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Cardiovascular Risk and Firefighting

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Risks / benefits of RTW discussed. Limitations of research being mostly from ... DCFO agrees RTW Jan '09. Risk to colleagues & the public adequately managed' ... – PowerPoint PPT presentation

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Title: Cardiovascular Risk and Firefighting


1
Cardiovascular Risk and Firefighting
  • Dr Ian Griffiths
  • Consultant Occupational Physician
  • Nottingham University Hospitals
  • March 2009

2
Content
  • Case presentation
  • Cardiovascular disease in Firefighters how much
    of a problem is it?
  • What might cause cardiovascular disease in
    Firefighters?
  • What can we do to reduce any risks?

3
Case Study
  • 41 year old male FF
  • Minor chest discomfort April 08
  • 3 days later, severe chest pain
  • In hospital 7 days
  • Inferior ST elevation MI

4
Risk factors
  • Male (RR 3.1)
  • Ex smoker aged 20
  • Cholesterol 5.6mmol/L
  • No family history
  • Exercise 5 miles of walking or cycling 2 or 3
    days a week
  • Not overweight
  • Lundblad et al, Biomed Central, 2008

5
Treatment
  • Clot busted by paramedics
  • Aspirin 75mg OD
  • Clopidogrel 75mg OD
  • Atorvastatin 40mg OD
  • Ramipril 10mg OD
  • Bisoprolol 2.5mg OD
  • 12 sessions in cardiac rehab

6
Occupational Health Involvement
  • Seen July 08
  • Return to Work after Cardiac illness, British
    Heart Foundation 09/98 states return to full
    activity including work in 4-6 weeks after MI
  • Well, cheerful, symptom free, returned to all
    activities

7
Job
  • WT crew manager
  • Shifts starting 0700 1900
  • No LGV licence
  • Likes job

8
Examination findings
  • Optimistic and positive
  • Realistic
  • Not overweight
  • P 48 regular
  • BP 128/76
  • No signs of heart failure

9
Advice to management July 08
  • Fit for any work except firefighting
  • Await info from specialist (asking specific
    questions)
  • Needs careful thought on risks of returning to
  • Firefighting
  • Shift work

10
Coronary Artery anatomy

11
Reply from specialist October 08
  • Angiogram May 08
  • Left main disease free
  • LAD modest stenosis in mid vessel, about 50
  • Circumflex plaque disease
  • RCA dominant, modest stenosis in mid vessel,
    presumably the cause of the infarct
  • Small area hypokinesia inferior wall

12
What constitutes significant narrowing?
  • Significant flow limitation occurs when there is
    a 50 reduction in diameter
  • Flow limitation sufficient enough to produce
    effort angina does not usually occur until there
    is greater than 70 reduction in luminal diameter
  • Medical and Occupational Evidence for Recruitment
    and Retention in the Fire and Rescue Service,
    ODPM, Sept 2004

13
Reply from specialist October 08
  • Best managed medically
  • Long-term outlook good because of preserved LV
    function and minor atheroma
  • Needs aggressive medical therapy in light of
    cardiac event aged 40

14
Guidance from the Bible
  • In asymptomatic individuals already in service,
    full post-infarction assessment, including stress
    testing is required.
  • A negative stress test should include no
    symptoms, no significant ST changes and the
    individual should have completed Stage III (at
    least 9 minutes) of the Bruce Protocol with no
    anti-anginal therapy. Any doubt about the stress
    test should lead to angiography.
  • Medical and Occupational Evidence for Recruitment
    and Retention in the Fire and Rescue Service,
    ODPM, Sept 2004

15
Advice to management Oct 08
  • Given reported levels of exercise, hed have no
    difficulty in undertaking tasks demanded of him
    as a FF
  • However, need to consider risks of further
    cardiac event associated with FFing and/or shift
    work

16
Subsequent Developments
  • Meeting with DCFO late Nov 08
  • Risks / benefits of RTW discussed
  • Limitations of research being mostly from USA
    apparent

17
Subsequent Developments (2)
  • DCFO agrees RTW Jan 09
  • Risk to colleagues the public adequately
    managed
  • Risks to you from shift work and emergency
    response are present
  • Asked to agree content of letter by signing
    returning it

18
Discussion
  • Do UK FFs have an excess of CVD?
  • US data showing numbers of MIs at work
  • Mechanisms of CVD in FFs
  • Preventative strategies

19
Coronary Artery Disease
20
Why might MIs occur more often in FFs?
  • Does Fire fighting-
  • Cause CVD to develop?
  • Cause plaque rupture to occur?
  • Cause arrhythmias in normal hearts?

21
Deaths from Heart Disease in FFs
  • Little data on extent of CVD in UK Firefighters
  • No excess noted in data from Office of
    Population, Censuses and Surveys
  • No other data that I could find showing excess

22
Deaths from Heart Disease in UK FFs
  • The 36 deaths (30 of total) attributed to
    natural causes were generally heart attacks,
    which took place either at operational incidents
    or shortly afterwards, or on fire service
    premises while on duty. These figures do not
    include firefighters who died whilst off duty
    from heart attacks.
  • Labour Research Dept. In the Line of Duty
    Firefighter Deaths in the UK Since 1978, Nov
    2008.

23
Deaths from Heart Disease in US FFs
  • Heart disease causes 45 of deaths of U.S. FFs
    whilst on duty
  • Police officers 22
  • Emergency Medical Service Workers 11
  • All workers 15
  • Kales et al, NEJM, 2007

24
Deaths from Heart Disease in US Fire Fighters
cont.
  • Risk of death compared to that during
    nonemergency duties Time
  • Fire suppression 12.1 136 (1-5)
  • Alarm response 2.8 14.1 (4-9)
  • Alarm return 2.2 10.5 (7-15)
  • Physical training 2.9 6.6 (8)
  • Kales et al, NEJM, 2007

25
Why should FFing cause heart disease?
  • Smoke chemical exposure
  • Irregular physical exertion
  • Heat stress
  • Shift work
  • High prevalence of CVS risk factors
  • Psychological stressors

26
Chemical Exposures in FFing
  • CO
  • Oxides of nitrogen
  • HCl
  • Isocyanates
  • Acetaldehyde
  • PAHs
  • Benzene

27
Physiological Demands of FFing
  • HR reaches 70 80 of age-predicted maximums
    within 1 minute of arriving at an active fire
  • HR sustained at 85 100 until fire is
    extinguished
  • Guidotti, Int Arch Occ Env Health, 1992

28
Shift work CVD
  • Fairly strong evidence for association
  • 45-55 yr olds RR 1.6 for men, 3.0 for women
  • Job strain no different in cases controls
  • Mechanism unclear
  • Knutsson et al, Occ Env Med 1999

29
Do workers with CVD or risk factors stop shift
work?
  • 7037 female nurses (5038 worked shifts, 1999 days
    only)
  • Data collected in 2000-02, and again in 2004, on
  • Known MI, angina or high BP
  • High cholesterol
  • Obesity
  • Diabetes

30
Do workers with CVD or risk factors stop shift
work? (2)
  • Among shift workers, likelihood of leaving
    organisation 1.83 (1.01 3.32) times higher if
    had diabetes c.f. no diabetes
  • 2.21 (1.12 4.39) times higher if had 3-4 risk
    factors c.f. no risk factors
  • BUT similar rates for leaving for day workers
  • Hence healthy worker effect does not cause bias
  • Kivimaki M et al, Scand J Work, Env health,
    June 2006

31
Mechanism of CVD in shift workers
  • 1543 young adults examined (age 24-39) as part of
    Cardiovascular Risk in Young Finns study
  • Measured thickness of common carotid artery
    intima/media
  • Puttonen et al, Atherosclerosis, Jan 2009

32
Mechanism of CVD in shift workers cont.
33
Mechanism of CVD in shift workers cont.
  • In men, shift work associated with a higher mean
    thickness of common carotid artery intima/media
    and 2.2 (1.2 4) fold risk of carotid plaque
  • Puttonen et al, Atherosclerosis, Jan 2009

34
Stress and CVD
  • Whitehall II
  • Chronic work stress associated with CVD
  • Association was stronger among participants aged
    lt 50 (RR 1.68, 95 CI 1.172.42)
  • Chandola et al, European Heart Journal 2007

35
Can we do anything about those at risk?
  • In 2005, 115 FFs died on duty in USA
  • 48 of fatalities were MIs
  • Mean age 47
  • Dept. of Homeland Security target to reduce FF
    fatalities by 50 within 10 years
  • Gaetano et al, AAOHN Journal, Feb 2007

36
Health Surveillance for US FFs
  • Volunteer FFs at higher risk of MI attributed to
    stress and overexertion
  • Virtually no standardised requirements for CV
    fitness in volunteers, even as recruits
  • Gaetano et al, AAOHN Journal, Feb 2007

37
Health Surveillance for US FFs cont.
  • 1998 2003 1,458 volunteer FFs and emergency
    medical services personnel had at least 1 health
    surveillance examination
  • 45 years or over get non fasting cholesterol
    HDL measured Framingham Risk Score calculated
  • 658 abnormal findings
  • Gaetano et al, AAOHN Journal, Feb 2007

38
Health Surveillance for US FFs cont.
39
Cardiovascular risk
  • 315 staff evaluated for CVD risk
  • 52 (17) had scores of 9 (substantial risk)
  • 39 of those saw GP or cardiologist
  • 1 had CABG, 2 had angioplasties, 14 had
    antihypertensive drugs, 9 begun lipid lowering
    medication, 13 no action

40
Obesity in FFs
  • Fireman sacked for being 'too fat'
    after failing three-month test to lose
    weight Daily Mail, 15/1/09

41
Obesity in FFs (2)
  • 332 Massachusetts FFs BMIs compared in 1996
    2001
  • Mean BMI changed from 29 to 30 kg/m2
  • Prevalence of obesity rose from 35 to 40 (p lt
    0.0001)
  • Morbid obesity increased 4 fold (0.6 to 2.4, p
    lt 0.0001)
  • Soteriades et al, Obesity Research, Oct 2005

42
Obesity in FFs (3)
  • Obese FFs more likely to have high BP
  • (p 0.03)
  • Normal weight FFs gained 1.1lb, c.f FFs with BMI
    gained 1.9 lb per year
  • Soteriades et al, Obesity Research, Oct 2005

43
Summary
  • Little data on CVD in UK Firefighters
  • Advice given currently has to use existing
    guidance and risk assessment principles
  • Plenty of scope for OH and Fitness depts to
    measure and address existing risk factors
    undertake research

44
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