Increased risk of heart attacks in firemen

Dr Helen posted for cardiology questions in order to structure a podcast with these questions as the seed material. It's safe to say that in any podcast there is never enough time to cover all the ground. As such we offered to provide input for any questions not already answered by the podcast. Here's one question

Joe asked

My question is from the perspective of firefighting. The number one killer of firefighters in the US is heart attacks. Besides the regular things to reduce the chance of heart attack (like eating right, regular exercise, etc) is there something that firefighters should be doing to reduce their chance of heart attack?

I believe much of the problem lies in the fact that firefighters go from a state of inactivity to a state of extremely vigorous activity in a couple of minutes.Is there a medication/vitamin/exercise routine that could be utilized enroute to a fire that would reduce the chance of heart attack?

Our reply to Joe is that it is true that firemen face an increased risk of heart attacks, or in more technical terms, acute cholesterol plaque rupture with coronary thrombosis. Unfortunately it has not been possible to point out one single causative factor. In return there is no "magic bullet" to solve this problem.

We have to deal with firemen as individuals with individual sets of risk factors. Obviously, the stress of going from a restful period to sudden, intense stress (as with fire fighters) is considerable. We know this as "occasional spurt activity".

Occasional spurt activities has been well studied and is associated with an increased risk of plaque rupture. This has implications for patients besides firemen. Well meaning patients who exercise (perhaps as a result of medical consultation) are adviced to exercise regularly, always warm up so as to lead gradually into the main exercise period and then to cool down after exercising.

Perhaps it's a sudden rush of adrenaline causing a sudden surge in blood pressure which in turn causes plaque to rupture.

Now that we know the nature of the beast, we obviously must determine the best action to take. Like everything else cardiac, we first identify the high risk group, likely to have vulnerable cholesterol plaque. This includes males above 40 yrs, and females above 50yrs, diabetics, hypertensives, those with family history of heart disease and sudden cardiac death, hyperlipidemia, and cigarette smoking. Those with none of the above factors are in a low risk group. Those with two of the risk factors are in the moderate risk group and those with two to four of the above risk factors are in the high risk group.

The best place to start is always with a comprehensive medical checkup, including ECG, Echocardiogram and Stress ECG. This way we can exclude hypertrophic cardiomyopathy and coronary artery disease (CAD). It may also be important to do an EBCT (electron beam CT) scan to see if the calcium score is zero, in order to exclude disease.

Also important is a look at prevention, where, besides a thorough workup to exclude important CAD, anyone with 2 or more risk factors should have their cholesterol well controlled, for example, with statins. Anyone with all of the risk factors should also be on medication such as aspirin or any other anti-platelet agents (if they are intolerant of aspirin).

This is assuming that a fireman who has all these risk factors would continue in this valuable but often under-rated profession.

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