be related to the times of day when the earthquakes took place. The San Francisco earthquake took place at 5:04 p.m., whereas the Los Angeles earthquake occurred at 4:31 a.m., the Kobe earthquake at 5:46 a.m., and the Ji-Ji earthquake at 1:47 a.m., when most people were sleeping. In a study of the effects of an earthquake of slightly less magnitude, the 1989 Newcastle, Australia, earthquake, which took place at 10:27 a.m., Dobson et al.14 found no increase in the number of acute myocardial infarction cases during the 4 days after the earthquake, compared with the same period in the previous year.
Examining onset of acute myocardial infarction, Muller et al.23,24 offered the hypothesis that the neurohormonal, hemodynamic, and coagulation changes associated with emotional or physical stress can cause rupture of a vulnerable atherosclerotic plaque, platelet activation, and coronary vasoconstriction. We suggest that for at-risk persons in areas affected by an early-morning earthquake, the sudden increase of physical activities after getting up in haste, in addition to the extreme emotional stress associated with the earthquake, could trigger acute myocardial infarction.
In a study of the Kobe earthquake, Suzuki et al.17 found that the number of patients with acute myocardial infarction during the first 4 weeks after the earthquake increased significantly by about 3.5 times, compared with the preceding years. We found that the number of admissions for acute myocardial infarction increased by 1.5 times after the Ji-Ji earthquake, compared with the same period in the previous year. The difference between studies may be due to the longer study period (6 weeks) and greater number of hospitals (16 hospitals) in our study. The results of the study by Suzuki et al. were based on fewer cases from one hospital in one area near the earthquake epicenter. In addition, with a comparatively higher percentage of older persons in the Japanese population, the at-risk population was larger, which could have resulted in a higher number of acute myocardial infarction admissions. Our finding for the first 3 days after the earthquake—a 3.6-fold increase in acute myocardial infarction admissions—is more similar to the results of the Kobe study. Kario et al.19 examined data for six villages and towns after the Kobe earthquake and found that the number of patients who died of coronary artery diseases was 1.5 times that during the same period in the previous year; the framework and results of this study were similar to those of our study. In both studies, a significantly higher rate of onset of acute myocardial infarction admissions was found during the first several weeks after the earthquake, and the admissions subsided gradually as the time since the source of stress (i.e., the earthquake) increased.
In our study, a chi-square test for trend found that the number of acute myocardial infarction cases decreased with time after the earthquake. Compared with the previous year, the largest number of cases was found in the first 3 weeks after the earthquake. Earlier studies have examined effects over different periods of time after an earthquake. Suzuki et al.17 found a significant increase of acute myocardial infarction cases in the 4 weeks after the Kobe earthquake and found that the incidence began to return to the norm from the fifth week. Taking 16 cities and towns into consideration, Ogawa et al.18 found that the death rate from acute myocardial infarction was higher in the 8 weeks after the Kobe earthquake. Taking the 14 weeks after the Kobe earthquake as the statistical period, Kario et al.19 also found that incidence of coronary artery diseases was higher. Leor et al.16 found a significant increase in the number of sudden deaths from cardiac causes in the first week after an earthquake. Taken together, these findings suggest that an increase in the incidence of acute myocardial infarction may be found as long as 14 weeks after an earthquake.
We found that there was no significant difference in the age of patients admitted with acute myocardial infarction after the earthquake, compared with the same period in the previous year. Regardless of whether the dividing point of age was 40, 50, or 65 years, no relationship between age and the onset of acute myocardial infarction after the earthquake was found, suggesting that the 1999 Ji-Ji earthquake did not lead to a higher incidence of acute myocardial infarction in elderly people. Age was not considered as a variable in other studies, although all the cases of acute myocardial infarction in two Japanese studies involved patients older than age 65 years.17,18 Other studies reported a temporary increase in blood pressure in the 2 weeks after an earthquake and an increase in the incidence of cardiovascular diseases among older patients with hypertension due to unstable blood pressure and other hemodynamic factors.21,22 The findings suggest that although the stress related to the earthquake did not directly increase the incidence of acute myocardial infarction in the elderly population, it directly influenced the control of hypertension, and, therefore, attention should be paid to this condition in the aftermath of an earthquake. Further study is needed to determine whether earthquakes have a greater influence on certain age groups.
Our study considered whether acute myocardial infarction patients with other risk factors (e.g., hypertension and diabetes) were differently affected by the earthquake. The rate of acute myocardial infarction admissions with hypertension or diabetes was 1.61 times of that of acute myocardial infarction admissions without these comorbid diseases, although this difference was not statistically significant. We could find no similar data from other studies for comparison, although some studies have shown that earthquakes can lead to unstable blood pressure and hemodynamic complications.21,22 Inui et al.25 evaluated blood glucose control in patients with diabetes living in regions at different distances from the epicenter after the Kobe earthquake. Using measurement of hemoglobin A1c values, they found deterioration of blood glucose control in regions nearer to the epicenter in the first year after the earthquake, compared with 2 years before the earthquake.
Because these studies were retrospective analyses of previously collected data rather than a direct investigation of patients with hypertension and diabetes, the conclusions may not reflect the actual experience of patients with hypertension and diabetes. However, follow-up investigation was used in most studies of the Kobe earthquake, and since these studies included relatively few subjects and the comparisons could be strictly controlled, the possible relationship of earthquakes and exacerbation of hypertension and diabetes deserves attention.
We found a significantly higher risk of acute myocardial infarction in locations with larger Richter scale measurements, such as Taichung city, Taichung county, and Chiayi county/city, in the 6 weeks after the 1999 Ji-Ji earthquake, compared with the same period in 1998. However, no significant differences were found in areas with smaller Richter scale measurements, such as Changhua county and Yunlin county. Similarly, after the Kobe earthquake in Japan, a study comparing blood glucose control in diabetes in locations with different Richter scale magnitudes found that deterioration of diabetes control was more prominent in places with larger Richter scale measurements.25 We suggest that the magnitude of the earthquake is related to the incidence of acute myocardial infarction after the earthquake.
In interpreting the results of our study, some limitations must be kept in mind. After the Ji-Ji earthquake, the region was in a state of chaos. A total of 2,321 people died, and it was difficult to differentiate the causes of death. On the other hand, the number of patients with admissions for acute myocardial infarction was small. Our study is based on hospital data, and patients who died from acute myocardial infarction and never reached the hospital were excluded. It is possible that fatal myocardial infarction was also increased in the aftermath of the earthquake, but these cases may not have been brought to the hospital because of facility problems. The cases in this study were chosen from counties and cities near the epicenter. Inclusion of comparison cases from places farther from the epicenter would have allowed more definite conclusions about the role of the earthquake as a trigger for acute myocardial infarction.
Despite these limitations, our findings suggest that emergency services in an area where a natural disaster has occurred should be prepared for an increase in the number of patients with acute myocardial infarction or aborted sudden death.
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REFERENCES
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- Muller JE, Tofler GH, Stone PH: Circadian variation and triggers of onset of acute cardiovascular disease. Circulation 1989; 79:733–743[Abstract/Free Full Text]
- Willich SN, Linderer T, Wegscheider K, Leizorovicz A, Alamercery I, Schroder R: Increased morning incidence of myocardial infarction in the ISAM Study: absence with prior B-adrenergic blockade. Circulation 1989; 80:853–858[Abstract/Free Full Text]
- Muller JE: Morning increase of onset of myocardial infarction. Cardiology 1989; 76:96–104[Medline]
- Andrews TC, Fenton T, Toyosaki N, Glasser SP, Young PM, MacCallum G, Gibson RS, Shook TL, Stone PH: Subsets of ambulatory myocardial ischemia based on heart rate activity: circadian distribution and response to anti-ischemic medication. Circulation 1993; 88:92–100[Abstract/Free Full Text]
- Kloner RA, Leor J: Natural disaster plus wake-up time: a deadly combination of triggers. Am Heart J 1999; 137:779–780[CrossRef][Medline]
- Tofler GH, Muller JE, Stone PH, Forman S, Solomon RE, Knatterud GL, Braunwald E: Modifiers of timing and possible triggers of acute myocardial infarction in the Thrombolysis in Myocardial Infarction Phase II (TIMI II) Study Group. J Am Coll Cardiol 1992; 20:1049–1055[Abstract]
- Muller JE: Circadian variation and triggering off acute coronary events. Am Heart J 1999; 137:S1-S8
- Johnstone MT, Mittleman M, Tofler G, Muller JE: The pathophysiology of the onset of morning cardiovascular events. Am J Hypertens 1996; 9:22S-28S
- Goenjian A: A mental health relief program in Armenia after the 1988 earthquake: implementation and clinical observations. Br J Psychiatry 1993; 163:230–239[Abstract/Free Full Text]
- Goenjian AK, Najarian LM, Pynoos RS, Steinberg AM, Manoukian G, Tavosian A, Fairbanks LA: Post-traumatic stress disorders in elderly and younger adults after the 1998 earthquake in Armenia. Am J Psychiatry 1994; 151:895–901[Abstract/Free Full Text]
- Meisel SR, Kutz I, Dayan KL: Effect of Iraqi missile war on incidence of acute myocardial infarction and sudden death in Israeli civilians. Lancet 1991; 338:660–661[CrossRef][Medline]
- Trevisan M, Jossa F, Farinaro E, Krogh V, Panico S, Giumetti D, Mancini M: Earthquake and coronary heart disease risk factors: a longitudinal study. Am J Epidemiol 1992; 135:632–637[Abstract/Free Full Text]
- Trichopoulos D, Katsouyanni K, Zavitsanos X, Tzonou A, Dalla-Vorgia P: Psychological stress and fatal heart attack: the Athens (1981) earthquake natural experiment. Lancet 1983; 1:441–444[CrossRef][Medline]
- Dobson AJ, Alexander HM, Malcolm JA, Steele PL, Miles TA: Heart attacks and the Newcastle earthquake. Med J Aust 1991; 155:757–761[Medline]
- Brown DL: Disparate effect of the 1989 Loma Prieta and 1994 Northridge earthquakes on hospital admissions for acute myocardial infarction: importance of superimposition of trigger. Am Heart J 1999; 137:830–836[CrossRef][Medline]
- Leor J, Poole WK, Kloner RA: Sudden cardiac death triggered by an earthquake. N Engl J Med 1996; 334:413–419[Abstract/Free Full Text]
- Suzuki S, Sakamoto S, Koide M, Fujita H, Sakuramoto H, Kuroda T, Kintaka T, Matsuo T: Hanshin-Awaji earthquake as a trigger for acute myocardial infarction. Am Heart J 1997; 134:974–977[CrossRef][Medline]
- Ogawa K, Tsuji I, Shiono K, Hisamichi S: Increased acute myocardial infarction mortality following the 1995 Great Hanshin-Awaji earthquake in Japan. Int J Epidemiol 2000; 29:449–445[Abstract/Free Full Text]
- Kario K, Matsuo T, Kobayashi H, Yamamoto K, Shimada K: Earthquake-induced potentiation of acute risk factors in hypertensive elderly patients: possible triggering of cardiovascular events after a major earthquake. J Am Coll Cardiol 1997; 29:926–933[Abstract]
- Kario K, Ohashi T: Increased coronary heart disease mortality after the Hanshin-Awaji earthquake among the older community on Awaji island. J Am Geriatr Soc 1997; 45:610–613[Medline]
- Saito K, Kim J, Maekawa K, Ikeda Y, Yokoyama M: The great Hanshin-Awaji earthquake aggravates blood pressure control in treated hypertensive patients. Am J Hypertens 1997; 10:217–221[CrossRef][Medline]
- Kario K, Matsuo T, Shimada K, Pickering TG: Factors associated with the occurrence and magnitude of earthquake-induced increases in blood pressure. Am J Med 2001; 111:379–384[CrossRef][Medline]
- Muller JE, Abela GS, Nestro RW, Tofliers GH: Triggers, acute risk factors and vulnerable plaque: the lexicon of a new frontier. J Am Coll Cardiol 1994; 23:809–813[Abstract]
- Muller JE, Tofler GH: Triggering and hourly variation of onset of arterial thrombosis. Am Epidermiol 1992; 2:393–405
- Inui A, Kitaoka H, Majima M, Takamiya S, Uemoto M, Yonenaga C, Honda M, Shirakawa K, Ueno N, Amano K, Morita S, Kawara A, Yokono K, Kasuga M, Taniguchi H: Effect of the Kobe earthquake on stress and glycemic control in patients with diabetes mellitus. Arch Intern Med 1998; 10:217–278
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ABSTRACT
INTRODUCTION
