What will you be doing on December 24th at around, oh, let’s say, 10 PM?  In the last week I’ve been polling patients, and here’s some of their answers: 
A.V.: Just chillin’ with the missus and a nice glass of port. 
B.W.: Drinking Diet Cokes and watching the Hallmark channel with my dog. 
F.L.: Once I’m sure the kids are asleep, I’m assembling a swing set in the backyard – should take about 4 hours. 
Me? If all goes according to plan, I’ll be on the fourth or fifth course of an Italian Christmas Eve dinner, probably linguine vongole – pasta with clams – which is an acquired taste. I keep trying. 
For some people, however, Christmas Eve may take a different course. This month the British Medical Journal published new data from SWEDEHEART – Sweden’s massive online cardiac data registry. Researchers examined 280,000 heart attack cases in Sweden over 16 years to see if they could identify daily, weekly, or seasonal patterns. They found a striking spike in heart attack risk during the Christmas season – specifically a 37% increased risk on Christmas Eve, 29% increased risk on Christmas Day, and 21% increased risk on Boxing day. The risk was especially high if you were over 75 years old, already had heart disease or were diabetic. Who knew Christmas could be so dangerous? The data revealed another shocker – when risk was analyzed according to time of day, most of the year’s heart attacks occurred just before 8 AM (and on Mondays – no surprise there), the exception being … Christmas Eve, where the peak heart attack time was 10 PM.
“The peak is very pronounced exactly on Christmas Eve and the following two days, so, I think it is something specific for the way we celebrate these holidays” 
Dr. David Erlinge, Head Cardiologist, Lund University, Sweden, speaking to the Telegraph.
Wow. What is going on in Sweden? Or more specifically, what is going on in Sweden at 9 or 9:30 that’s leading to the 10 PM heart attack? Are Swedish festivities any different from a Bermuda Christmas? Well for starters, it turns out their big celebration is on the 24th. If you’re Italian, as is my wife’s family, this is the norm, so in our house and in most of Sweden, by 10 PM on Christmas Eve the holiday activities, for better or worse, are in full swing. 
What are they eating over there? Apparently, Swedish Christmas dinners involve pickled herring, lutfisk (fish in lye), bread dipped in ham stock, beet salad (a vegetable, at last, but this one camouflaged in mayonnaise and sour cream), and rice pudding, all helped down with glogg (mulled wine), porter, or julmust (super sweet, alcohol-free beer alternative). Compare that to a Bermudian Christmas menu of turkey (butter surreptitiously slipped under the skin), stuffing (salt, saturated-fat sausage), ham (more salt), gravy (salt), cassava pie (sugar, butter, eggs), potatoes (salt, butter), greens (salt, butter), and lots of desserts (sugar/tax, sugar/tax, sugar/tax), and who knows what kind and how many alcoholic beverages are consumed before, during, and after. No judgment, but I think Gosling’s does a brisk business this time of year. It seems, whether in Sweden or Bermuda, many citizens, perhaps soon to become patients, will be bathing themselves in salt, sugar, fat, and alcohol.
But is it all about food and drink? Is there anything unique to Bermuda that will spare us the fate of the Swedes? Can we at least take comfort in our kinder climate? We know that heart attack risk goes up in cold weather, and it’s got to be colder in Sweden. Although, as I think about it, if anyone else attended In Motion’s 2018 Nutcracker at the Ruth Seaton James auditorium where the temperature is permanently set to frigid, they’ll understand how even a Bermuda night out at the ballet can carry its own heart attack risk. 
We all know there are certain established risk factors for having a heart attack – family history, age, gender (males more likely than females, until after menopause, when females catch up), diabetes, high cholesterol, high blood pressure, smoking, obesity, and physical inactivity. In a way, these are all considered “internal” risk factors.  But what about external factors – i.e., things imposed on you?  
As it happens, there are some well-recognized external triggers that can cause a heart attack. Some are weather related – in addition to cold temperatures, earthquakes and hurricanes result in an increased incidence of heart attacks. Other environmental factors like air pollution also raise the risk. So, does war, by the way, and so does financial loss – a 2010 American Journal of Cardiology study showed that stock market crashes were associated with an increased risk of heart attacks. One unifying thread that seems to link these external triggers is that little problem of stress. 
Would you characterize Christmas as a relaxing time of year?  I think not. Guests are arriving with high expectations, meals must be prepared and presented in extravagance, the house cleaned, gifts purchased, parties attended, decorations unboxed and de-roached, smiles recharged, and for some reason this Christmas is always in competition with every past holiday for “the best Christmas ever.” 
I know I’m not the only one for whom Christmas has morphed from a season of sheer elation and wild Santa-anticipating insomnia (for me, peaking at age 7, living in a Minnesota 2-bedroom basement apartment with 6 others, including a beloved grandmother and a fake silver tree, December spent poring over the Sears Christmas catalogue, allowed to choose any items adding up to $25.00, total), to a less snowy, more prosperous time, tinged, for one reason or another, with sadness. For some of my patients without family (or with difficult family), or who have recently lost loved ones (or harder still, lost a difficult loved one), sadness may be the over-riding Christmas emotion.
“We do not know for sure, but emotional distress with acute anger, anxiety, sadness, grief, and stress increases the risk of a heart attack. Excessive food intake, alcohol, long distance travelling, may also increase the risk.”
Dr. David Erlinge, Head Cardiologist, Lund University, Sweden
Before we draw any conclusions, let’s see what other nuggets turned up in the Swedish study. Besides Christmas, two other holidays revealed heart attack spikes: New Year’s Day had a 20% higher risk, and the mid-summer holiday (it’s in mid-June and I understand it involves nonstop drinking and dancing, maybe a Bermuda Heroes Weekend carnival equivalent, I’m not sure) had a 12% increased risk. New Year’s Eve – no increased risk. Good Friday – no increased risk. Easter – no increased risk. So, there are your three “safe days”.  And what about major sporting events – we all know Europeans love their soccer – no increased risk during the FIFA World Cup, UEFA Euro Cup, or the summer or winter Olympics. The authors conclude “viewing sporting events can therefore be considered safe.”  Good to know. I still think you should get off the couch.
Can Bermudians learn anything from this Swedish study?  For me, it is a reminder that none of us are machines, we are biological creatures. And although for some aspects of medicine we liken the body to a machine, in fact we are organisms which, like organizations, do not adapt well to sudden changes of any sort, whether it’s sleep deprivation, excessive food volume or type, extreme temperatures, unexpected physical exertion, or emotional over-comings, all things the holiday season can bring. So, in Christmas parlance, be ye not dismayed by these Swedish observations. Use them to your advantage. Here’s my five tips for a happy and healthy holiday season:
1. Don’t neglect your regular exercise schedule. By maintaining your exercise program, you’ll have less time and inclination to binge eat or drink.
2. Don’t compromise on sleep. Plan ahead, and advise people with a smile – “this has been lovely, but, sorry, it’s past my bedtime”. I’ve been getting away with this for years. You can, too.
3. If someone in your family is elderly, diabetic, or already has heart disease, make sure they’re included and attended to during the holiday season. It’s easy to ignore Aunt Eunice because she’s hearing-impaired or because she fell asleep on the couch (uh, she is sleeping, right?).
4. Approach the holidays as a tasting menu. There’s so much rich food around that you shouldn’t go by serving sizes. Just taste stuff. If Christmas dinner comes with 12 items, a tablespoon of each fills a plate completely. Remember, you’re lucky. You don’t have to attack Christmas dinner as if you’ll never see food again. Chances are, tomorrow you’ll still have access to calories. 
5. Spend some advance time reflecting on the meaning of the holidays, specifically, for you. Remember, no family is perfect. We are all a big jumble of disparate personalities, quirky senses of humor, natural gifts, and hidden and not-so-hidden hardships. Above all, be grateful for what you have, specifically what you have to offer. And when all else fails, look around the dinner table and repeat after me: I am here.
Happy holidays from Dr. Marshall. Thinking of you, and not just at 10 PM on Christmas Eve. 
For more news on the latest developments in cardiology, visit www.ShaneMarshallMD.com, subscribe to the free newsletter The Annals of Cardiology, and follow Dr. Marshall on Twitter @ShaneMarshallMD.