Article Text

Immediate surge in female visits to the cardiac emergency department following the economic collapse in Iceland: an observational study
  1. Guðlaug Rakel Guðjónsdóttir1,2,
  2. Már Kristjánsson1,3,
  3. Örn Ólafsson2,
  4. Davíð O Arnar4,
  5. Linn Getz5,6,
  6. Jóhann Ágúst Sigurðsson7,8,
  7. Sigurður Guðmundsson2,
  8. Unnur Valdimarsdóttir2,9
  1. 1Department of Emergency, Landspítali University Hospital, Reykjavík, Iceland
  2. 2Centre of Public Health Sciences, University of Iceland, Stapi v/Hringbraut, Reykjavík, Iceland
  3. 3Department of Infectious Diseases, Landspítali University Hospital, Reykjavík, Iceland
  4. 4Department of Cardiology and Cardiovascular Research Centre, Landspítali University Hospital, Reykjavík, Iceland
  5. 5Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
  6. 6Department of Human Resources, Landspítali University Hospital, Reykjavík, Iceland
  7. 7Department of Family Medicine, Faculty of Medicine, University of Iceland, Reykjavík, Iceland
  8. 8Centre of Development, Primary Health Care of the Capital Area, Thönglabakki, Iceland
  9. 9Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA
  1. Correspondence to Dr Unnur Valdimarsdóttir, Centre of Public Health Sciences, University of Iceland, Stapi v/Hringbraut, Reykjavík 101, Iceland; unnurav{at}


Objective To study potential changes in attendance at emergency departments (ED) in Reykjavík immediately following the swift economic meltdown in Iceland in October 2008.

Methods Using electronic medical records of the National University Hospital in Reykjavík, a population-based register study was conducted contrasting weekly attendance rates at Reykjavík ED (cardiac and general ED) during 10-week periods in 2006, 2007 and 2008. The weekly number of all ED visits (major track), with discharge diagnoses, per total population at risk were used to estimate RR and 95% CI of ED attendance in weeks 41–46 (after the 2008 economic collapse) with the weekly average number of visits during weeks 37–40 (before the collapse) as reference.

Results Compared with the preceding weeks (37–40), the economic collapse in week 41 2008 was associated with a distinct increase in the total number of visits to the cardiac ED (RR 1.26; 95% CI 1.07 to 1.49), particularly among women (RR 1.41; 95% CI 1.17 to 1.69) and marginally among men (RR 1.15; 95% CI 0.96 to 1.37). A similar increase was not observed in week 41 at the general ED in 2008 or in either ED in 2007 or 2006. In week 41 2008, visits with ischaemic heart disease as discharge diagnoses (ICD-10: I20–25) were increased among women (RR 1.79; 95% CI 1.01 to 3.17) but not among men (RR 1.07; 95% CI 0.71 to 1.62).

Conclusion The dramatic economic collapse in Iceland in October 2008 was associated with an immediate short-term increase in female attendance at the cardiac ED.

  • Acute coronary syndrome
  • cardiac care
  • diagnosis
  • economic recession
  • emergency service
  • guidelines
  • heart disease
  • hospital
  • major incidents
  • population surveillance
  • psychological
  • stress

Statistics from

The national economic collapse in Iceland in early October 2008 was unique in magnitude and velocity in western countries of modern times. On 29 September, one of the three largest banks in the country was nationalised, and just days later, from 6 October to 9 October, the other two suffered the same fate changing the national economy abruptly from one of the most prosperous in the world to one of the most challenged. The crisis has had unprecedented consequences for the Icelandic economy, with the national currency free-falling in value and the value of the Icelandic stock exchange dropping by approximately 90%.1 The citizens' earthshaking experience was instigated on 6 October by Prime Minister Geir Haarde's live television address to the nation:“There is a very real danger, fellow citizens, that the Icelandic economy, in the worst case, could be sucked with the banks into the whirlpool and the result could be national bankruptcy. […]“I am well aware that this situation is a great shock for many, which raises both fear and anxiety. In such circumstances it is extremely urgent that the authorities, companies, social organisations, parents and others who can contribute make every effort to ensure that daily life is not disrupted.“If there was ever a time when the Icelandic nation needed to stand together and show fortitude in the face of adversity, then this is the moment. I urge you all to guard that which is most important in the life of every one of us, protect those values which will survive the storm now beginning. I urge families to discuss together and not to allow anxiety to get the upper hand even though the outlook is grim for many. We need to explain to our children that the world is not on the edge of a precipice and we all need to find an inner courage to look to the future. […] God bless Iceland.”2

While the long-term economic and health consequences of the financial meltdown are unclear, it also remains unexplored whether these dramatic days of October 2008 brought about short-term health hazards in the Icelandic population. Immediate health consequences, particularly cardiovascular events, have repeatedly been reported following various sudden, stressful occurrences.3–10 With respect to national economic fluctuations, Stuckler et al11 reported a 6.4% increase in male cardiovascular mortality rates during the first year following banking crises in 19 high-income countries. Yet, few, if any, have explored health risks of both genders during the first week following a sudden national economic collapse.

Following up on alarm made by The Chief Epidemiologist for Iceland,12 our aim was to explore whether the sudden national economic collapse on 6–9 October 2008 (week 41 and onwards) resulted in an increase in the number of visits to the two hospital emergency departments (ED) in the Reykjavík capital area, particularly pertaining to cardiac or chest symptoms.


Study design and venue

This is an observation of emergency care attendance rates in the greater capital area of Reykjavík over a 10-week period, before (weeks 37–40) and after (weeks 41–46) the economic collapse in Iceland in October 2008. To preclude normal seasonal variations, we also observed emergency care attendance rates during the same 10-week period (37–46) in the preceding 2 years, 2006 and 2007.

There are two hospital ED in Reykjavík capital area, both within the organisation of Landspítali University Hospital, the only tertiary referral centre in Iceland. Hringbraut campus ED incorporates a specialised chest pain centre (hereafter referred to as cardiac ED) and thus primarily serves patients with chest and abdominal pain; approximately 90% of the visits to the cardiac ED are due to chest or abdominal symptoms while the remaining visits are due to urological, renal, haematotology or oncology emergencies by referral. Fossvogur campus ED (hereafter referred to as general ED) serves unselected acutely ill patients (non-paediatric) and accidents (including children). All acutely ill patients who are hospitalised are admitted through the ED. There is a separate ED for children, thus the two ED considered here primarily serve adults (over 18 years of age) with the exception of accidents or trauma in the general ED. The two ED as a rule serve the larger Reykjavík area and in extreme circumstances (eg, natural disasters, large accidents) also the whole country.

The greater capital area of Reykjavík and suburbs, representing 64% of the national population, comprises the total population at risk for emergency care in this study. From Statistics Iceland ( we obtained population information on all adult individuals (≥ 18 years) living in the larger capital area on 1 July in 2006 (N=140 997), 2007 (N=145 380) and 2008 (N=151 530).

Data acquisition

The total number of adult visits (≥18 years) to the major tracks of the ED of each consecutive week, 37–46 (starting on a Monday) in 2008 (index year) were observed as well as the same 10-week period in 2006 and 2007. Data were retrieved from the electronic medical records system (the SAGA system) of Landspítali University Hospital Health Information Technology Department. All visits to the two ED (major tracks) are recorded on a personal identification number (unique to all inhabitants in Iceland) of the attendee in the SAGA system on arrival. All visits are recorded within a few minutes of arrival. Other information on visits retrieved for the purpose of this study was age of attendees (18 years or older), gender and discharge diagnosis.

All discharge diagnoses considered here are made by the attending cardiologist and registered according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). We observed discharge diagnoses of the cardiovascular system (I00–I99), specifically ischaemic heart disease (I20–I25), as well as relevant symptom diagnoses of the cardiovascular system (R00–R09). Patients discharged directly home from the ED receive their discharge diagnoses there. Approximately a third of the ED attendees are admitted to the hospital where they receive a final discharge diagnosis. Therefore, in order to achieve completeness of diagnoses of ED attendees, we made a record linkage to the ‘inpatient’ discharge system of SAGA. Patients who were then admitted to inhospital care within 24 h after arrival at the ED receive their final discharge diagnosis from inhospital departments (used here).

Approvals for the study were obtained from the Science Ethics Committee of Landspítali University Hospital (ref no 48/2008) and the Data Protection Authority (ref no 2008/080540).

Statistical analysis

We present the weekly number of visits to both ED by gender, age and diagnoses during the 10-week periods in each of the years 2006, 2007 and 2008. We calculated attendance rates per 100 000 inhabitants during the 10-week period for all three consecutive years. Trends in counts were tested by the χ2 trend test. The level of significance was set at 0.05. We calculated overall and gender-stratified RR and 95% CI13 as ED visits per total population at risk in weeks 41–46 of 2008 (after the economic collapse) with the average weekly attendance rate during weeks 37–40 (before the economic collapse) as reference. We performed identical analyses for the years 2006 and 2007. We further calculated risks of visits with discharge diagnoses pertaining to the cardiovascular system (ICD-10 I00–I99 or R00–R09) in week 41 relative to the average weekly number of similar visits in weeks 37–40. Finally, we calculated the RR of visits with ischaemic heart disease as the discharge diagnosis (ICD-10 I20–I25) in week 41 with weeks 37–40 as reference.


The average weekly attendance at the cardiac ED in weeks 37–46 (per 100 000 population) increased from 155.5 in 2006, to 160.1 in 2007 and 171.0 in 2008 (p<0.001). In contrast, the weekly attendance rate to the general ED decreased from 184.9 in 2006, to 181.5 in 2007 and 157.4 in 2008 (p<0.001). Approximately two-thirds of attendees were 18–67 years and one-third was 68 years or older (table 1). The total attendance rate per 100 000 to both ED receiving cardiovascular discharge diagnoses (I00–I99) diminished during the study period from 74.0 in 2006, to 71.1 in 2007 and 65.8 in 2008 (p=0.008).

Table 1

Characteristics of visits to the ED in Reykjavík in weeks 37–46 in 2006, 2007 and 2008

Figure 1 shows the weekly number of visits to the cardiac and general ED major tracks. Compared with the average weekly attendance in previous weeks 37–40, a distinct 26% increase in visits was observed in the cardiac ED during week 41 2008. In contrast, there seems to be a small decrease in attendance at the cardiac ED during the same period in 2006 and 2007. Similarly, the attendance rates at the general ED were somewhat stable during the 10-week period in 2006 and 2007 and, if anything, decreased modestly in 2008.

Figure 1

Number of weekly visits to emergency departments (ED) in Reykjavík from week 37 to week 46 in 2006, 2007 and 2008.

Table 2 shows the weekly number and gender-stratified RR of visits to the cardiac ED in weeks 41–46 2008 with weeks 37–40 as reference. The RR were overall amplified in weeks 41 and 42 while reaching 1.0 at week 43, going below 1.0 in week 44 and then again towards 1.0 in weeks 45 and 46. The RR of all visits in week 41 were 1.26 (1.11–1.43) in 2008, 0.92 (0.79–1.06) in 2007 and 0.97 (0.84–1.12) in 2006. The RR of visits to the general ED in week 41 were 0.99 (0.87–1.14) in 2008, 1.03 (0.90–1.17) in 2007 and 0.96 (0.84–1.10) in 2006. Gender-stratified analyses revealed similar patterns while the effect was markedly stronger among women; the RR of female and male visits in week 41 to cardiac ED were 1.41 (1.17–1.69) and 1.15 (0.96–1.37), respectively. In 2007 the RR of female and male visits in week 41 were 1.00 (0.81–1.22) and 0.85 (0.69–1.04), respectively; for 2006 the corresponding RR were 1.06 (0.86–1.30) and 0.89 (0.73–1.10). At the general ED, the gender-specific RR for week 41 were for all 3 years in the vicinity of 1.0 and were non-significant (data not shown).

Table 2

Number and RR of female and male visits to cardiac ED in weeks 41–46 2008 with weeks 37–40 as reference

Table 3 shows the number and gender-specific RR of attendance at the cardiac ED as well as both EDs with cardiovascular discharge diagnoses and, in particular, diagnoses of ischaemic heart disease. Although with limited statistical power, attendance for cardiovascular disorders showed a similar pattern to previous analyses on all visits, ie, marginally increased risks of attendance, particularly among women, although not statistically significant. When focusing on visits due to definitive ischaemic heart disease, the RR in week 41 2008 was statistically significantly increased among women (RR 1.79; 95% CI 1.01 to 3.17) but not among men (RR 1.07; 95% CI 0.71 to 1.62). The corresponding RR for women and men in week 41 were 1.24 (0.66 to 2.31) and 0.88 (0.55 to 1.40) in 2006 and 1.05 (0.54 to 2.03) and 1.15 (0.71 to 1.87) in 2007.

Table 3

Number and RR of female and male visits with discharge diagnoses I20–I25 and I00–I99/R00–R09 in week 41 2008 with weeks 37–40 as reference


The findings from this population-based study indicate that the Icelandic economic collapse in October 2008 resulted in a sharp short-term increase in individuals seeking emergency medical care in the Reykjavík capital area, particularly among women whose attendance at the cardiac ED was increased by more than 40%. Although limited by small numbers, the findings suggest that during the week of the economic collapse the total female attendance due to ischaemic heart disease was increased by almost 80%; no such increase was observed among men.

This is, to our knowledge, the first study exploring potential adverse health effects during and within the first weeks following a swift national economic collapse driven by a banking crisis. The role of acute mental stress as a trigger of cardiovascular events is, however, well established. Our findings are indeed in line with findings from a number of studies indicating an immediate increase in cardiovascular morbidity or mortality following stressful events, such as natural disasters,3 ,4 war or terrorism,5 ,6 the diagnosis of a life-threatening disease,7 ,8 loss of a child9 and major sporting events.10 Furthermore, Stuckler and coworkers11 reported a 6.4% increase in male cardiovascular mortality during the first year following banking crises in 19 high-income countries; the study did not address female cardiovascular morbidity. Our results indicating 40% increased attendance at cardiac ED among women are consistent with the findings of Kark et al,5 who reported higher overall mortality among women than men in Israel following Iraqi missile attacks. Moreover, the long-term follow-up of Danish bereaved parents showed that bereaved mothers had a higher excess risk of fatal myocardial infarction than bereaved fathers.9 The majority of patients presenting with Takotsubo cardiomyopathy (‘broken heart syndrome’) following emotional stress have indeed been reported to be women.14 On the other hand, Wilbert-Lampen and coworkers10 found that the risk of acute cardiovascular events was higher in men than women during World Cup football matches. It is possible that the experience of different stressors is somewhat gender specific, which may partly explain differential effects across studies on morbidity. Financial and occupational losses during weeks of the economic collapse in Iceland represented a great threat to family security, which may affect women differently from men.

Until recently, the pathophysiological pathways linking strong emotional experience to acute disease in general, and cardiac syndromes in particular, have been poorly described. However, emerging evidence indicates that neuroendocrine activation15 and inflammatory responses16 associated with acute stress may contribute to the risk of myocardial ischaemia.17 While little is known on the role of gender in acute and stress-induced cardiovascular syndromes, it can be hypothesise that the pathophysiological pathways of stress and cardiac morbidity may differ across gender. Wittstein et al15 reported two to three times higher plasma catecholamine levels in patients with stress-induced cardiomyopathy compared with those with Killip class III myocardial infarction; 18 out of 19 patients with stress-induced cardiomyopathy were women. On the other hand, Wilbert-Lampen and coworkers16 found stress-induced acute coronary syndrome at the football World Cup was associated with a profound increase in inflammatory and vasoconstrictive mediators, including tumour necrosis factor alpha and endothelin 1; only six out of 58 patients with stress-induced acute coronary syndrome were women and no gender-specific were differences reported. There are, however, indications of gender differences in brain activation18 and inflammatory reactions19 in response to standardised stress testing, with specific relevance for the development of acute coronary syndromes. Some data suggest that post-menopausal women, with no hormonal treatment, may be particularly vulnerable to stress-induced cardiomyopathy.13

Strengths and limitations

With the unique personal identification numbers in Iceland, this study is firmly nested in the population of the larger capital area where changes in the denominator—by immigration and emigration—is reliably monitored. Furthermore, minimising risks of measurement errors, the electronic medical records system of the University Hospital (SAGA system) has been used for several years for the complete registration of each admitted individual to the ED within minutes of arrival. It is possible that at times of heavily increased work load, such as occurred in week 41 at the cardiac ED, that registration is temporarily delayed; it is, however, unlikely that the weekly estimates are largely affected, and if anything, this would only dilute the RR obtained for week 41. To increase the validity and obtain completeness of the discharge diagnoses, we linked the ED admission records to the inpatient records, which contained discharge diagnoses of attendees hospitalised within 24 h after arrival at the ED. Through the study design and analyses, we tried to address many important potential confounders, for example seasonal variation, by restricting our study to a narrow seasonal time window and by including identical seasonal periods of previous years (before the collapse); residency by restricting our study to the capital area; and gender by conducting gender-stratified analyses throughout. The main limitation of our study is the small size of the source population—the greater Reykjavík capital area only has approximately 150 000 inhabitants. The scarcity of weekly events in key diagnostic strata prohibits detailed analysis and mitigates our conclusion on the association observed between the economic collapse and ischaemic heart disease in women. The unique nature of the Icelandic society and the national economic collapse in 2008 limits the generalisability of our findings; future studies in other cultures are indeed needed to explore a potential rise in emergency care attendance following a rapid economic collapse.

Conclusion and implications

The seemingly prosperous economy of Iceland collapsed in only a few days in the beginning of October 2008—week 41. This week was associated with over a 40% increase in female attendance at the cardiac ED in Reykjavík capital area. A similar increase was not observed among men. Our findings suggest a gender-specific stress reaction to the national financial crisis; the mechanisms underlying this immediate effect among women as well as the general long-term health consequences of the economic crisis in Iceland await further study.

These findings on the immediate rise in cardiac emergency care needs may have implications for emergency care planning in all societies facing sudden economic collapse or other significant societal changes.

What is already known on this subject

  • Stressful events may have immediate health consequences, particularly affecting the risk of cardiovascular events.

  • The immediate health consequences of a national economical collapse are unknown.

What this study adds

  • Swift national economic breakdowns, such as in Iceland in October 2008, may increase attendance at the ED due to ischaemic heart disease, particularly among women.


The authors would like to thank Bjarki Stefánsson for his assistance with data acquisition as well as Dr. Haraldur Briem and all members of the extended CRISIS group for fruitful discussions.


View Abstract


  • Competing interests None.

  • Ethics approval Approvals for the study were obtained from the science ethics committee of Landspítali University Hospital (ref no 48/2008) and the Data Protection Authority (ref no 2008/080540).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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