M. Dominique Ashen PhD, CRNP
The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease

This was the conclusion by Dr. Stefanos Kales and his colleagues in the New England Journal of medicine in 2007^* after reviewing deaths of all on-duty firefighters between 1994 and 2004 (except for deaths associated with 9/11/2001). In evaluating deaths from heart disease among certain emergency firefighting duties, they noted that fire suppression was associated with the highest risk (32% of deaths), estimating a 10-100 times higher risk than that for non-emergency duties. By comparison, the risk of death from heart disease in the US population in 2006 was 26%, as determined by the Centers for Disease Control and Prevention and the National Center for Health Statistics.^**

What are some of the underlying factors that contribute to this high rate of death from heart disease in firefighters? Contributing factors may include exposure to physically demanding emergencies which increase the work of the heart and blood vessels, lack of adequate physical fitness, underlying risk factors for heart disease (including high blood pressure, high cholesterol, smoking, obesity, and advancing age) and a previous diagnosis of heart disease and/or diabetes in firefighters. These contributing factors may be compounded by lack of periodic medical exams, mandatory return-to-work evaluations after a major illness and programs that promote fitness and health in fire departments across the country. Unfortunately, illness or death from heart disease contribute to loss of productivity and financial burden to individual firefighters and their families as well as the communities they serve and the local government bodies that support them.

What can you do to minimize your risk of heart disease or progression of known heart disease and thus, reduce your risk heart attack and death from heart disease? At the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, we use the ABCs of Prevention to help individuals develop a program of medication management and lifestyle modification to reduce risk factors for heart disease and minimize risk for heart attack.

Aspirin: If you are over 55 years old, talk to your health care provider about whether you should take an aspirin or not. You should probably be taking an aspirin most days of the week if you have known heart disease or diabetes.

Blood Pressure: Normal 120/80 or below; Borderline 121/81-139/89; High 140/90 or higher. When your blood pressure is high, you are at greater risk for heart attack. You should have your blood pressure checked at least every year or more frequently if you have had high readings. Blood pressure is affected by many factors such as increased weight, increased salt intake, poor diet, smoking, lack of exercise, stress and family history. Lifestyle improvement (such as a low salt diet rich in fruits and vegetables and low in saturated fat, regular exercise, achieving and maintaining a desirable weight) and, in some cases, medication will be important to maintain a normal blood pressure.

Cholesterol: Normal values are: total cholesterol less than 200, triglycerides less than 150, HDL ("good" cholesterol) greater than 50 in women and greater than 40 in men, and LDL ("bad" cholesterol) less than 130 and optimally less than 100, unless you have known heart disease and/or diabetes and then it should be optimally less than 70. Cholesterol is made by your liver and also comes from the food you eat. While too much total cholesterol , triglycerides and LDL cholesterol can produce plaque (fatty substance) in your blood vessels and increase your risk for heart attack, HDL cholesterol acts as a protective factor. Lifestyle improvements (such as eating less saturated fat and cholesterol, substituting monounsaturated or polyunsaturated fats for saturated fats, achieving and maintaining a desirable weight, and eating more soluble fiber including whole grain cereals, breads, pasta, as well as beans, fruits and vegetables) and, in some cases, medication will be important to maintain normal cholesterol.

Cigarette Smoking Cessation: If you smoke, make a plan to quit. You can use nicotine patches, gum, or inhalers. Talk to your health care provider about prescription medication in conjunction with a smoking cessation program to assist you.

Diabetes Prevention and Management: Normal fasting glucose (blood sugar) 70-100. If you have diabetes, your HbA1C (a measure of long term blood glucose control) should be < 7%. About 16 million Americans have diabetes. A fasting blood glucose greater than or equal to 125 on 2 consecutive occasions is one way of diagnosing diabetes. A fasting blood glucose between100-125 is considered high and is a sign of the metabolic syndrome or pre-diabetes. Risk factors for diabetes include: family history, race (American Indian, Hispanic, or African American), age greater than 40, high blood pressure, high cholesterol, obesity, smoking, and a history of diabetes during pregnancy. People with diabetes are two to four times more likely to develop heart disease and have a heart attack. Lifestyle improvements (such as regular exercise, a healthy diet and achieving and maintaining a desirable weight) and, in some cases, medication will be important for prevention of diabetes or optimal control of existing diabetes.

Diet and Weight Management: The 2010 Dietary Guidelines for Americans^*** outlines a healthy diet: limit daily sodium consumption to less than 2300 mg (high risk groups such as those over 50, are black or who have high blood pressure diabetes or kidney disease limit to 1500 mg), restrict saturated fats to less than 10%, consume less than 300 mg of cholesterol daily, replace refined grains with whole grains, restrict consumption of solid fats and added sugars, limit alcohol to one drink per day for women and two for men, eat a variety of fruits and vegetables and more of them, and replace some meat and poultry with seafood. You can achieve and maintain an optimal weight through a healthy diet and regular exercise. A normal body mass index (a measure of body fat based on height and weight) is less than 25, overweight is 29-29.9 and obese is greater than 30. An optimal waist circumference is less than 40 inches in men and less than 35 inches in women.

Exercise: A good exercise program consists of regular aerobic activity, strength training and flexibility exercises. Brisk walking or similar aerobic activities for 30 minutes a day most days of the week is recommended. Also try to increase your daily activity (gardening, housework, taking the steps and parking farther away). Use a pedometer with a goal of 10,000 steps per day. An exercise stress test may be useful before you begin a vigorous exercise program.

One of the first steps in reducing your risk of heart disease should be to see your health care provider and review your risk factors. It is important to discuss your family history of heart disease with your health care provider and to find out what your blood pressure, cholesterol, fasting blood glucose, BMI, waist circumference, and, if diabetic, HbA1C values are. In addition, you can use some of this information to determine your Framingham Risk Score, which is your 10 year risk for having a heart attack and dying of heart disease (http://hp2010.nhlbihin.net/atpIII/calculator.asp?usertype=prof).

Once you have this information you can use the ABCs of Prevention to develop a plan of lifestyle modification and medication management with your healthcare provider. When it comes to lifestyle modifications, there is ample evidence to support the importance of regular aerobic exercise, healthy dietary habits and maintenance of an optimal weight in optimizing blood pressure, cholesterol, blood glucose and weight and reducing your risk for heart disease. You will likely discuss making changes in one or more lifestyle areas with your health care provider which will require behavior change to develop and sustain those healthy lifestyle habits. To maximize your success in sustaining behavior change, keep in mind that you should: (1) set goals that are specific, attainable and forgiving, (2) meet short term goals, (3) institute self monitoring (keep a journal of what you eat, your exercise regimen and your weight), (4) reward yourself when you have reached your goals and (5) learn the social or environmental cues that result in setbacks and avoid them (http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/behavior.htm). Overall, your goal is PREVENTION of heart disease. The use of the ABCs of Prevention and regular visits with your health care provider will help you accomplish this. Be proactive!

^* Kales et al. New England Journal of Medicine. 2007;356(12):1207-1215
^** http://cfpub.epa.gov/eroe/index.cfm?fuseaction=detail.viewInd&lv=list.listByAlpha&r=216637&subtop=381
^*** http://www.cnpp.usda.gov/DGAs2010-PolicyDocument.htm