High Blood Pressure Screening: An Opportunity to Reduce Line-of-Duty Deaths

High blood pressure, or hypertension, is a national epidemic. In 2007, an estimated 50 million adults in America had high blood pressure and that number is increasing. The risk of developing high blood pressure increases with age as the percentage of Americans with this ailment continues to grow. Hypertension is recognized as a major risk factor for cardiovascular disease and heart attacks. Heart attacks are the leading cause of line-of-duty deaths (LODD) in firefighters.

Firefighters are at an increased risk of cardiac death due to the inherent physical demands of firefighting. The physical intensity required to perform firefighting operations increases the exertional demands on the cardiovascular systems of firefighters. If you have high blood pressure, your risk of suffering a heart attack is greater. It should be no surprise that hypertension in firefighters has been demonstrated to increase the risk of suffering a heart attack. Multiple studies have demonstrated firefighters frequently have high blood pressure. This is important since firefighters with high blood pressure are at an increased risk of cardiac LODD. Firefighters with a history of cardiovascular disease are at the highest risk of suffering an LODD cardiac death.

High blood pressure has many detrimental aspects to overall health. The most serious consequences of hypertension are the effects of chronic elevated blood pressure on the cardiovascular system. High blood pressure increases the workload of the heart. The heart is a pump and the cardiovascular system acts as a pressure regulator for blood; mechanical concepts with which firefighters are familiar. Blood pressure is the force at which the heart is contracting with each pulse times the resistance to the pressure in the stiffness of the blood vessels throughout the body. As blood pressure increases, the heart has to pump harder to overcome this resistance, leading to an increasing strain on the heart. The increased pressure within blood vessels may cause damage to the walls of the arteries, accelerating the process of atherosclerosis. Atherosclerosis is the formation of cholesterol plaque within blood arteries that may ultimately rupture, causing a heart attack or stroke.

The heart is mainly composed of muscle. Just like other muscles in the body, the harder it works, the more it will grow or in this case thicken. Chronic high blood pressure can stimulate the heart to enlarge to overcome the high-pressure resistance of stiff arteries. An enlarged heart requires more oxygen since there is more muscle mass. Also, the extra work the heart must perform to overcome the high-pressure resistance of stiff arteries also increases the oxygen demand on the heart. As a result, a bigger heart that is working harder will also require more blood flow rich in oxygen. These factors can make the heart particularly vulnerable during a heart attack when blood flow is decreased to the heart, as when a coronary artery is partially blocked by cholesterol plaque.

Added Risks

Firefighters may have other risks due to high blood pressure. As discussed above, high blood pressure is thought to accelerate the development of atherosclerosis, or the formation of plaques in arteries. Certain plaques may be unstable and vulnerable to rupture. When plaques rupture, the interior surface of the plaque can stimulate the formation of a clot. When a blood clot forms, the flow of blood through the artery will be reduced or stopped altogether. If this occurs in an artery in the heart, a heart attack occurs and can result in sudden cardiac death.

Unstable plaques are vulnerable to rupture when there is a sudden increase in blood pressure. This is important since studies have demonstrated that firefighters have a sudden increase in blood pressure and heart rate in response to receiving an alarm. We know this as the adrenaline rush, or that initial excitement when an alarm comes in. The adrenaline causes an immediate increase in blood pressure, causing unstable plaques to rupture, which results in a heart attack. This can help explain why firefighters with high blood pressure are at a higher risk of cardiovascular disease and cardiac LODD.

Screening Needed

The presence of high blood pressure in firefighters has been documented in multiple studies. Hypertension in firefighters is significant since those with the worst hypertension are at the highest risk of cardiac LODD. It also has been demonstrated that the prevalence of high blood pressure increases with age. This is primarily due to the stiffness within the blood vessels as we age. However, identifying and treating high blood pressure reduces the risk of having a heart attack or stroke.

Annual screening exams offer an opportunity to detect and treat high blood pressure in firefighters. Additionally, annual medical screening exams will identify high blood pressure and perhaps avoid the consequences. The current definitions of blood pressure are listed in Table 1. If your department has an established medical screening program, this can be conducted by department physicians. If your department physicians conduct only the screening exams with no follow-up, firefighters should be referred to their doctors for treatment. Once hypertension is identified, a treatment plan is developed and may require diet and exercise as a first step. Thereafter, treatment should include monitoring by a doctor and perhaps medication.

A national commission made up of health-care professionals released national recommendations to prevent high blood pressure in 2003. The first step to controlling blood pressure is lifestyle changes (Table 2). Lifestyle changes include eating a low-fat/low-sodium diet that is high in fruits, vegetables and whole grains, and aerobic exercise. The current recommendation is a minimum of 30 minutes of aerobic exercise four times a week. Usually, a series of office visits over the next months is required to determine whether these measures are effective in controlling blood pressure.

If lifestyle changes do not reduce a firefighter's blood pressure sufficiently, then medical therapy is initiated. Many different medications are available to help control blood pressure. Repeat office visits at timed intervals are usually required to measure the effectiveness of the medication at controlling blood pressure and to determine the most effective dose. It should be noted that, depending on your blood pressure reading, your physician may elect to start medical therapy right away in addition to lifestyle changes. Also, national guidelines recommend lifestyle changes for everyone for prevention of high blood pressure, even individuals with normal blood pressure readings.

The good news here is that the newer medications for hypertension are very safe, effective and taken once per day. In fact, many medications are less likely to produce a side effect than a placebo or sugar pill used to test for side effects. Taking a blood pressure medication should be as easy as taking a vitamin every morning. Take it and forget about it for the rest of the day.

Cardiovascular disease is the leading cause of LODDs in firefighters. High blood pressure increases the risk of cardiovascular disease, and ultimately increases the risk of having a cardiac LODD. Annual screening exams offer an excellent opportunity for medical professionals to identify firefighters with high blood pressure. Once firefighters with high blood pressure are identified, effective therapies can be instituted to control blood pressure and reduce the risk of cardiac LODD.

Fire departments with established medical screening exams should ensure that blood pressure screening is an integral part of every exam. For individual firefighters with no established medical screening in place, schedule annual physical exams with your primary care provider and tell your doctor that you want your blood pressure monitored. Additionally, as part of the national health initiative on preventing high blood pressure, all firefighters should initiate lifestyle changes included above for a heart-healthy lifestyle.

DR. RAYMOND BASRI, MD, FACP, is in the private practices of internal medicine and diagnostic cardiology in Middletown, NY. Dr. Basri is a Diplomate of the American Board of Internal Medicine and president of the Mid-Hudson Section. He received the 2008 Laureate Award of the American College of Physicians, of which he is a Fellow. Dr. Basri also is clinical assistant professor of medicine at New York Medical College, attending physician in the Department of Internal Medicine at Orange Regional Medical Center and on the consulting staff in cardiology at The Valley Hospital in Ridgewood, NJ. He is a member of the Excelsior Hook and Ladder Company in Middletown and a deputy fire coordinator for Orange County. Dr. Basri is the senior physician of the Disaster Medical Assistance Team (DMAT NY-4). He is a senior aviation medical examiner for the Federal Aviation Administration (FAA) and chief physician for Health & Safety Specialists in Medicine, which does onsite medical examinations for the fire service and consultant to FirePhysicals.com. ERIC BERGMAN, PA-C, is a physician assistant practicing internal medicine at Hartford Hospital in Hartford, CT. He earned a bachelor of science degree in allied health from the University of Connecticut and a master's degree from Albany Medical College. He is a member of the Killingworth, CT, Volunteer Fire Company; a past company officer and life member of the Avon, CT, Volunteer Fire Department; and a past member of the Shaker Road-Loudonville Fire Department in Colonie, NY.

Table 1. Classifications of Hypertension
SBP= Systolic blood pressure, DBP= Diastolic blood pressure
Normal 120 and &llt;80
Pre-hypertension 120-139 or 80-89
Stage 1 Hypertension 140-159 or 90-99
Stage 2 Hypertension =160 or =100
Table 2.
Lifestyle Changes for the Prevention of High Blood Pressure
• Low fat
• Low sodium
• Rich in whole grains, fruits and vegetables
• Minimum of 30 minutes of aerobic exercise 4 times a week