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For Caroline, the holidays are always bittersweet because of the memory of her father’s death. The family had just finished dessert and were sitting around the table talking. But her father was not participating, and Caroline was the first to notice the distress on his face. He died of a heart attack at 7 p.m. on Dec. 25.

Far from being a macabre coincidence, heart attacks and deaths are common during the holiday season. Numbers start going up in mid-November and continue to increase through New Year’s Day.

A study published in 2004, based on 26 years of data, found that the peak incidence of heart attack deaths comes on three days — Dec. 25 and 26 and Jan. 1, in that order.

An earlier (1999) study by Robert A. Kloner, M.D., and his colleagues found one third more deaths in December and January than from June through September over a 12-year period in Los Angeles County. And the greatest number of heart-related deaths came on Dec. 25 and Jan. 1.

What’s the reason for this holiday spike in heart attack deaths? There are many possible explanations.

Winter weather.

One of the most obvious answers is winter weather. During cold weather, blood vessels constrict, causing blood pressure to rise. Blood clots form more readily in cold weather, and it’s easy to stress your heart with snow shoveling and outdoor activities.

In Los Angeles County, however, with its moderate winter temperatures, none of these factors come into play.

Emotional stress.

Always high during the holidays, was another possible factor listed by Dr. Kloner. Having to interact with relatives can be a negative as well as a positive part of the holidays. There are also financial pressures, demands on time and the stress of having to traverse busy highways or crowded airports.

Dr. Phillips was dubious about emotional stress as a major cause, however, because Alzheimer’s patients in his study, who presumably are less aware than others of the meaning of holidays, had an even more pronounced risk of death over the holidays.

Over-indulgence.

This is a typical part of the holiday scene. An increase in salt intake can make blood pressure rise. A heavy meal, high in fat and calories, has been shown to be a short-term risk factor for a heart attack.

Alcohol is good for the heart in moderation, but binge drinking can irritate the heart muscle and trigger an abnormal rhythm known as atrial fibrillation. The study, however, found a lower holiday peak for heart attack deaths with substance abuse as a secondary cause.

Respiratory infections.

Respiratory infections, such as the flu, also prevalent during December and January, can weaken a person’s immune system and increase the risk of death. In Dr. Phillips’ study, however, deaths with respiratory illness listed as a secondary cause also had a less prominent holiday peak.

Delay in seeking treatment.

Caroline’s father had been feeling symptoms all morning, but he didn’t want to spoil everyone’s holiday by rushing to the hospital for a false alarm.

Persons away from home or on the highway may feel even more reluctant to seek care promptly. And hospital emergency rooms tend to be under-staffed or staffed with less experienced personnel during the holidays.

What to do.

While researchers look for answers, there are things we can all do to lower our risk.

Dr. Oz of TV fame, gives four tips:

■ Never have two drinks in a row. If you want a second beer, have a drink of water first.

■ Avoid high-fat foods and, at a party, keep one hand free for shaking hands; it may slow down your urge to over-eat.

■ Be aware of your feelings and the sources of your stress. And reach out to others who may be in pain rather than dwelling on your own problems.

■ Stay six to eight feet away from a fireplace. Even for persons with no respiratory issues, a wood burning fire releases particulate airborne pollutants that are associated with an increase in blood pressure and the risk of heart attack and stroke.

Think about it; you can probably can add many suggestions of your own.

If you’ve already had a heart attack or have one or more risk factors such as high blood pressure, high cholesterol or a family history, you know you have to be careful every day. Holidays are to enjoy, but they may add one more risk factor.

Tory Wettstein is an exercise physiologist at Bay Area Medical Center.