Cardiovascular Disease: a Continuing Threat to Homeland Defense

First responders—firefighters, police, and rescue squad members—are in the front line of homeland defense, not only during terrorist attacks, but also in any emergency or natural disaster. These highly trained and motivated individuals often make a difference in human life. Between periods of inactivity, they face high stress and life-threatening personal danger while exerting sustained physical effort with intense energy demands for as long as it takes, whenever needed, without concern for personal safety. Heart attack is second only to injury or asphyxiation in causing firefighter deaths while on duty.1 All on-duty firefighter deaths are investigated by the US Fire Administration within the Federal Emergency Management Agency. During the period 1990–2000, 44% of all on-duty deaths were due to cardiovascular disease. In 2000 there were 42 heart attacks and two strokes among the 102 deaths that year.1 This annual death rate was less than the 62% of on-duty firefighter deaths due to cardiovascular disease in 1967.1 The incidence of firefighter on-duty heart attacks is age dependent, causing 34% of annual deaths in the 36–40 year age group and increasing to 76% in those aged 56–60 years.1 The yearly firefighter heart attack death rate is greater than that which occurs in other physically demanding occupations like construction.1 The article by Soteriades et al.2 in this issue of The Journal of Clinical Hypertension provides insight into factors underlying the high rate of firefighter heart attacks (coronary artery disease) and provides another view of community hypertension control rates. The article reports the prevalence of six coronary artery risk factors during three annual physical examinations (1996, 1998, 2000) in a group of almost all male Massachusetts firefighters who volunteered for Hazard Materials teams. At the first examination, 41.3% (138/334) had either high-normal or Stage I or II hypertension. Whether hypertensive or normotensive, 35% (115/330) had a body mass index of 35,10% (32/333) reported smoking, 23% (74/321) had elevated blood cholesterol, 32% (65/203) had elevated serum triglycerides, and 4% (6/146) had elevated blood glucose. Thirty-six percent of the firefighters had a serum creatinine >1.2 mg%. While this may represent renal insufficiency, it may only represent increased muscle mass because firefighters often engage in bodybuilding exercise. It was not reported how many firefighters had multiple risk factors; however, the presence of 408 total risk factors among 334 individuals indicates that some had more than one. Individuals often have multiple risk factors.3 This report does not provide the risk factor prevalence other than for hypertension at the two subsequent examinations. In this group of predominantly older men with one or more risk factors, increased risk for coronary artery mortality is present. At each of the three examinations, one of every five firefighters was either hypertensive or was receiving antihypertensive medications. Over the study period there was an increasing number of hypertensive subjects receiving antihypertensive medications and having blood pressure reduced to <140/90 mm Hg (8%, 14%, and 26%, respectively). However, the majority of the hypertensives did not have their blood pressure controlled to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) recommended goal level.4 The National Fire Protection Association (NFPA) has published recommendations for fire departments concerning medical screening and fitness for duty.5 Medical evaluations, healthful lifestyles, and physical conditioning are recommended. Physician-performed medical examination is recommended for all firefighters including new applicants. Standards for medical fitness-for-duty are defined by the NFPA. A report of the medical evaluation is given to the firefighter with recommendations for follow-up with a personal physician. The choice to seek appropriate treatment is left to the firefighter, and the treatment received is left to the firefighter's physician. It should be recognized that such medical evaluation programs are not available in all fire departments, and it is estimated that 73% of all fire departments consists of volunteers.1 There are NFPA standards for adequacy of hypertension and diabetes mellitus control. In 2003, these inexplicably define controlled hypertension as <180/100 mm Hg without end organ damage as a Category B NFPA medical condition, meaning the firefighter is fit for duty if he or she can perform certain physical activities with the condition.5 The 2002 NFPA definition of “controlled hypertension” is difficult to understand since the excepted goal for hypertension control is <140/90 mm Hg.4 There are no NFPA standards for periodic lipid screening or treatment or for further cardiac evaluation of asymptomatic firefighters with one or more coronary artery disease risk factors. This is inappropriate in light of the demonstrated benefit in coronary artery mortality that can be realized when hypertension and hyperlipemia are treated to currently recommended levels.4,6 The rate of hypertension control among these Massachusetts firefighters was similar to that reported in the general population, which remains unacceptably low.4 Hypertension control has been improving in one group of hypertensives. The percentage of hypertensive patients with blood pressure <140/90 mm Hg within commercial managed care organizations that participate in the National Committee on Quality Assurance Health Plan Data and Information (HEDIS). Performance Measures has increased from 39% in 1999 to 55% in 2001.7 Poor hypertension control is multifactoral.8 Physicians should be more aggressive in their efforts to control hypertension and should utilize treatments that are effective, practical, and affordable. Hypertension treatment delivered at the worksite, as noted by the authors, would be very applicable to firefighters, and it has been shown to improve blood pressure control and to reduce morbidity, mortality, and the cost of long-term care for cardiovascular disease.9 Several conclusions can be made: Older firefighters can have one or more coronary artery risk factors, which increases their risk for premature death. Comprehensive risk factor assessment is needed in these individuals. Medical screening for firefighters should include lipid measurements and utilize hyperlipemia and hypertension treatment goals consistent with cur rently recommended standards. Older individuals with one or more coronary artery risk factors who are seeking high-stress and physically demanding jobs, like firefighters, should be referred for cardiac evaluation before being submitted to employment task competency. Hypertension control among hypertensive fire fighters, as in the general population, should be improved. It is unfortunate that firefighters like those in the current study, who place their life on the line for others, have so many untreated coronary artery disease risk factors. Risk factors place not only them at mortal risk but also those they attempt to assist. Just as Al-Qaeda works silently in the shadows to cause unexpected injury to targeted individuals, untreated coronary artery risk factors cause unexpected morbidity and mortality among those on whom we often depend the most. Every possible effort should be made to prevent this from happening.