Cardiovascular Disease in Firefi ghters: Defining the Problem

This new column is intended to give readers the most current information regarding medical studies and standards in a coherent and relevant manner as it applies to the fire service. The hope is that this information can be used to help keep firefighters safe and healthy and to return us all home. The first topic is a series of columns discussing in depth the number-one cause of deaths in firefighters: heart disease.

We are reminded of the statistics every time we open a fire service journal: an average of more than 100 firefighters die each year in the line of duty. With the exception of 9/11, over the past 20 years, approximately half of these deaths are due to cardiovascular disease. This makes cardiovascular disease the leading cause of death in firefighters consistently over the past two decades. Although cardiovascular disease is the leading cause of death in the United States, recent medical studies have demonstrated that firefighters are at a higher risk of dying from a heart attack than the public.

Anyone who has done it knows that firefighting is a dangerous job. Firefighters have one of the highest occupational mortality rates in the country with cardiovascular disease representing the number-one cause of death. Line-of-duty deaths (LODDs) for firefighters are approximately 50%, which is higher than the cardiac mortality rate for similar professions such as police officers (22%) and EMS professionals (11%). In addition, LODDs in firefighters due to heart attacks are much higher than the occupational cardiac mortality rate for the entire nation (15%) (see Table 1). Clearly stated, firefighters are at a higher risk of dying from a heart attack on the job than the rest of the public. These alarming statistics led researchers to investigate cardiac deaths more closely. The results of these studies are so important that they are discussed below to better characterize and understand the problem.

In a study published in 2003, researchers examined the medical records of 50 randomly chosen firefighters who died of cardiovascular disease over a 10-year period. They concluded that all of these deaths were attributed to work-related activities. The most strenuous activities, such as interior firefighting, had the highest risk of cardiac death, whereas non-emergency activities had a relatively low risk of cardiac death. It is important to note there were no statistical differences in the incidence of cardiac deaths between career and volunteer firefighters.

Another study analyzed on-duty cardiac deaths to determine if there were certain activities that placed firefighters at higher risk of suffering a heart attack. Although most cardiac deaths occurred during fire suppression (32%), firefighters spent the least amount of time fighting fires (see Table 2).

Firefighters who spent the most time performing non-emergency and station duties (48% of a shift) had the lowest risk of cardiac deaths of all activities. In fact, the mortality rate for non-emergency duties is the same as the national average (15%). What was interesting is that in the busiest metropolitan department they studied, firefighters spent only 2% of their time conducting fire suppression activities, while smaller departments spent less than 1% of their time fighting fires.

We need to understand the basics of firefighter LODDs. Fire suppression carried a 67% risk of death over non-emergency duties. Non-emergency duties did not have a higher risk of cardiac death. In addition, responding to and returning from alarms and physical training all had higher risks of death over non-emergency duties. Also important to note is that non-fire emergency responses, including EMS calls, did not have a higher risk of cardiac death than non-emergency duties. This is important since in departments that perform EMS, these represent the majority of emergency responses. Again, it should be noted that no differences were found in the risk of cardiac death between career and volunteer firefighters.

The important points from the discussed studies are summarized below:

  • Cardiovascular disease is the number-one cause of on-duty cardiac deaths in firefighters
  • Firefighters are at a higher risk of cardiac death than the public
  • Fire suppression, alarm response, returning from alarms and physical training all have a high risk of cardiac death
  • Non-emergency duties and non-fire emergency do not have a higher risk of cardiac death than the general public
  • Career and volunteer firefighters are equally at risk

The data presented in this column can be used to help justify a medical screening program to show decision makers how focused medical examinations may reduce LODD from heart attacks.

Next: Who is at risk?

Dr. Raymond Basri acknowledges the assistance of Brad Pinsky, Esq., Ray Maguire, G. Mark Davis and Dr. Jack Ruthberg, MD. Eric Bergman thanks Dr. Barbara Poetszch PhD, PA-C, and David Irvine, DHSc, PA-C, for their assistance.

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 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
Profession Cardiac Mortality Rate
Firefighting 50%
Police officer 22%
EMS professionals 11%
National cardiac Mortality rate 15%
Activity Observed Deaths (N=449) Percent of time per shift Risk of Death over Non-emergency Duties
Fire suppression 144 (32.1%) 2.6% 67%
Alarm response 60 (13.4%) 6.3% 8.1%
Alarm return 78 (17.4%) 11% 6.2%
Physical training 56 (12.5%) 8% 4.9%
Non-fire and EMS emergencies 42 (9.4%) 24% 1.4%*
Non-emergency duties 69 (15.4%) 48% -