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

Kales et al Background More than one million firefighters in US About 100 firefighters die each year on- Duty (1 in 10,000 per year) , CVD has caused ~45% on-Duty Deaths CHD ~40%

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

Kales et al Heart Deaths by Occupation % of On-Duty Deaths caused by CVD Firefighters 45% Police22% Overall*15% Construction11.5% EMS11% *Average % of all Occupational Fatalities, all industries

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

Kales et al DeathDiseaseDisability Age BMI/ Body Composition Dyslipidemia Hypertension FamilyHistory Diabetes Hypertrophy +/- Known CHD SubclinicalDisease Regular Exercise/ activity + Moderate EtOH + Diet - / + Tobacco - Irregular Physical Exertion - Pollution/Gases - Noise - Shift Work - Job Stress with Low Control - THEORETICAL MODEL OF CVD Pro-Inflammatory – (bad); Anti-Inflammatory + (good)

Kales et al Cohort Studies vs. Presumption Laws Definitive evidence of an increased CHD risk in Firefighters lacking. Definitive evidence of an increased CHD risk in Firefighters lacking. Based on >/=10 cohort mortality studies 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 High proportion of CHD deaths and recognition of Cardiovascular Stressors has led to “Heart Presumption” laws in 37 / 50 states and 2 Canadian Provinces “Heart Presumption” laws in 37 / 50 states and 2 Canadian Provinces

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

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

Kales et al

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 ( ) <0.001 Training 17 (9)8 (4) 7.6 ( ) Alarm Response 10 (5)6 (3) 5.6 ( ) Alarm Return 10 (5) 3.4 ( ) 0.12 EMS or Non- Fire Emergency 12 (6)23 (12) 1.7 ( ) 0.52 Fire House and Non-emergency activities 15 (8)52 (27)1.0 _

Kales et al

U.S. Fire Administration: narrative summaries all US firefighting deaths (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

Type of DutyKales 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 ( )51 (12-223)53 (40-72) Physical training – OR** (95%CI £ ) 7.6 ( )0.68 ( )5.2 ( ) Alarm response – OR** (95% CI) 5.6 ( )6.4 (2.5-17)7.4 (5.1-11) Alarm return –OR (95% CI £ )3.4 ( )0.37 ( )5.8 ( ) EMS and other non-fire emergencies – OR** (95% CI £ ) 1.7 ( )0.75 ( )1.3 ( ) Firehouse and other non- emergency activities – OR** (95% CI £ ) 1.0

Kales et al Duty-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

Kales et al 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 CHD Death Risk by Age and Duty

Kales et al 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

Obesity Trends* Among U.S. Adults 1991, 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%

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

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

Independent Adverse Associations of Hypertension in Firefighters EndpointHypertension CriteriaAdjusted OR or Hazard Ratio (95% CI) Study Design Adverse Change in Employment Stage II BP Stage II BP & No BP Meds 2.9 ( ) 4.6 ( ) Prospective Cohort CHD Retirement >/=140/90, Diagnosis of Hypertension, or Antihypertensive Medication 1.2 (0.6 –2.4)Retrospective Case-Control Non-CHD Cardiovascular Retirement 4.8 ( ) On-Duty CHD Death 4.7 ( ) Case-Fatality for On-Duty CHD Events 2.9 ( )Cross-Sect. Case-Fatality

Kales et al Reviewed all completed fatality reports on NIOSH website from December 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 professionally active in firefighting in 1998

Kales et al

Heart Retirements Describe Massachusetts firefighters receiving pensions under state “Heart Presumption” legislation : All cases approved by PERAC after review by PERAC- appointed medical panels.

Kales et al 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 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 CHD Retirements versus Active Firefighters (Controls) CHD Retirements (n=277) % (n) Active Firefighters (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 ( ) 2.9 (1.3 – 6.3) Hypertension 59.0 (141)21.0 (65)5.4 ( ) 1.2 (0.6 – 2.4) Diabetes Mellitus 25.7 (62)2.6 (8)13.0 ( ) 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 >/= (98)34.1 (104)1.4 (0.96 – 1.93) 0.7 (0.3 – 1.3)

Kales et al Non-CHD Retirements versus Active Firefighters (Controls) Non-CHD Retirements (n=84) % (n) Active Firefighters (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) Cholesterol >/= 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 >/= (41)34.1 (104)3.6 (2.0 – 6.4) 2.9 (0.8 – 11.4)

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

Kales et al A. Fire Fighter Fatality Investigation and Prevention Program of NIOSH: On-Duty Fatalities reported between January 1996 and July B. Massachusetts Heart Disease Disability Pensions received between 1997 and 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 event 115 CHD Pensions linked to Specific On-Duty Events 113 Non-Fatal, On-Duty CHD Events (controls) 2 Fatalities NON-Cardiovascular Deaths

Kales et al 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 +/ /- 7.4<0.001 Age Range (years) N/A % Male100 (113)100 (90) % Professional Firefighters100 (113)63 (56)<0.001 Mean BMI +/- SD30.3 +/- 5.7 (n=86) /- 6.2 (n=33) 0.466

Kales et al 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) (n=90) % (n) 31 (28) 8 (7) 11 (10) 16 (14) 10 (9) 24 (22) Strenuous Duty at Time of Event # 62 (56) (n=90) 66 (59)0.642

Kales et al Bivariate Odds Ratios for Fatal Outcome among On Duty CHD Events Non Fatal Events n=113 % (n) Fatal Events n=90 % (n) Odds Ratio for Fatal Event (95% CI) Age ≥ 45 years old95 (107)79 (71)0.21 ( ) Current Smoking24 (27)41 (37)2.22 ( ) Hypertension49 (55)68 (61)2.22 ( ) Diabetes Mellitus21 (24)13 (12)0.57 ( ) Cholesterol >/= 5.18 mmol/L (200 mg/dl) 58 (66)63 (57)1.23 ( ) Prior Diagnosis of CHD/arterial-occlusive disease 18 (20)34 (31)2.44 ( ) Obesity, BMI >/=3041 (35) (n=86) 61 (20) (n=33) 2.24 ( )

Kales et al Multivariate Odds Ratios for Fatal Outcome among On Duty CHD Events Multivariate OR (95% CI)* P- Value Current Smoking4.25 (1.86, 9.74) <0.001 Hypertension2.89 (1.32, 6.34) Diabetes Mellitus0.28 (0.09, 0.86) 0.03 Cholesterol >/= 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) <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.

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

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.

Kales et al PREVENTION 2 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 CHD Death Risk by Age and Duty

Kales et al PREVENTION 3 3)Risk Factor Reduction: Low rates of HTN and lipid treatment Change Blood Pressure Standards Data supports Smoking BAN 4)Exercise Testing: Should be mandated >45 and sooner if excess risk factors, study needed to determine best protocols Should be mandated >45 and sooner if excess risk factors, study needed to determine best protocols

Kales et al 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 Once CHD is diagnosed, most affected Firefighters should be removed from Emergency Operations

Kales et al Major Study Team Members 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

Kales et al 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: Kales SN, Christiani DC. Cardiovascular Fitness in Firefighters. Journal of Occupational and Environmental Medicine 2000; 42: 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: 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:

Kales et al Bibliography Soteriades ES, Kales SN, Liarokapis D, Christiani, DC. Prospective Surveillance of Hypertension in Firefighters. J Clinical Hypertension 2003; 5: 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: Holder JD, Stalling L, Peeples L, Burress JW, Kales SN. Firefighter Heart Presumption Retirements in Massachusetts: J Occup Environ Med. 2006; 48: 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: 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.