Cardiovascular impact of modern warfare: STEMI patterns before and during the Israel-Hamas conflict

Emotional stress in conflict zones may impact cardiovascular health, particularly acute coronary syndrome incidence. This retrospective study assesses the Israel-Hamas conflict's impact on ST-elevation myocardial infarction (STEMI) by comparing admissions during conflict versus previous years. Using Clalit Israeli data center records, we conducted multi-level STEMI analysis: (1) conflict period (October 2023-October 2024) versus preceding year, (2) outbreak day and subsequent week analysis, (3) comprehensive trend analysis (2013-2024), and (4) geographic distribution across nine hospitals. Sudden cardiac death (SCD) patterns were analyzed throughout 2023. The primary outcome was the comparison of STEMI incidence between conflict and non-conflict periods. Secondary outcomes included risk factors and post-STEMI left ventricular ejection fraction (LVEF). STEMI incidence increased non-significantly from 526.03 to 539.62 per 100,000 during the conflict period compared with the pre-conflict year (P = 0.85). No significant increase occurred on October 7, 2023, or during the following week compared to 2022. Geographic analysis revealed stable hospital-specific STEMI proportions (p > 0.05). SCD demonstrated minimal variation (October 2023: 6 cases; pre-conflict monthly average: 2.9 cases) and subsequently returned to baseline. Decade-long analysis revealed a gradual increase in STEMI from 377.68 per 100,000 (2013-2014) to 539.62 per 100,000 (2023-2024). LVEF improved from 46.9% to 51.8% despite a non-significant mortality increase (16.29 to 17.96 per 100,000, P = 0.2). Acute conflict-related stress did not significantly impact STEMI incidence beyond established progressive trends. These findings are consistent with, though do not prove, population-level attenuation of acute cardiovascular stress responses. The lack of significance should be interpreted with caution, given potential confounders and limited power. Continued surveillance and the inclusion of care-quality metrics in future analyses are warranted.