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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Type of Duty Kales et al 2003 (relative risk of CHD death) Holder et al 2006 (relative risk of heart event leading to retirement) Kales et al 2007 (relative risk of CHD death)
Fire suppression OR (95 CI) 64.1 (7.4-556) 51 (12-223) 53 (40-72)
Physical training OR (95CI) 7.6 (1.8-31.3) 0.68 (0.2-2.7) 5.2 (3.6-7.5)
Alarm response OR (95 CI) 5.6 (1.1-28.8) 6.4 (2.5-17) 7.4 (5.1-11)
Alarm return OR (95 CI) 3.4 (0.8-14.7) 0.37 (0.07-1.8) 5.8 (4.1-8.1)
EMS and other non-fire emergencies OR (95 CI) 1.7 (0.5-5.9) 0.75 (0.3-1.8) 1.3 (0.9-2.0)
Firehouse and other non-emergency activities OR (95 CI) 1.0 1.0 1.0
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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
Endpoint Hypertension Criteria Adjusted OR or Hazard Ratio (95 CI) Study Design
Adverse Change in Employment Stage II BP Stage II BP No BP Meds 2.9 (1.1-8.1) 4.6 (2.1-10.1) Prospective Cohort
CHD Retirement gt/140/90, Diagnosis of Hypertension, or Antihypertensive Medication 1.2 (0.6 2.4) Retrospective Case-Control
Non-CHD Cardiovascular Retirement gt/140/90, Diagnosis of Hypertension, or Antihypertensive Medication 4.8 (1.3-17.9) Retrospective Case-Control
On-Duty CHD Death gt/140/90, Diagnosis of Hypertension, or Antihypertensive Medication 4.7 (2.0-11.1) Retrospective Case-Control
Case-Fatality for On-Duty CHD Events gt/140/90, Diagnosis of Hypertension, or Antihypertensive Medication 2.9 (1.3-6.3) Cross-Sect. Case-Fatality
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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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CHD Retirements versus Active Firefighters (Controls) CHD Retirements versus Active Firefighters (Controls) CHD Retirements versus Active Firefighters (Controls) CHD Retirements versus Active Firefighters (Controls)
CHD Retirements (n277) (n) Active Firefighters (n310) (n) OR (95 CI) and MultiVar OR (95CI)
Age 45 years old 94.2 (261) 20.7 (64) 62.7 (35 111) 52 (19.4 139.4)
Current Smoking 30.3 (76) 10.0 (31) 3.9 (2.5 - 6.2) 2.9 (1.3 6.3)
Hypertension 59.0 (141) 21.0 (65) 5.4 (3.7 - 7.9) 1.2 (0.6 2.4)
Diabetes Mellitus 25.7 (62) 2.6 (8) 13.0 (6.1 - 27.8) 5.0 (1.7 15.4)
Cholesterol gt/ 5.18 mmol/L (200 mg/dl) 80.5 (169) 63.2 (196) 2.4 (1.6 3.6) 0.8 (0.4 1.6)
Prior Diagnosis of CHD 22.4 (48) 1.0 (3) 29.6 (9.1 96.5) 8.8 (1.9 41.3)
Obesity, BMI gt/30 41.4 (98) 34.1 (104) 1.4 (0.96 1.93) 0.7 (0.3 1.3)
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Non-CHD Retirements versus Active Firefighters (Controls) Non-CHD Retirements versus Active Firefighters (Controls) Non-CHD Retirements versus Active Firefighters (Controls) Non-CHD Retirements versus Active Firefighters (Controls)
Non-CHD Retirements (n84) (n) Active Firefighters (n310) (n) OR (95 CI) and MultiVar OR (95 CI)
Age 45 years old 86.8 (72) 20.7 (64) 25.5 (12.8 50.9) 7.8 (2.0 31.4)
Age gt/50 years old 77.1 (64) 4.5 (14) 72.3 (34.5 151.7)
Current Smoking 21.7 (13) 10.0 (31) 2.5 (1.2 5.1) 2.9 (0.6 13.6)
Hypertension 75.3 (55) 21.0 (65) 10.9 (6.1 19.7) 4.8 (1.3 17.9)
Diabetes Mellitus 17.0 (10) 2.6 (8) 7.7 (2.9 20.3) 4.3 (0.7 27.8)
Cholesterol gt/ 5.18 mmol/L (200 mg/dl) 64.7 (22) 63.2 (196) 1.1 (0.51 2.24) 1.3 (0.3 5.5)
Obesity, BMI gt/30 66.1 (41) 34.1 (104) 3.6 (2.0 6.4) 2.9 (0.8 11.4)
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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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Table 1 Characteristics Of On Duty CHD Events Table 1 Characteristics Of On Duty CHD Events Table 1 Characteristics Of On Duty CHD Events Table 1 Characteristics Of On Duty CHD Events
Non Fatal Events (n113) (n) Fatal Events (n90) (n) P-Value
Mean Age /- SD (years) 54.5 /- 6.6 50.5 /- 7.4 lt0.001
Age Range (years) 33-66 29-69 N/A
Male 100 (113) 100 (90) --------
Professional Firefighters 100 (113) 63 (56) lt0.001
Mean BMI /- SD 30.3 /- 5.7 (n86) 31.2 /- 6.2 (n33) 0.466
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Type of Duty at Time of Event Fire Suppression Alarm Response Alarm Return Physical Training Non-fire Emergency Non-Emergency Duty (n) 40 (36) 18 (16) 1 (1) 3 (3) 11 (10) 27 (24) (n90) (n) 31 (28) 8 (7) 11 (10) 16 (14) 10 (9) 24 (22) 0.001
Strenuous Duty at Time of Event 62 (56) (n90) 66 (59) 0.642
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Bivariate Odds Ratios for Fatal Outcome among On Duty CHD Events Bivariate Odds Ratios for Fatal Outcome among On Duty CHD Events Bivariate Odds Ratios for Fatal Outcome among On Duty CHD Events Bivariate Odds Ratios for Fatal Outcome among On Duty CHD Events
Non Fatal Events n113 (n) Fatal Events n90 (n) Odds Ratio for Fatal Event (95 CI)
Age 45 years old 95 (107) 79 (71) 0.21 (0.08-0.55)
Current Smoking 24 (27) 41 (37) 2.22 (1.22-4.06)
Hypertension 49 (55) 68 (61) 2.22 (1.25-3.94)
Diabetes Mellitus 21 (24) 13 (12) 0.57 (0.27-1.22)
Cholesterol gt/ 5.18 mmol/L (200 mg/dl) 58 (66) 63 (57) 1.23 (0.70-2.17)
Prior Diagnosis of CHD/arterial-occlusive disease 18 (20) 34 (31) 2.44 (1.28-4.68)
Obesity, BMI gt/30 41 (35) (n86) 61 (20) (n33) 2.24 (0.99-5.09)
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Multivariate Odds Ratios for Fatal Outcome among On Duty CHD Events Multivariate Odds Ratios for Fatal Outcome among On Duty CHD Events Multivariate Odds Ratios for Fatal Outcome among On Duty CHD Events
Multivariate OR (95 CI) P- Value
Current Smoking 4.25 (1.86, 9.74) lt0.001
Hypertension 2.89 (1.32, 6.34) 0.008
Diabetes Mellitus 0.28 (0.09, 0.86) 0.03
Cholesterol gt/ 5.18 mmol/L (200 mg/dl) 1.17 (0.54, 2.57) 0.69
Prior Diagnosis of CHD / arterial-occlusive disease 5.29 (2.06, 13.59) lt0.001
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.