3 Important Steps -- Firefighters & Heart Disease
Identifying Cardiac Disease
Dr. Gonzalo Fernandez and Dr. Lance Walker
|Firefighters have about three times the risk of the general population of suffering a fatal heart attack. The exact mechanism of action is unclear and may be due to stress, shift work, micro-particulates, poor diet or some combination of these factors. What is clear however is that identifying and dealing with cardiac disease in firefighters should be an integral component of all medical surveillance programs.
Currently there is no national standard for cardiac testing in firefighters. The closest we have is NFPA 1582, which calls for the testing of aerobic capacity using various protocols. This testing can be augmented with electrocardiogram (EKG) monitoring, and some departments even use maximal stress testing protocols under a physician’s supervision.
Sounds effective right? Not really. The problem is that in an individual with risk factors and symptoms such as chest pain, a standard treadmill stress test will only identify about 70 percent of the individuals with heart disease. Restated this means that a standard stress test is wrong three out of every 10 times in people who have chest pain symptoms and risk factors for heart disease.
Missing three out of every 10 is not very reassuring.
These odds are made even worse when we screen a group of firefighters by the fact that we are testing individuals without symptoms. In addition, many firefighters are young and generally healthy. When we test young healthy people, the risk of false positive test results can go up as high as 50 percent. These false positive results lead to time away from work and unnecessary and potentially risky further testing. Cardiologists tell us that stress testing in firefighters will result in one half of the positive tests being false alarms. Stated another way, half of all the positive results found on healthy individuals with a standard treadmill stress test are wrong!
Standard testing methods miss firefighters with cardiac disease and cause unnecessary testing, worry and cost by getting false alarm positives on firefighters with no disease. But did you know there was a better way? As physicians who administer 1582 physicals and testing we are always trying to make our program more effective and useful to the departments we work with.
We have identified three key components to developing a more effective cardiac screening program.
- Take and Review a Thorough Medical History
One of the most effective and easiest things that can be done is to know a firefighters history prior to making decisions regarding further cardiac screenings and testing. As physicians if we don’t know a firefighter’s smoking history, family medical history, blood pressure and cholesterol, we are flying blind.
We have seen many unnecessary referrals and removals from duty because of an “abnormal” stress test. The firefighter’s history was never asked or reviewed, but rather the decision to send him for further testing was made just on the basis of the “abnormal” stress test. This is both inconvenient, expensive and sometimes not without risk. Procedures like cardiac catheterizations can have complications that can occasionally be fatal. A thorough medical history helps avoid unnecessary testing.
- Identify High Risk Individuals
By using the medical history, physical examination and testing results, it is possible to identify firefighters that are at high risk of heart disease. Risk is based on a number of factors including age, sex, family history, blood pressure, weight, fitness, tobacco use and cholesterol. This is the basic information that we get from every 1582 physical we perform.
However, as physicians we now take this one step further. There are advanced tests that can be ordered to help us better identify which firefighters are at the most risk. Did you know that high cholesterol is not always bad? The cholesterol test that you get at your doctor’s office is a very basic screening test. As physicians, we have access to a panel of tests that look at cholesterol in much more detail and can paint a more accurate picture of cardiac risk.
Did you know that there is a blood test that is more predictive for heart disease than measuring bad cholesterol? There is, and using it can prevent unnecessary referrals. There is also genetic testing for the markers of heart disease, and when used appropriately they can help predict cardiac issues. As physicians we are able to bring this advanced testing to our fire departments to better help detect heart disease and risks for heart attacks and hear related issues.
- Make Appropriate Referrals Based on Numbers 1 and 2
If we find concerns based on risk factors and testing results we will refer firefighters to a cardiologist. We try not to refer to just any cardiologist; we want one who understands firefighters and the demands of their jobs. In Atlanta we have partnered with a hospital and a cardiologist group that received a million dollar grant from FEMA to study heart disease in first responders. They know firefighters.
They have developed a comprehensive First Responders Program using the most advanced testing available to detect and treat firefighters. In areas where this program is not available, we as physicians are able to work with local cardiologists to help guide appropriate testing and follow up.
It is our desire that no firefighter die from a preventable disease like heart disease.
SiteMed, is a physician owned occupational medicine company specializing in on-site firefighter exams. Drs. Fernandez and Walker have over 20 years combined experience in the occupational medicine industry. They welcome comments or questions at 888-837-4819 and through e-mail:
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