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Heart Disease in Firefighters

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,

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Heart Disease in Firefighters

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  1. 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

  2. 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% Background Kales et al

  3. US Firefighter Fatalities 45% Heart Disease 25% Motor Vehicle Related 12% Asphyxiation 18% Burns, Other Trauma, other Kales et al

  4. % 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 Heart Deaths by Occupation Kales et al

  5. Development of Atherosclerotic Plaques Fatty streak Normal Lipid-rich plaque Foam cells Fibrous cap Lipid core Thrombus Kales et al

  6. Age BMI/ Body Composition Hypertension Dyslipidemia Diabetes Family History 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) Kales et al

  7. Definitive evidence of an increased CHD risk in Firefighters lacking. Based on >/=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 Cohort Studies vs. Presumption Laws Kales et al

  8. Heavy Physical Exertion - on an Irregular Basis > 50 lbs Personal Protective Equipment Near Maximal-Maximal HR (at least 10 METS) Heat Stress & Fluid losses On-Duty Events, Work-Related or Just happen at Work???Potential Occupational Cardiovascular Stressors Kales et al

  9. Methods: Case-control study, 52 male firefighters CHD deaths investigated by NIOSH. Control population: 51 male firefighters on-duty trauma deaths Kales et al

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  14. Actual CHD Deaths (N=52) %(n) Expected Deaths (N=52) %(n) Estimated OR relative to Non-Emergency Duty OR (95%CI) p Value Type of Duty Fire Supp. 36 (19) 2 (1) 64.1 (7.4-556) <0.001 Training 17 (9) 8 (4) 7.6 (1.8-31.3) 0.006 Alarm Response 10 (5) 6 (3) 5.6 (1.1-28.8) 0.042 Alarm Return 10 (5) 10 (5) 3.4 (0.8-14.7) 0.12 EMS or Non- Fire Emergency 12 (6) 23 (12) 1.7 (0.5-5.9) 0.52 Fire House and Non-emergency activities 15 (8) 52 (27) 1.0 _ Kales et al

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  16. 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. Kales et al

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  21. Fire Suppression:Heavy Physical Exertion, > 50 lbs PPE, Near Maximal, Heat Stress & Fluid losses, Smoke Exposure, Danger & Stress Training:Risk concentrated in live-fire/simulation drills (exposures as above) & Physical testing in persons without adequate medical clearance. Alarm Response:“Fight or Flight” physiology with full cardiovascular arousal, Noise Duty-related Risks: Interpretation Kales et al

  22. 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 Kales et al

  23. CHD Death Risk by Age and Duty Kales et al

  24. 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 Kales et al

  25. 1991 Obesity Trends* Among U.S. Adults1991, 1996, 2003 (CDC) (*BMI 30, or about 30 lbs overweight for 5’4” person) 1996 2003 No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

  26. Obesity Trends Among U.S. Adults 2006 (CDC) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

  27. 1996- Present: Obesity Prevalence 30-40% Professionals 45% Volunteers (NVFC) Kales et al

  28. OBESITY Adverse Effects in Firefighters: Blood Pressure Pulmonary Function Exercise Tolerance Lipids Liver Function Cardiovascular Risk Factor clustering Adverse Employment Outcomes Kales et al

  29. Independent Adverse Associations of Hypertension in Firefighters

  30. 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 Kales et al

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  32. 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. Kales et al

  33. 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. Kales et al

  34. 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%) Kales et al

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  37. Predictors of Fatal on-Duty CHD Events (vs. Non-Fatal Events) Kales et al

  38. 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 > 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) Kales et al

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  42. * 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. Kales et al

  43. PREVENTION 1 • Fitness Promotion: Physical Standards not maintained; high prevalence of obesity (>33%); ~75% Nationally- NO fitness programs Mandatory exercise programs Nutrition programs Flu Shots Kales et al

  44. 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.

  45. 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 Kales et al

  46. CHD Death Risk by Age and Duty Kales et al

  47. 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 >45 and sooner if excess risk factors, study needed to determine best protocols Kales et al

  48. 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 Kales et al

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