Cardiovascular Disease in Firefighting and Law Enforcement: Odyssey from Resident Project to State of the Science

Size: px

Start display at page:

Download "Cardiovascular Disease in Firefighting and Law Enforcement: Odyssey from Resident Project to State of the Science"

Loren Miles
5 years ago
Views:

KALES MD, MPH, FACP, FACOEM DIVISION CHIEF, OCCUPATIONAL &

MEDICINE ASSOCIATE PROFESSOR OF MEDICINE HARVARD MEDICAL SCHOOL

1 Cardiovascular Disease in Firefighting and Law Enforcement: Odyssey from Resident Project to State of the Science STEFANOS N. KALES MD, MPH, FACP, FACOEM DIVISION CHIEF, OCCUPATIONAL & ENVIRONMENTAL MEDICINE MEDICAL DIRECTOR, EMPLOYEE HEALTH & INDUSTRIAL MEDICINE ASSOCIATE PROFESSOR OF MEDICINE HARVARD MEDICAL SCHOOL ASSOCIATE PROFESSOR & DIRECTOR, OCCUPATIONAL MEDICINE RESIDENCY, HARVARD SCHOOL OF PUBLIC HEALTH

1953: Sufficient evidence in recent years (for) wider acceptance of firefighting as an occupational factor in the production or aggravation of certain heart diseases Etiologic

2 1953: Sufficient evidence in recent years (for) wider acceptance of firefighting as an occupational factor in the production or aggravation of certain heart diseases Etiologic factors: heat/cold, exertion, stresses, smokes and gases to which firemen are repeatedly subjected Dis Chest 1953;24; (

3 Harriet Hardy and Cardiovascular Disease Industrial Toxicology, 3 rd ed., 1974 Recognized Carbon Monoxide Exposure to be associated with: -EKG Changes -Myocardial Ischemia -Myocardial Infarctions

4 NFFF 2005: Risk Factors relating to Cardiovascular Disease in the Fire Service While there is a general understanding of the relationships between...risk factors and the risk of cardiovascular events in the general public, very little is known about the specific relationship between these risk factors and cardiovascular event in the fire service

5 PubMed Hits on Firefighter : A Rapidly Evolving Field FEMA R&D Starts 2005 >50% of Pubs since Kales et al

6 The Odyssey from Resident Project to State of Science 1. Take the Workers Input 2. Be Receptive to Student Ideas 3. Utilize Publicly Available Databases 4. Never Give Up - Failure as Motivation 5. Learn Optimally from Peer Reviews 6. Apply Successful Approaches to New Questions 7. Network throughout the Community Kales et al

7 The Odyssey from Resident Project to State of Science 1. Take the Workers Input 2. Be Receptive to Student Ideas 3. Utilize Publicly Available Databases 4. Never Give Up - Failure as Motivation 5. Learn Optimally from Peer Reviews 6. Apply Successful Approaches to New Questions 7. Network throughout the Community Kales et al

8 Workers Input: Metrofire & Mass Regional HazMat Teams Started with n=40, N= 300, Pseudoelevation of carboxyhemoglobin levels in firefighters Epidemiology of hazardous materials responses by Massachusetts district HAZMAT teams Medical Surveillance of Hazardous Materials Response Fire Fighters: A Two-Year Prospective Study Kales et al

9 Late s: CVD ~45% all Deaths Source: NFPA.org

10 Scope of Problem US Fire Service : CVD ~45% on-duty Deaths (~ 45/yr) ~ 17 Non-fatal CV events / Fatal Event Major FD s: cases/month in FF s One major city, HDz and HTN WC claims 6-10% of all FF s every year Soteriades et al Kales Cardiology in Review 2011.

11 The Odyssey from Resident Project to State of Science 1. Take the Workers Input 2. Be Receptive to Student Ideas 3. Utilize Publicly Available Databases 4. Never Give Up - Failure as Motivation 5. Learn Optimally from Peer Reviews 6. Apply Successful Approaches to New Questions 7. Network throughout the Community Kales et al

12 Be Receptive to Student Ideas Dans les champs de l'observation le hasard ne favorise que les esprits prepares. (Where observation is concerned, chance favors only the prepared mind.) Louis Pasteur Kales et al

Be Receptive to Student Ideas 1999 - Correlates of body mass index in hazardous materials firefighters.

13 Be Receptive to Student Ideas Correlates of body mass index in hazardous materials firefighters Firefighters' blood pressure and employment status on hazardous materials teams in Massachusetts: a prospective study Lipid profile of firefighters over time: opportunities for prevention. Kales et al

14 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 Kales et al

15 The Odyssey from Resident Project to State of Science 1. Take the Workers Input 2. Be Receptive to Student Ideas 3. Utilize Publicly Available Databases 4. Never Give Up - Failure as Motivation 5. Learn Optimally from Peer Reviews 6. Apply Successful Approaches to New Questions 7. Network throughout the Community Kales et al

16 Fire Fighter Fatality Investigation Reports NIOSH conducts investigations of line-of-duty deaths to formulate recommendations for preventing future deaths and injuries. What about a Case-Control Study? Kales et al

17 The Odyssey from Resident Project to State of Science 1. Take the Workers Input 2. Be Receptive to Student Ideas 3. Utilize Publicly Available Databases 4. Never Give Up - Failure as Motivation 5. Learn Optimally from Peer Reviews 6. Apply Successful Approaches to New Questions 7. Network throughout the Community Kales et al

18 NOT Random in TIME Firefighters and on-duty deaths from coronary heart disease: a case control study. Kales et al. 2003

Not Random in Time- Duty Line of Duty Deaths - CHD related N=449, 1994-2004 Time

Training 8% Nonfire emergencies 15% Nonemergency duties 65% Fatalities (%) 32.10% 13.

19 Not Random in Time- Duty Line of Duty Deaths - CHD related N=449, Time Spent (%) Fire Suppression 1% Response to Alarm 4% Return from Alarm 7% Physical Training 8% Nonfire emergencies 15% Nonemergency duties 65% Fatalities (%) 32.10% 13.40% 17.40% 12.50% 9.40% 15.40% Odds Ratio Kales, et al. NEJM, 2007

20 Heavy PPE > 22 kg Metabolic work Heat dissipation Strenuous work Climbing stairs Forcible entry Search and rescue Hot and Dangerous Environment Over 100º C routinely Chaotic Low visibility Smith, Kales, NFFF

21 Kales et al

22 Cohort Studies & Presumption Laws Some evidence of possible increased in Lifetime CHD risk in among Police. 6 US mortality studies Mixed methods (SMR, PMR, OR) 1.05 to 1.49 Heart Presumption laws in some US states for Police Kales et al

transportationrelated incidents On-duty deaths due to SCD

23 Scope of Problem- US Police Law enforcement is dangerous Majority of on-duty deaths are homicides and transportationrelated incidents On-duty deaths due to SCD not well studied, But Concern rising among public and law enforcement community

24 The Odyssey from Resident Project to State of Science 1. Take the Workers Input 2. Be Receptive to Student Ideas 3. Utilize Publicly Available Databases 4. Never Give Up - Failure as Motivation 5. Learn Optimally from Peer Reviews 6. Apply Successful Approaches to New Questions 7. Network throughout the Community Kales et al

25 Professional Time across LEO Duties Korre at al. Policing 2014.

26 Varvarigou et al.

27 Varvarigou et al. BMJ 2014.

28 Kales et al Not Random among Firefighters

29 Not Random among Police: Justice Academy Survey of 168 NC Police Heart Attack Survivors % were Sedentary 60% overweight ( >/= 16 pounds) 53% high cholesterol 46% smokers 46% hypertension

30 Effects of Age Police Fire Kales et al

Cardiovascular (Increased HR and BP, Decreased SV) Hematological (Hemoconcentration & Pro-Coagulatory) Thermoregulatory (Elevated Core Temperature, Dehydration) Respiratory (Increased Breathing Rate

31 Cardiovascular (Increased HR and BP, Decreased SV) Hematological (Hemoconcentration & Pro-Coagulatory) Thermoregulatory (Elevated Core Temperature, Dehydration) Respiratory (Increased Breathing Rate and Oxygen Consumption) Metabolic (High Oxygen Cost, Increased Lactate, Fatigue) Immune/Endocrine (Increased Leukocytes and Hormones) Summary of Physiological Responses to Firefighting Nervous (Sympathetic Surge and Increased Adrenaline) Muscular (Increased Oxygen Use and Heat Production) Smith, Kales, NFFF

32 Perceived Stress Across Duties Korre at al. Policing Spearman s rho 0.95, 95%CI

33 Pursuit of DUI- then Confrontation Hickman et al.,2011

34 Hypertension and Left Ventricular Hypertrophy Inddent risk factor for CVD. Increased Risk of Ventricular Arrhythmia Independent Predictor of Death-- SCD -- 57% of On-Duty CHD FF Fatalities had LVH at Autopsy!! Geibe et al, Kales. Am J Cardiology 2008.

35 Sudden Cardiac Death among Firefighters 45 Year of Age in the United States Obesity via cardiomegaly Kales et al

36 How might Triggering Occur? Smith DL, Barr DA, Kales SN. 2013

37 Physical Fitness, Activity and CHD Risk. (Williams, 2001) Persons in the >/=75%ile of Fitness >/=60% Lower Risk Williams PT. Physical fitness and activity as separate heart disease risk factors: a meta-analysis. Med Sci Sports Exerc May;33(5):754-61

38 The Odyssey from Resident Project to State of Science 1. Take the Workers Input 2. Be Receptive to Student Ideas 3. Utilize Publicly Available Databases 4. Never Give Up - Failure as Motivation 5. Learn Optimally from Peer Reviews 6. Apply Successful Approaches to New Questions 7. Network throughout the Community Kales et al

39 Network throughout the Community William B. Patterson, MD

40 ETT/CRF and Outcomes Study Populations Prospective White Completed Bsln ETT Analyzed: >1100 men X-sectionally Retrospective- Pink Completed bsln ETT IFD >900 Other Indiana FD Bsln > 850 Kales et al Drs. Sogolow, Ziporin, Ramphal, O Nieal, Janke, Gist, Czeisler and Moffatt

41 Fitness Predicts Metabolic Syndrome better than Age Baur et al Kales

42 Baur, Leiba, Christophi, Kales 2012.

43 Prelim data: Longitudinal Analysis of Indiana FD s Analysis of 39 events in 8,383 person-years (males) Preliminary analyses show that Push-up capacity at Bsln predicts development of CVD. After about 8 years, Over 15% of those capable of 0-10 push=ups had developed CVD Versus about 1% of those who could do more than 40 push-ups

44 Prelim data: Longitudinal Analysis of Indiana FD s Analysis of 228 events in 8,383 person-years (males) Preliminary analyses BSLN Push-up capacity and a Combined Outcome (Development of CVD, death or retirement). After about 9 years, Over 50% of those capable of only 0-10 push=ups had developed CVD, died or retired Over 90% of those who could do more than 40 push-ups were still professionally active and free of CVD

45 NFPA Guideline

46 Prelim data: MA Police Recruits: Probability of not graduating Police Academy, based on Push-ups and VO2 max. N=1236 subjects with Complete Information Low push-up capapcity and slow run times (1.5 mile run) at Bsln predicted a much higher probability of failing to graduate from the academy in both male and female recruits.

47 Mean BMI Historical BMI changes in U.S. firefighters: Mean Age (years) Recruits Year of Study Soteriades et al Kales. Cardiol in Review 2011

48 They re New York s Fattest During the first week of the academy, 166 of the (318) probies flunked the physical-fitness test (4 pull-ups, 30 push-ups in one minute, 30 sit-ups in one minute and a 1.5-mile run in 12 minutes). I ve never given out so many size-38 pants before.

50 Model of CVD in Public Safety

51 CVD in Public Safety: Resident Project to State of Science 2014 On-Duty Heart Events - NOT random in time (duty, hour, season) - NOT random among FF & LEO - MOST could be Prevented Triggering on Underlying Dz Kales et al

52 Evidence-Based Recommendations 1. Tobacco Free Fire/Police Services (smoking and smokeless) 2. CHD RTW Standard (EMS work ok for selected cases) 3. Periodic Exams & Rx Blood Pressure, other RF 4. Obesity/Fitness Standards; Kales, Smith 2014

53 Evidence-Based Recommendations 5. On-duty Fitness Programs 6. Consider Mandatory retirement from fire suppression and other strenuous duties at 60 years of age Kales, Smith 2014

54 Evidence-Based Recommendations MORE RESEARCH 1. Implementing Wellness & Fitness (Best Practices) 2. Non-Invasive CVD Screening (ETT, CAC, CT, Echo) Kales, Smith 2014

55 ETT-CRF ECHOcMRI Adapted from Soteriades et al. Cardiol in Review 2011.

56 THANK YOU Firefighters; IAFC, IAFF, NFFF & NVFC U.S. Department of Homeland Security Collaborating Cities, Clinics, Researchers Harvard Research Team DHS R&D Colleagues Police: IACP, IUPA, FOP, NAPO, MA Municipal Police Training Academies Harvard ERC/NIOSH Comm. Of MA Kales et al

57 Am J Hypertens. 2009;22:11 20.

59 Kales et al

60 Kales et al

Updates on Cardiac Enlargement in US Firefighters. Maria Korre, MSc, ScD

Updates on Cardiac Enlargement in US Firefighters Maria Korre, MSc, ScD Research Associate-Instructor Environmental & Occupational Medicine & Epidemiology Program Department of Environmental Health Harvard