Post on 23-Dec-2015
Heart Disease in FirefightersHeart Disease in Firefighters
STEFANOS N. KALES,STEFANOS N. KALES, MD, MPH, FACP, FACOEMMD, MPH, FACP, FACOEM
MEDICAL DIRECTOR
EMPLOYEE HEALTH & INDUSTRIAL MEDICINE CAMBRIDGE HEALTH ALLIANCE
ASSISTANT PROFESSOR OF MEDICINE
HARVARD MEDICAL SCHOOL
ASSISTANT PROFESSOR & DIRECTOR,
OCCUPATIONAL & ENVIRONMENTAL MEDICINE RESIDENCY, HARVARD SCHOOL OF PUBLIC HEALTH
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BackgroundBackground
• More than one million firefighters in US
• About 100 firefighters die each year on-Duty (1 in 10,000 per year)
• 1977-2004, CVD has caused ~45% on-Duty Deaths
• CHD ~40%
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US Firefighter Fatalities
45% Heart Disease
25% Motor Vehicle Related
12% Asphyxiation
18% Burns, Other Trauma, other
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Heart Deaths by OccupationHeart Deaths by Occupation
% of On-Duty Deaths % of On-Duty Deaths caused by CVD caused by CVD
Firefighters Firefighters 45%45%
PolicePolice 22%22%
Overall*Overall* 15%15%
ConstructionConstruction 11.5%11.5%
EMSEMS 11%11%
*Average % of all Occupational Fatalities, *Average % of all Occupational Fatalities, all industriesall industries
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Development of Atherosclerotic Plaques
Normal
Fatty streak
Foam cells
Lipid-rich plaque
Lipid core
Fibrous cap
Thrombus
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DeathDeath
DiseaseDisease
DisabilityDisability
Age Age
BMI/ Body BMI/ Body CompositionComposition
DyslipidemiaDyslipidemia
HypertensionHypertension
FamilyFamily
HistoryHistory
DiabetesDiabetes
Hypertrophy +/-Hypertrophy +/-Known CHDKnown CHD
SubclinicalSubclinicalDiseaseDisease
Regular Exercise/ activity +Regular Exercise/ activity +Moderate EtOH +Moderate EtOH +Diet - / +Diet - / +Tobacco -Tobacco -Irregular Physical Exertion -Irregular Physical Exertion -Pollution/Gases -Pollution/Gases -Noise -Noise -Shift Work -Shift Work -Job Stress with Low Control -Job Stress with Low Control -
THEORETICAL MODEL OF CVD THEORETICAL MODEL OF CVD
Pro-Inflammatory – (bad); Anti-Inflammatory + (good)
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Cohort Studies vs. Presumption LawsCohort Studies vs. Presumption Laws
• Definitive evidence of an Definitive evidence of an increased CHD risk in increased CHD risk in Firefighters lacking. Firefighters lacking.
• Based on >/=10 cohort Based on >/=10 cohort mortality studiesmortality studies Firefighters’ risk of CHD Death
SMR of ~0.9
• High proportion of High proportion of CHD deaths and CHD deaths and recognition of recognition of Cardiovascular Cardiovascular Stressors has led toStressors has led to
“ “Heart Presumption” Heart Presumption”
laws in 37 / 50 states laws in 37 / 50 states and 2 Canadian and 2 Canadian ProvincesProvinces
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On-Duty Events, Work-Related or On-Duty Events, Work-Related or Just happen at Work???Just happen at Work???
Potential Occupational Cardiovascular Potential Occupational Cardiovascular StressorsStressors
Heavy Physical Exertion - on an Irregular Basis
> 50 lbs Personal Protective Equipment
Near Maximal-Maximal HR (at least 10 METS)
Heat Stress & Fluid losses
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Methods: Case-control study, 52 male firefighters CHD deaths investigated by NIOSH.
Control population: 51 male firefighters on-duty trauma deaths
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Circadian Distribution of Firefighter Fatalities
Compared with the Distribution of Emergency Calls
Quartile of time of day
1800-23591200-17590600-11590000-0559
Pe
rce
nt
50
40
30
20
10
0
Trauma Death
CHD Death
EC = Emergency Calls
EC
EC
ECEC
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Circadian Distribution of CHD Deaths
Present Study and 1990-2000 FEMA Study
Comparison to Emergency Calls
Quartile of time of day
1800-2359
1200-1759
0600-1159
0000-0559
Perc
ent
50
40
30
20
10
0
CHD Present Study
CHD 1990-2000 FEMA
EC
EC
ECEC
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Circadian Distribution of CHD Deaths
for Firefighters and the General Population
Quartile of time of day
1800-23591200-17590600-11590000-0559
Pe
rce
nt
50
40
30
20
10
0
Firef ighters
General Population
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CHD Deaths vs. Time Spent in
Each Activity
Job Activity
Pe
rce
nt
60
50
40
30
20
10
0
Cardiac/Non Cardiac
% of CHD Deaths
Average % of Time
Spent per Year
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Type of Duty
Actual CHD Deaths
(N=52) %(n)
Expected Deaths
(N=52) %(n)
Estimated OR relative to Non-Emergency Duty
OR (95%CI)
p Value
Fire Supp. 36 (19) 2 (1) 64.1 (7.4-556)
<0.001
Training 17 (9) 8 (4) 7.6 (1.8-31.3)
0.006
Alarm Response
10 (5) 6 (3) 5.6 (1.1-28.8)
0.042
Alarm Return 10 (5) 10 (5) 3.4 (0.8-14.7)
0.12
EMS or Non-Fire Emergency
12 (6) 23 (12) 1.7 (0.5-5.9)
0.52
Fire House and Non-emergency activities
15 (8) 52 (27) 1.0 _
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U.S. Fire Administration: narrative summaries all US firefighting deaths 1994-2004 (n= 1144)
Excluded deaths associated September 11, 2001
Classified as cardiovascular or noncardiovascular
Excluded deaths more than 24 hours after the on-duty incident
Excluded cardiovascular deaths other than CHD
449 deaths due to CHD (39%).
Selected deaths classified according to the specific duty performed during onset of symptoms/ immediately preceding sudden death.
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Type of Duty Kales et al 2003(relative risk of
CHD death)
Holder et al 2006(relative risk of heart
event leading to retirement)
Kales et al 2007(relative risk of
CHD death)
Fire suppression – OR** (95% CI£)
64.1 (7.4-556) 51 (12-223) 53 (40-72)
Physical training – OR** (95%CI£)
7.6 (1.8-31.3) 0.68 (0.2-2.7) 5.2 (3.6-7.5)
Alarm response – OR** (95% CI)
5.6 (1.1-28.8) 6.4 (2.5-17) 7.4 (5.1-11)
Alarm return –OR (95% CI£) 3.4 (0.8-14.7) 0.37 (0.07-1.8) 5.8 (4.1-8.1)
EMS and other non-fire emergencies – OR** (95% CI£)
1.7 (0.5-5.9) 0.75 (0.3-1.8) 1.3 (0.9-2.0)
Firehouse and other non-emergency activities – OR** (95% CI£)
1.0 1.0 1.0
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Duty-related Risks: InterpretationDuty-related Risks: Interpretation
• Fire Suppression: Heavy Physical Exertion,
> 50 lbs PPE, Near Maximal, Heat Stress & Fluid losses, Smoke Exposure, Danger & Stress
• Training: Risk concentrated in live-fire/simulation drills (exposures as above) &
Physical testing in persons without adequate medical clearance.
• Alarm Response: “Fight or Flight” physiology with full cardiovascular arousal, Noise
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On-Duty CHD Death: Work-related? On-Duty CHD Death: Work-related? ConclusionsConclusions
Both circadian and job activity data support Both circadian and job activity data support that on-duty CHD death is often job-that on-duty CHD death is often job-precipitated.precipitated.
Events within a day of firefighting or onset Events within a day of firefighting or onset during strenuous dutyduring strenuous duty** resulting in resulting in cardiovascular arousal support work-cardiovascular arousal support work-relatedness.relatedness.
* Does not include * Does not include
Non-emergency duty, Most EMS work, Off-dutyNon-emergency duty, Most EMS work, Off-duty
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CHD Death Risk by Age and Duty
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Potential Personal Cardiovascular Potential Personal Cardiovascular Risk FactorsRisk Factors
Poor exercise tolerance
High prevalences of obesity and hypercholesterolemia
Hypertension and Dyslipidemia often untreated
Most firefighters do not receive regular periodic examinations
19961991
2003
Obesity Trends* Among U.S. Adults1991, 1996, 2003 (CDC)
(*BMI 30, or about 30 lbs overweight for 5’4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Obesity Trends Among U.S. Adults 2006 (CDC)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
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30.00 35.00 40.00
Mean Age
25.00
26.00
27.00
28.00
29.00
30.00
Me
an
BM
I
1992
1990
199619981999
2001
2001
2005
Relation to Age & Year of Cohort
Mean BMI among N. American Firefighters
1996- Present: Obesity Prevalence 30-40% Professionals
45% Volunteers (NVFC)
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OBESITY
Adverse Effects in Firefighters:
Blood Pressure
Pulmonary Function
Exercise Tolerance
Lipids
Liver Function
Cardiovascular Risk Factor clustering
Adverse Employment Outcomes
Independent Adverse Associations Independent Adverse Associations of Hypertension in Firefightersof Hypertension in Firefighters
Endpoint Hypertension Criteria Adjusted OR or Hazard Ratio (95% CI)
Study Design
Adverse Change in Employment
Stage II BP
Stage II BP & No BP Meds
2.9 (1.1-8.1)
4.6 (2.1-10.1)
Prospective Cohort
CHD Retirement >/=140/90, Diagnosis of
Hypertension, or Antihypertensive Medication
1.2 (0.6 –2.4) RetrospectiveCase-Control
Non-CHD Cardiovascular Retirement
4.8 (1.3-17.9)
On-Duty CHD Death
4.7 (2.0-11.1)
Case-Fatality for On-Duty CHD Events
2.9 (1.3-6.3) Cross-Sect.Case-Fatality
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Reviewed all completed fatality reports on NIOSH Reviewed all completed fatality reports on NIOSH website from 1996- December 2002.website from 1996- December 2002.
52 male firefighters who died of CHD52 male firefighters who died of CHD
(69% autopsies + 12% known pre-morbid CHD)(69% autopsies + 12% known pre-morbid CHD)
310 firefighters examined in 1996 and documented as 310 firefighters examined in 1996 and documented as professionally active in firefighting in 1998professionally active in firefighting in 1998
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Heart Retirements
Describe Massachusetts firefighters receiving pensions under state “Heart Presumption” legislation
1997-2004: All cases approved by PERAC after review by PERAC-appointed medical panels.
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Research Plan
Controls: Active- Non-retired Firefighters drawn from all regions of Massachusetts
310 male firefighters examined in 1996/1997, whose vital status and continued professional activity were re-documented in 1998.
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Results• 362 Heart presumption retirements• 278 CHD retirements (77%)
• 84 Non-CHD retirements HTN 30 (36%)
AFIB, Flutter or SVT 19 (23%)Cardiomyopathy 11 (13%)
CVA 11 (13%) Syncope 5 (6%)
Aortic Aneurysm 4 (5%) Other 4 (5%)
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CHD Retirements versus Active Firefighters (Controls)
CHDRetirements
(n=277)% (n)
ActiveFirefighters
(n=310)% (n)
OR (95% CI) and
MultiVar OR(95%CI)
Age ≥ 45 years old 94.2 (261) 20.7 (64) 62.7 (35 – 111)52 (19.4 – 139.4)
Current Smoking 30.3 (76) 10.0 (31) 3.9 (2.5 - 6.2)2.9 (1.3 – 6.3)
Hypertension 59.0 (141) 21.0 (65) 5.4 (3.7 - 7.9)1.2 (0.6 – 2.4)
Diabetes Mellitus 25.7 (62) 2.6 (8) 13.0 (6.1 - 27.8)5.0 (1.7 – 15.4)
Cholesterol >/= 5.18 mmol/L (200 mg/dl)
80.5 (169) 63.2 (196) 2.4 (1.6 – 3.6)0.8 (0.4 – 1.6)
Prior Diagnosis of CHD 22.4 (48) 1.0 (3) 29.6 (9.1 – 96.5)8.8 (1.9 – 41.3)
Obesity, BMI >/=30 41.4 (98) 34.1 (104) 1.4 (0.96 – 1.93)0.7 (0.3 – 1.3)
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Non-CHD Retirements versus Active Firefighters (Controls)
Non-CHDRetirements
(n=84)% (n)
ActiveFirefighters
(n=310)% (n)
OR (95% CI)and
MultiVar OR(95% CI)
Age ≥ 45 years old 86.8 (72) 20.7 (64) 25.5 (12.8 – 50.9)7.8 (2.0 – 31.4)
Age >/=50 years old 77.1 (64) 4.5 (14) 72.3 (34.5 – 151.7)
Current Smoking 21.7 (13) 10.0 (31) 2.5 (1.2 – 5.1)2.9 (0.6 – 13.6)
Hypertension 75.3 (55) 21.0 (65) 10.9 (6.1 – 19.7)4.8 (1.3 – 17.9)
Diabetes Mellitus 17.0 (10) 2.6 (8) 7.7 (2.9 – 20.3)4.3 (0.7 – 27.8)
Cholesterol >/= 5.18 mmol/L (200 mg/dl)
64.7 (22) 63.2 (196) 1.1 (0.51 – 2.24)1.3 (0.3 – 5.5)
Obesity, BMI >/=30 66.1 (41) 34.1 (104) 3.6 (2.0 – 6.4)2.9 (0.8 – 11.4)
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Predictors of Fatal on-Duty CHD Events (vs. Non-Fatal Events)
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A. Fire Fighter Fatality Investigation and Prevention Program of NIOSH: On-Duty Fatalities reported between January 1996 and July 2006.
B. Massachusetts Heart Disease Disability Pensions received between 1997 and 2004. 362 Pension Awardees
110 Cardiovascular Deaths
5 deaths > 24 hours from event 105 Acute
Cardiovascular Deaths within 24 hours
14 Non- CHD Deaths
1 Cocaine Related Death
90 Acute On-Duty CHD Fatalities (cases)
84 non-CHD Pensions
288 CHD Pensions
173 CHD pensions NOT related to a specific on-Duty event115 CHD Pensions
linked to Specific On-Duty Events
113 Non-Fatal, On-Duty CHD Events (controls)
2 Fatalities
NON-Cardiovascular Deaths
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Table 1: Characteristics Of On Duty CHD Events
Non Fatal Events
(n=113)% (n)
Fatal Events(n=90)% (n)
P-Value
Mean Age +/- SD (years) 54.5 +/- 6.6 50.5 +/- 7.4 <0.001
Age Range (years) 33-66 29-69 N/A
% Male 100 (113) 100 (90) --------
% Professional Firefighters 100 (113) 63 (56) <0.001
Mean BMI +/- SD 30.3 +/- 5.7(n=86)
31.2 +/- 6.2(n=33)
0.466
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Type of Duty at Time of Event Fire Suppression
Alarm ResponseAlarm Return
Physical TrainingNon-fire Emergency
Non-Emergency Duty
% (n)
40 (36)18 (16)1 (1)3 (3)
11 (10)27 (24)(n=90)
% (n)
31 (28)8 (7)
11 (10)16 (14)10 (9)
24 (22)
0.001
Strenuous Duty at Time of Event #
62 (56)(n=90)
66 (59) 0.642
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Bivariate Odds Ratios for Fatal Outcome among On Duty CHD Events
Non Fatal Eventsn=113% (n)
Fatal Eventsn=90% (n)
Odds Ratio for Fatal Event(95% CI)
Age ≥ 45 years old 95 (107) 79 (71) 0.21 (0.08-0.55)
Current Smoking 24 (27) 41 (37) 2.22 (1.22-4.06)
Hypertension 49 (55) 68 (61) 2.22 (1.25-3.94)
Diabetes Mellitus 21 (24) 13 (12) 0.57 (0.27-1.22)
Cholesterol >/= 5.18 mmol/L (200 mg/dl)
58 (66) 63 (57) 1.23 (0.70-2.17)
Prior Diagnosis of CHD/arterial-occlusive disease
18 (20) 34 (31) 2.44 (1.28-4.68)
Obesity, BMI >/=30 41 (35) (n=86)
61 (20)(n=33)
2.24 (0.99-5.09)
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Multivariate Odds Ratios for Fatal Outcome among On Duty CHD Events
Multivariate OR (95% CI)*
P- Value
Current Smoking 4.25(1.86, 9.74)
<0.001
Hypertension 2.89(1.32, 6.34)
0.008
Diabetes Mellitus 0.28(0.09, 0.86)
0.03
Cholesterol >/= 5.18 mmol/L (200 mg/dl)
1.17(0.54, 2.57)
0.69
Prior Diagnosis of CHD / arterial-occlusive disease
5.29(2.06, 13.59)
<0.001
* Multivariate Odds Ratios adjusted for all other Risk Factors in the table, as well as professional status, age above/below 45 years and strenuous duty.
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PREVENTION 1PREVENTION 1
1)1) Fitness Promotion: Fitness Promotion: Physical Standards not maintained; high Physical Standards not maintained; high prevalence of obesity (>33%); prevalence of obesity (>33%);
~75% Nationally- NO fitness programs~75% Nationally- NO fitness programs
Mandatory exercise programsMandatory exercise programs
Nutrition programsNutrition programs
Flu ShotsFlu Shots
USA Today Wed, August 29, 2007 USA Today Wed, August 29, 2007
““Firefighters plagued by heart attacks get fitness challenge” Firefighters plagued by heart attacks get fitness challenge”
““I would rather fire I would rather fire you for your health you for your health than to go tell your than to go tell your wife or your mother wife or your mother
that you're laying out that you're laying out here with a heart here with a heart
attack, dead" attack, dead"
Chief JolleyChief Jolley
Each quarter, Pelham-Batesville (SC) firefighters Each quarter, Pelham-Batesville (SC) firefighters take a test that includes running, push-ups, sit-ups take a test that includes running, push-ups, sit-ups
and a flexibility test.and a flexibility test.
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PREVENTION 2PREVENTION 2
2)2) Medical Screening: Medical Screening: Few CHD fatalities or Retirements had Few CHD fatalities or Retirements had a FD medical w/in 48 months of their a FD medical w/in 48 months of their eventevent
Ideally should integrate occupational Ideally should integrate occupational exams with primary care follow-upexams with primary care follow-up
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CHD Death Risk by Age and Duty
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PREVENTION 3PREVENTION 3
3)3) Risk Factor Reduction: Risk Factor Reduction: Low rates of HTN and lipid treatmentLow rates of HTN and lipid treatment
Change Blood Pressure StandardsChange Blood Pressure Standards
Data supports Smoking BANData supports Smoking BAN
4)4) Exercise Testing: Exercise Testing: Should be mandated >45 and sooner if Should be mandated >45 and sooner if
excess risk factors, study needed to excess risk factors, study needed to determine best protocolsdetermine best protocols
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PREVENTION 4PREVENTION 4
5) RTW Protocols: 5) RTW Protocols: Need Occupational Medicine Clearance after Need Occupational Medicine Clearance after
Illness or InjuryIllness or Injury
6) Pre-Existing CHD:6) Pre-Existing CHD: Once CHD is diagnosed, most affected Once CHD is diagnosed, most affected
Firefighters should be removed from Firefighters should be removed from Emergency OperationsEmergency Operations
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Major Study Team Members 1996-2007
Elpidoforos Soteriades, MD, MSc, ScDJonathan Holder, DO, MPHCostas Christophi, PhDIbe Mbanu MD, MPHJesse Geibe, MD, MPHGerry Polyhronopoulos, MDJon Aldrich, MDStavros ChristoudiasAntonios TsismenakisDavid Christiani, MD, MPH, MS Professor &
Director Occupational Health Program, HSPH
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Bibliography
Kales SN, Polyhronopoulos GN, Aldrich JM, Leitao ED, Christiani DC. Correlates of body mass index in hazardous materials firefighters. J Occup and Environ Med 1999;41: 589-595.
Kales SN, Christiani DC. Cardiovascular Fitness in Firefighters. Journal of Occupational and Environmental Medicine 2000; 42: 467-468.
Kales SN, Soteriades ES, Christoudias SG, Tucker S, Nicolaou M, Christiani DC. Firefighters’ blood pressure and Employment Status on Hazardous Materials Teams in Massachusetts: A Prospective Study. J Occup Env Med 2002;44:669-676.
Soteriades ES, Kales SN, Christoudias, SG, Tucker S, Liarokapis D, Christiani, DC. The Lipid Profile of Firefighters Over Time: Opportunities for Prevention. J Occup Env Med 2002;44:840-846.
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Bibliography
Soteriades ES, Kales SN, Liarokapis D, Christiani, DC. Prospective Surveillance of Hypertension in Firefighters. J Clinical Hypertension 2003; 5:315-321.
Kales SN, Soteriades ES, Christoudias SG, Christiani DC. Firefighters and On-Duty Deaths from Coronary Heart Disease: a Case Control Study. Environmental Health: A Global Access Science Source 2003, 2:14.
Soteriades ES, Hauser R, Kawachi I, Liarokapis D, Christiani DC, Kales SN. Obesity and Cardiovascular Disease Risk Factors in Firefighters: A Prospective Cohort Study. Obesity Research 2005;13: 1756-1763.
Holder JD, Stalling L, Peeples L, Burress JW, Kales SN. Firefighter Heart Presumption Retirements in Massachusetts: 1997-2004. J Occup Environ Med. 2006; 48:1047-1053.
Kales SN, Soteriades ES, Christouphi CA, Christiani DC. Emergency Duties and Deaths from Heart Disease among Firefighters in the United States. N Engl J Med 2007;356:1207-1215.
Mbanu I, Wellenius GA, Mittleman MA, Peeples L, Stallings LA, Kales SN. Seasonality and Coronary Heart Disease Deaths in United States Firefighters. Chronobiol Int. 2007; 24: 715–726.