Heart Disease in Heart Disease in Firefighters Firefighters STEFANOS N. KALES, STEFANOS N. KALES, MD, MPH, MD, MPH, FACP, FACOEM 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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Heart Disease in Firefighters STEFANOS N. KALES, MD, MPH, FACP, FACOEM STEFANOS N. KALES, MD, MPH, FACP, FACOEM MEDICAL DIRECTOR EMPLOYEE HEALTH & INDUSTRIAL.
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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
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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 -
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???
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)
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.
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
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.
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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
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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PREVENTION 2PREVENTION 2
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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PREVENTION 3PREVENTION 3
3)3) Risk Factor Reduction: Risk Factor Reduction: Low rates of HTN and lipid treatmentLow rates of HTN and lipid treatment
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.
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.