Heart Disease in Firefighters

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Kales et al. Background. More than one million firefighters in USAbout 100 firefighters die each year on-Duty (1 in 10,000 per year) 1977-2004, CVD has caused ~45% on-Duty Deaths CHD ~40%. . Kales et al. US Firefighter Fatalities. 45% Heart Disease25% Motor Vehicle Related12% Asphyxiation18% Burns, Other Trauma, other.

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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. 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) 1977-2004, CVD has caused ~45% on-Duty Deaths CHD ~40%

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

4. Kales et al 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

5. Kales et al Development of Atherosclerotic Plaques During the initiation of atherosclerosis, LDL cholesterol accumulates in the subendothelial extracellular space within the arterial wall. Local vascular cells mildly oxidize LDL to a form known as minimally modified LDL, which is able to stimulate recruitment of monocytes and eventual deposition of macrophages.1 These further oxidize LDL to a form that can be scavenged and internalized, resulting in so-called foam cells.1 Such cells form the earliest visible lesion of atherosclerosis, the fatty streak.2 The aggregation of LDL-rich foam cells, derived from macrophages and T lymphocytes within the intima, progresses to development of an atherosclerotic plaque.2 This results from the death and rupture of the lipid-laden foam cells in the fatty streak. A crucial component of the maturing atherosclerotic plaque is the formation of a fibrous cap that separates the highly thrombogenic lipid-rich core from circulating platelets and other coagulation factors.3 Stable atherosclerotic plaques are characterized by the necrotic lipid core covered by a thicker, almost protective vascular smooth muscle cell-rich fibrous cap.3 Such a cap can be better strengthened and maintained by reducing LDL cholesterol.3 References Diaz MN, Frei B, Vita JA, Keaney JF. Antioxidants and atherosclerotic heart disease. New Engl J Med. 1997;337(6):408-416. Ross R. The pathogenesis of atherosclerosis: A perspective for the 1990s. Nature. 1993;362:801-809. Weissberg PL. Atherosclerosis involves more than just lipids: Plaque dynamics. Eur Heart J. 1999;1(suppl T):T13-T18.During the initiation of atherosclerosis, LDL cholesterol accumulates in the subendothelial extracellular space within the arterial wall. Local vascular cells mildly oxidize LDL to a form known as minimally modified LDL, which is able to stimulate recruitment of monocytes and eventual deposition of macrophages.1 These further oxidize LDL to a form that can be scavenged and internalized, resulting in so-called foam cells.1 Such cells form the earliest visible lesion of atherosclerosis, the fatty streak.2 The aggregation of LDL-rich foam cells, derived from macrophages and T lymphocytes within the intima, progresses to development of an atherosclerotic plaque.2 This results from the death and rupture of the lipid-laden foam cells in the fatty streak. A crucial component of the maturing atherosclerotic plaque is the formation of a fibrous cap that separates the highly thrombogenic lipid-rich core from circulating platelets and other coagulation factors.3 Stable atherosclerotic plaques are characterized by the necrotic lipid core covered by a thicker, almost protective vascular smooth muscle cell-rich fibrous cap.3 Such a cap can be better strengthened and maintained by reducing LDL cholesterol.3 References Diaz MN, Frei B, Vita JA, Keaney JF. Antioxidants and atherosclerotic heart disease. New Engl J Med. 1997;337(6):408-416. Ross R. The pathogenesis of atherosclerosis: A perspective for the 1990s. Nature. 1993;362:801-809. Weissberg PL. Atherosclerosis involves more than just lipids: Plaque dynamics. Eur Heart J. 1999;1(suppl T):T13-T18.

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7. Kales et al Cohort Studies vs. Presumption Laws 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

8. 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

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21. 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

22. 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

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25. 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

27. Obesity Trends Among U.S. Adults 2006 (CDC) We have never had an epidemic like this that we have been able to track so thoroughly and see. As I told you, this is conservative. About 60 million adults, or 30 percent of the adult population, are now obese, which represents a doubling of the rate since 1980. We have never had an epidemic like this that we have been able to track so thoroughly and see. As I told you, this is conservative. About 60 million adults, or 30 percent of the adult population, are now obese, which represents a doubling of the rate since 1980.

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

30. Independent Adverse Associations of Hypertension in Firefighters

31. Kales et al 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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34. Kales et al 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.

35. 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.

36. 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%)

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45. Kales et al 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

47. Kales et al 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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49. Kales et al 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

50. 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

51. Kales et al 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

52. 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: 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.

53. Kales et al 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.

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