Heart Disease in Firefighters STEFANOS N. KALES, MD, MPH, FACP, FACOEM STEFANOS N. KALES, MD, MPH,...

Heart Disease in FirefightersHeart Disease in Firefighters

STEFANOS N. KALES,STEFANOS N. KALES, MD, MPH, FACP, FACOEMMD, 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

Kales et al

BackgroundBackground

• 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 OccupationHeart Deaths by Occupation

% of On-Duty Deaths % of On-Duty Deaths caused by CVD caused by CVD

Firefighters Firefighters 45%45%

PolicePolice 22%22%

Overall*Overall* 15%15%

ConstructionConstruction 11.5%11.5%

EMSEMS 11%11%

*Average % of all Occupational Fatalities, *Average % of all Occupational Fatalities, all industriesall industries

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Development of Atherosclerotic Plaques

Normal

Fatty streak

Foam cells

Lipid-rich plaque

Lipid core

Fibrous cap

Thrombus

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DeathDeath

DiseaseDisease

DisabilityDisability

Age Age

BMI/ Body BMI/ Body CompositionComposition

DyslipidemiaDyslipidemia

HypertensionHypertension

FamilyFamily

HistoryHistory

DiabetesDiabetes

Hypertrophy +/-Hypertrophy +/-Known CHDKnown CHD

SubclinicalSubclinicalDiseaseDisease

Regular Exercise/ activity +Regular Exercise/ activity +Moderate EtOH +Moderate EtOH +Diet - / +Diet - / +Tobacco -Tobacco -Irregular Physical Exertion -Irregular Physical Exertion -Pollution/Gases -Pollution/Gases -Noise -Noise -Shift Work -Shift Work -Job Stress with Low Control -Job Stress with Low Control -

THEORETICAL MODEL OF CVD THEORETICAL MODEL OF CVD

Pro-Inflammatory – (bad); Anti-Inflammatory + (good)

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Cohort Studies vs. Presumption LawsCohort Studies vs. Presumption Laws

• Definitive evidence of an Definitive evidence of an increased CHD risk in increased CHD risk in Firefighters lacking. Firefighters lacking.

• Based on >/=10 cohort Based on >/=10 cohort mortality studiesmortality studies Firefighters’ risk of CHD Death

SMR of ~0.9

• High proportion of High proportion of CHD deaths and CHD deaths and recognition of recognition of Cardiovascular Cardiovascular Stressors has led toStressors has led to

“ “Heart Presumption” Heart Presumption”

laws in 37 / 50 states laws in 37 / 50 states and 2 Canadian and 2 Canadian ProvincesProvinces

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On-Duty Events, Work-Related or On-Duty Events, Work-Related or Just happen at Work???Just happen at Work???

Potential Occupational Cardiovascular Potential Occupational Cardiovascular StressorsStressors

Heavy Physical Exertion - on an Irregular Basis

> 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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Circadian Distribution of Firefighter Fatalities

Compared with the Distribution of Emergency Calls

Quartile of time of day

1800-23591200-17590600-11590000-0559

Pe

rce

nt

50

40

30

20

10

0

Trauma Death

CHD Death

EC = Emergency Calls

EC

EC

ECEC

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Circadian Distribution of CHD Deaths

Present Study and 1990-2000 FEMA Study

Comparison to Emergency Calls


1800-2359

1200-1759

0600-1159

0000-0559

Perc

ent

50

40

30

20

10

0

CHD Present Study

CHD 1990-2000 FEMA

EC

EC

ECEC

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Circadian Distribution of CHD Deaths

for Firefighters and the General Population


1800-23591200-17590600-11590000-0559

Pe

rce

nt

50

40

30

20

10

0

Firef ighters

General Population

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CHD Deaths vs. Time Spent in

Each Activity

Job Activity

Pe

rce

nt

60

50

40

30

20

10

0

Cardiac/Non Cardiac

% of CHD Deaths

Average % of Time

Spent per Year

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Type of Duty

Actual CHD Deaths

(N=52) %(n)

Expected Deaths

(N=52) %(n)

Estimated OR relative to Non-Emergency Duty

OR (95%CI)

p Value

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 _

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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** (95%CI£)

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: InterpretationDuty-related Risks: Interpretation

• 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

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On-Duty CHD Death: Work-related? On-Duty CHD Death: Work-related? ConclusionsConclusions

Both circadian and job activity data support Both circadian and job activity data support that on-duty CHD death is often job-that on-duty CHD death is often job-precipitated.precipitated.

Events within a day of firefighting or onset Events within a day of firefighting or onset during strenuous dutyduring strenuous duty** resulting in resulting in cardiovascular arousal support work-cardiovascular arousal support work-relatedness.relatedness.

* Does not include * Does not include

Non-emergency duty, Most EMS work, Off-dutyNon-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 Potential Personal Cardiovascular Risk FactorsRisk Factors

Poor exercise tolerance

High prevalences of obesity and hypercholesterolemia

Hypertension and Dyslipidemia often untreated

Most firefighters do not receive regular periodic examinations

19961991

2003

Obesity Trends* Among U.S. Adults1991, 1996, 2003 (CDC)

(*BMI 30, or about 30 lbs overweight for 5’4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends Among U.S. Adults 2006 (CDC)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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30.00 35.00 40.00

Mean Age

25.00

26.00

27.00

28.00

29.00

30.00

Me

an

BM

I

1992

1990

199619981999

2001

2001

2005

Relation to Age & Year of Cohort

Mean BMI among N. American Firefighters

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

Independent Adverse Associations Independent Adverse Associations of Hypertension in Firefightersof 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 >/=140/90, Diagnosis of

Hypertension, or Antihypertensive Medication

1.2 (0.6 –2.4) RetrospectiveCase-Control

Non-CHD Cardiovascular Retirement

4.8 (1.3-17.9)

On-Duty CHD Death

4.7 (2.0-11.1)

Case-Fatality for On-Duty CHD Events

2.9 (1.3-6.3) Cross-Sect.Case-Fatality

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Reviewed all completed fatality reports on NIOSH Reviewed all completed fatality reports on NIOSH website from 1996- December 2002.website from 1996- December 2002.

52 male firefighters who died of CHD52 male firefighters who died of CHD

(69% autopsies + 12% known pre-morbid CHD)(69% autopsies + 12% known pre-morbid CHD)

310 firefighters examined in 1996 and documented as 310 firefighters examined in 1996 and documented as professionally active in firefighting in 1998professionally 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)

CHDRetirements

(n=277)% (n)

ActiveFirefighters

(n=310)% (n)

OR (95% CI) and

MultiVar OR(95%CI)

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 >/= 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 >/=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-CHDRetirements

(n=84)% (n)

ActiveFirefighters

(n=310)% (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 >/=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)


64.7 (22) 63.2 (196) 1.1 (0.51 – 2.24)1.3 (0.3 – 5.5)

Obesity, BMI >/=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

110 Cardiovascular Deaths

5 deaths > 24 hours from event 105 Acute

Cardiovascular Deaths within 24 hours

14 Non- CHD Deaths

1 Cocaine Related Death

90 Acute On-Duty CHD Fatalities (cases)

84 non-CHD Pensions

288 CHD Pensions

173 CHD pensions NOT related to a specific on-Duty event115 CHD Pensions

linked to Specific On-Duty Events

113 Non-Fatal, On-Duty CHD Events (controls)

2 Fatalities

NON-Cardiovascular Deaths

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Table 1: Characteristics Of On Duty CHD Events

Non Fatal Events

(n=113)% (n)

Fatal Events(n=90)% (n)

P-Value

Mean Age +/- SD (years) 54.5 +/- 6.6 50.5 +/- 7.4 <0.001

Age Range (years) 33-66 29-69 N/A

% Male 100 (113) 100 (90) --------

% Professional Firefighters 100 (113) 63 (56) <0.001

Mean BMI +/- SD 30.3 +/- 5.7(n=86)

31.2 +/- 6.2(n=33)

0.466

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Type of Duty at Time of Event Fire Suppression

Alarm ResponseAlarm Return

Physical TrainingNon-fire Emergency

Non-Emergency Duty

% (n)

40 (36)18 (16)1 (1)3 (3)

11 (10)27 (24)(n=90)

% (n)

31 (28)8 (7)

11 (10)16 (14)10 (9)

24 (22)

0.001

Strenuous Duty at Time of Event #

62 (56)(n=90)

66 (59) 0.642

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Bivariate Odds Ratios for Fatal Outcome among On Duty CHD Events

Non Fatal Eventsn=113% (n)

Fatal Eventsn=90% (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)


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 >/=30 41 (35) (n=86)

61 (20)(n=33)

2.24 (0.99-5.09)

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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)

<0.001

Hypertension 2.89(1.32, 6.34)

0.008

Diabetes Mellitus 0.28(0.09, 0.86)

0.03


1.17(0.54, 2.57)

0.69

Prior Diagnosis of CHD / arterial-occlusive disease

5.29(2.06, 13.59)

<0.001

* 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 1PREVENTION 1

1)1) Fitness Promotion: Fitness Promotion: Physical Standards not maintained; high Physical Standards not maintained; high prevalence of obesity (>33%); prevalence of obesity (>33%);

~75% Nationally- NO fitness programs~75% Nationally- NO fitness programs

Mandatory exercise programsMandatory exercise programs

Nutrition programsNutrition programs

Flu ShotsFlu Shots

USA Today Wed, August 29, 2007 USA Today Wed, August 29, 2007

““Firefighters plagued by heart attacks get fitness challenge” Firefighters plagued by heart attacks get fitness challenge”

““I would rather fire I would rather fire you for your health you for your health than to go tell your than to go tell your wife or your mother wife or your mother

that you're laying out that you're laying out here with a heart here with a heart

attack, dead" attack, dead"

Chief JolleyChief Jolley

Each quarter, Pelham-Batesville (SC) firefighters Each quarter, Pelham-Batesville (SC) firefighters take a test that includes running, push-ups, sit-ups take a test that includes running, push-ups, sit-ups

and a flexibility test.and a flexibility test.

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2)2) Medical Screening: Medical Screening: Few CHD fatalities or Retirements had Few CHD fatalities or Retirements had a FD medical w/in 48 months of their a FD medical w/in 48 months of their eventevent

Ideally should integrate occupational Ideally should integrate occupational exams with primary care follow-upexams with primary care follow-up

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CHD Death Risk by Age and Duty

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3)3) Risk Factor Reduction: Risk Factor Reduction: Low rates of HTN and lipid treatmentLow rates of HTN and lipid treatment

Change Blood Pressure StandardsChange Blood Pressure Standards

Data supports Smoking BANData supports Smoking BAN

4)4) Exercise Testing: Exercise Testing: Should be mandated >45 and sooner if Should be mandated >45 and sooner if

excess risk factors, study needed to excess risk factors, study needed to determine best protocolsdetermine best protocols

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5) RTW Protocols: 5) RTW Protocols: Need Occupational Medicine Clearance after Need Occupational Medicine Clearance after

Illness or InjuryIllness or Injury

6) Pre-Existing CHD:6) Pre-Existing CHD: Once CHD is diagnosed, most affected Once CHD is diagnosed, most affected

Firefighters should be removed from Firefighters should be removed from Emergency OperationsEmergency Operations

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Major Study Team Members 1996-2007

Elpidoforos Soteriades, MD, MSc, ScDJonathan Holder, DO, MPHCostas Christophi, PhDIbe Mbanu MD, MPHJesse Geibe, MD, MPHGerry Polyhronopoulos, MDJon Aldrich, MDStavros ChristoudiasAntonios TsismenakisDavid 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 1999;41: 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 2002;44:669-676.

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 2002;44:840-846.

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Bibliography

Soteriades ES, Kales SN, Liarokapis D, Christiani, DC. Prospective Surveillance of Hypertension in Firefighters. J Clinical Hypertension 2003; 5:315-321.

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, 2:14.

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 2005;13: 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; 48:1047-1053.

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 2007;356:1207-1215.

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: 715–726.

Heart Disease in Firefighters STEFANOS N. KALES, MD, MPH, FACP, FACOEM STEFANOS N. KALES, MD, MPH,...

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