Heart Disease in Firefighters

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Heart Disease in Firefighters

• STEFANOS N. KALES, MD, MPH, FACP, FACOEM
• MEDICAL DIRECTOR
• EMPLOYEE HEALTH INDUSTRIAL MEDICINE CAMBRIDGE
  HEALTH ALLIANCE
• ASSISTANT PROFESSOR OF MEDICINE
• HARVARD MEDICAL SCHOOL
• ASSISTANT PROFESSOR DIRECTOR,
• OCCUPATIONAL ENVIRONMENTAL MEDICINE RESIDENCY,
  HARVARD SCHOOL OF PUBLIC HEALTH

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Background

• More than one million firefighters in US
• About 100 firefighters die each year on-Duty
  (1 in 10,000 per year)
• 1977-2004, CVD has caused 45 on-Duty Deaths
• CHD 40

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US Firefighter Fatalities

• 45 Heart Disease
• 25 Motor Vehicle Related
• 12 Asphyxiation
• 18 Burns, Other Trauma, other

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Heart Deaths by Occupation

• of On-Duty Deaths
• caused by CVD
• Firefighters 45
• Police 22
• Overall 15
• Construction 11.5
• EMS 11
• Average of all Occupational Fatalities,
• all industries

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Development of Atherosclerotic Plaques
Fatty streak
Normal
Lipid-rich plaque
Foam cells
Fibrous cap
Lipid core
Thrombus
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THEORETICAL MODEL OF CVD
Hypertrophy /- Known CHD
Subclinical Disease
Death Disease Disability
Regular Exercise/ activity Moderate EtOH Diet
- / Tobacco - Irregular Physical Exertion
-Pollution/Gases - Noise - Shift Work - Job
Stress with Low Control -
Pro-Inflammatory (bad) Anti-Inflammatory
(good)
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Cohort Studies vs. Presumption Laws

• Definitive evidence of an increased CHD risk in
  Firefighters lacking.
• Based on gt/10 cohort mortality studies
  Firefighters risk of CHD Death
• SMR of 0.9

• High proportion of CHD deaths and recognition of
  Cardiovascular Stressors has led to
• Heart Presumption laws in 37 / 50 states and 2
  Canadian Provinces

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On-Duty Events, Work-Related or Just happen at
Work???Potential Occupational Cardiovascular
Stressors

• Heavy Physical Exertion - on an Irregular Basis
• gt 50 lbs Personal Protective Equipment
• Near Maximal-Maximal HR (at least 10 METS)
• Heat Stress Fluid losses

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Methods Case-control study, 52 male firefighters
CHD deaths investigated by NIOSH. Control
population 51 male firefighters on-duty trauma
deaths
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U.S. Fire Administration narrative summaries all
US firefighting deaths 1994-2004 (n
1144) Excluded deaths associated September 11,
2001 Classified as cardiovascular or
noncardiovascular Excluded deaths more than 24
hours after the on-duty incident Excluded
cardiovascular deaths other than CHD 449 deaths
due to CHD (39). Selected deaths classified
according to the specific duty performed during
onset of symptoms/ immediately preceding sudden
death.
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Duty-related Risks Interpretation

• Fire Suppression Heavy Physical Exertion,
• gt 50 lbs PPE, Near Maximal, Heat Stress Fluid
  losses, Smoke Exposure, Danger Stress
• Training Risk concentrated in live-fire/simulatio
  n drills (exposures as above)
• Physical testing in persons without adequate
  medical clearance.
• Alarm Response Fight or Flight physiology with
  full cardiovascular arousal, Noise

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On-Duty CHD Death Work-related? Conclusions

• Both circadian and job activity data support that
  on-duty CHD death is often job-precipitated.
• Events within a day of firefighting or onset
  during strenuous duty resulting in
  cardiovascular arousal support work-relatedness.
• Does not include
• Non-emergency duty, Most EMS work, Off-duty

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CHD Death Risk by Age and Duty
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Potential Personal Cardiovascular Risk Factors

• Poor exercise tolerance
• High prevalences of obesity and
  hypercholesterolemia
• Hypertension and Dyslipidemia often untreated
• Most firefighters do not receive regular periodic
  examinations

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Obesity Trends Among U.S. Adults1991, 1996,
2003 (CDC)
(BMI ?30, or about 30 lbs overweight for 54
person)
1996
2003
No Data lt10 1014 1519
2024 25
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Obesity Trends Among U.S. Adults 2006 (CDC)
No Data lt10 1014
1519 2024 2529
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1996- Present Obesity Prevalence 30-40
Professionals 45 Volunteers (NVFC)
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OBESITY

• Adverse Effects in Firefighters
• Blood Pressure
• Pulmonary Function
• Exercise Tolerance
• Lipids
• Liver Function
• Cardiovascular Risk Factor clustering
• Adverse Employment Outcomes

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Independent Adverse Associations of Hypertension
in Firefighters
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• Reviewed all completed fatality reports on NIOSH
  website from 1996- December 2002.
• 52 male firefighters who died of CHD
• (69 autopsies 12 known pre-morbid CHD)
• 310 firefighters examined in 1996 and documented
  as professionally active in firefighting in 1998

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Heart Retirements

• Describe Massachusetts firefighters receiving
  pensions under state Heart Presumption
  legislation
• 1997-2004 All cases approved by PERAC after
  review by PERAC-appointed medical panels.

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Research Plan

• Controls Active- Non-retired Firefighters drawn
  from all regions of Massachusetts
• 310 male firefighters examined in 1996/1997,
  whose vital status and continued professional
  activity were re-documented in 1998.

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Results

• 362 Heart presumption retirements
• 278 CHD retirements (77)
• 84 Non-CHD retirements
• HTN 30 (36)
• AFIB, Flutter or SVT 19 (23)
• Cardiomyopathy 11 (13)
• CVA 11 (13)
• Syncope 5 (6)
• Aortic Aneurysm 4 (5)
• Other 4 (5)

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Predictors of Fatal on-Duty CHD Events (vs.
Non-Fatal Events)
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A. Fire Fighter Fatality Investigation and
Prevention Program of NIOSH On-Duty Fatalities
reported between January 1996 and July 2006.
B. Massachusetts Heart Disease Disability
Pensions received between 1997 and 2004. 362
Pension Awardees
84 non-CHD Pensions
NON-Cardiovascular Deaths
288 CHD Pensions
110 Cardiovascular Deaths
5 deaths gt 24 hours from event
173 CHD pensions NOT related to a specific
on-Duty event
105 Acute Cardiovascular Deaths within 24 hours
115 CHD Pensions linked to Specific On-Duty Events
14 Non- CHD Deaths
1 Cocaine Related Death
2 Fatalities
90 Acute On-Duty CHD Fatalities (cases)
113 Non-Fatal, On-Duty CHD Events (controls)
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Multivariate Odds Ratios adjusted for all other
Risk Factors in the table, as well as
professional status, age above/below 45 years and
strenuous duty.
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PREVENTION 1

• Fitness Promotion
• Physical Standards not maintained high
  prevalence of obesity (gt33)
• 75 Nationally- NO fitness programs
• Mandatory exercise programs
• Nutrition programs
• Flu Shots

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USA Today Wed, August 29, 2007 Firefighters
plagued by heart attacks get fitness challenge
I would rather fire you for your health than to
go tell your wife or your mother that you're
laying out here with a heart attack, dead" Chief
Jolley
Each quarter, Pelham-Batesville (SC) firefighters
take a test that includes running, push-ups,
sit-ups and a flexibility test.
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PREVENTION 2

• Medical Screening
• Few CHD fatalities or Retirements had a FD
  medical w/in 48 months of their event
• Ideally should integrate occupational exams with
  primary care follow-up

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CHD Death Risk by Age and Duty
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PREVENTION 3

• Risk Factor Reduction
• Low rates of HTN and lipid treatment
• Change Blood Pressure Standards
• Data supports Smoking BAN
• Exercise Testing
• Should be mandated gt45 and sooner if excess risk
  factors, study needed to determine best protocols

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PREVENTION 4

• 5) RTW Protocols
• Need Occupational Medicine Clearance after
  Illness or Injury
• 6) Pre-Existing CHD
• Once CHD is diagnosed, most affected
  Firefighters should be removed from Emergency
  Operations

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• Major Study Team Members 1996-2007
• Elpidoforos Soteriades, MD, MSc, ScD
• Jonathan Holder, DO, MPH
• Costas Christophi, PhD
• Ibe Mbanu MD, MPH
• Jesse Geibe, MD, MPH
• Gerry Polyhronopoulos, MD
• Jon Aldrich, MD
• Stavros Christoudias
• Antonios Tsismenakis
• David Christiani, MD, MPH, MS Professor
  Director Occupational Health Program, HSPH

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• Bibliography
• Kales SN, Polyhronopoulos GN, Aldrich JM, Leitao
  ED, Christiani DC. Correlates of body mass index
  in hazardous materials firefighters. J Occup and
  Environ Med 199941 589-595.
• Kales SN, Christiani DC. Cardiovascular Fitness
  in Firefighters. Journal of Occupational and
  Environmental Medicine 2000 42 467-468.
• Kales SN, Soteriades ES, Christoudias SG, Tucker
  S, Nicolaou M, Christiani DC. Firefighters blood
  pressure and Employment Status on Hazardous
  Materials Teams in Massachusetts A Prospective
  Study. J Occup Env Med 200244669-676.
• Soteriades ES, Kales SN, Christoudias, SG, Tucker
  S, Liarokapis D, Christiani, DC. The Lipid
  Profile of Firefighters Over Time Opportunities
  for Prevention. J Occup Env Med 200244840-846.

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• Bibliography
• Soteriades ES, Kales SN, Liarokapis D,
  Christiani, DC. Prospective Surveillance of
  Hypertension in Firefighters. J Clinical
  Hypertension 2003 5315-321.
• Kales SN, Soteriades ES, Christoudias SG,
  Christiani DC. Firefighters and On-Duty Deaths
  from Coronary Heart Disease a Case Control
  Study. Environmental Health A Global Access
  Science Source 2003, 214.
• Soteriades ES, Hauser R, Kawachi I, Liarokapis D,
  Christiani DC, Kales SN. Obesity and
  Cardiovascular Disease Risk Factors in
  Firefighters A Prospective Cohort Study. Obesity
  Research 200513 1756-1763.
• Holder JD, Stalling L, Peeples L, Burress JW,
  Kales SN. Firefighter Heart Presumption
  Retirements in Massachusetts 1997-2004. J Occup
  Environ Med. 2006 481047-1053.
• Kales SN, Soteriades ES, Christouphi CA,
  Christiani DC. Emergency Duties and Deaths from
  Heart Disease among Firefighters in the United
  States. N Engl J Med 20073561207-1215.
• Mbanu I, Wellenius GA, Mittleman MA, Peeples L,
  Stallings LA, Kales SN. Seasonality and Coronary
  Heart Disease Deaths in United States
  Firefighters. Chronobiol Int. 2007 24 715726.