Usefulness of Coronary and Carotid Imaging Rather than Traditional Atherosclerotic Risk Factors to Identify Firefighters at Increased Risk for Cardiovascular Disease

Published:February 13, 2014DOI:
      Cardiovascular disease (CVD) accounts for 45% of deaths in on-duty firefighters, in contrast to 15% of all deaths occurring on conventional jobs. Therefore, with the goal of developing a tailored prevention program, we assessed CVD risk in a cohort of 50 firefighters using imaging and traditional risk factors. Participants were aged ≥40 years without a history of CVD or diabetes. CVD risk was assessed by way of history, physical examination, blood tests, risk scores, coronary artery calcium (CAC), and carotid intima-media thickness (cIMT). Median age was 46 years; 90% of subjects were men, 92% were white, and 30% were former smokers. Only 4% of subjects were hypertensive but 48% were prehypertensive. Only 14% of subjects had a normal body mass index; 38% were overweight, 48% were obese, and 46% had a high waist circumference. Based on fasting glucose ≥100 mg/dl or hemoglobin A1c ≥5.6%, 50% of subjects had prediabetes and 2% had diabetes. Median total cholesterol was 196 mg/dl; median high-sensitivity C-reactive protein was 1.0 mg/L. CAC was detected in 22% of subjects and carotid plaque was detected in 36%. Using standard reference databases, 54% of subjects had cIMT greater than the seventy-fifth percentile; 66% had carotid plaque and/or cIMT greater than the seventy-fifth percentile. Atherogenic lipoprotein markers and risk scores did not differ between firefighters who had subclinical atherosclerosis and those who did not. Traditional CVD risk assessment does not adequately identify at-risk firefighters. In contrast, CAC and cIMT were useful for identifying increased risk and implementing primary prevention. In conclusion, early detection and integration of imaging with traditional risk assessment will be important in preventing premature death and disability among firefighters.
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        • Kales S.N.
        • Soteriades E.S.
        • Christophi C.A.
        • Christiani D.C.
        Emergency duties and deaths from heart disease among firefighters in the United States.
        N Engl J Med. 2007; 356: 1207-1215
        • Soteriades E.S.
        • Smith D.L.
        • Tsismenakis A.J.
        • Baur D.M.
        • Kales S.N.
        Cardiovascular disease in US firefighters.
        Cardiol Rev. 2011; 19: 202-215
        • Hsu S.
        • Ton V.K.
        • Dominique Ashen M.
        • Martin S.S.
        • Gluckman T.J.
        • Kohli P.
        • Sisson S.D.
        • Blumenthal R.S.
        • Blaha M.J.
        A clinician's guide to the ABCs of cardiovascular disease prevention: the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease and American College of Cardiology Cardiosource Approach to the Million Hearts Initiative.
        Clin Cardiol. 2013; 36: 383-393
        • Agatston A.S.
        • Janowitz W.R.
        • Hildner F.J.
        • Zusmer N.R.
        • Viamonte Jr., M.
        • Detrano R.
        Quantification of coronary artery calcium using ultrafast computed tomography.
        J Am Coll Cardiol. 1990; 15: 827-832
        • Stein J.H.
        • Korcarz C.E.
        • Hurst R.T.
        • Lonn E.
        • Kendall C.B.
        • Mohler E.R.
        • Najjar S.S.
        • Rembold C.M.
        • Post W.S.
        • American Society of Echocardiography Carotid Intima-Media Thickness Task Force
        Use of carotid ultrasound to identify subclinical vascular disease and evaluate cardiovascular disease risk: a consensus statement from the American Society of Echocardiography Carotid Intima-Media Thickness Task Force. Endorsed by the Society for Vascular Medicine.
        J Am Soc Echocardiogr. 2008; 21: 93-111
        • Howard G.
        • Sharrett A.R.
        • Heiss G.
        • Evans G.W.
        • Chambless L.E.
        • Riley W.A.
        • Burke G.L.
        Carotid artery intimal-medial thickness distribution in general populations as evaluated by B-mode ultrasound.
        Stroke. 1993; 24: 1297-1304
        • Youn Y.J.
        • Lee N.S.
        • Kim J.Y.
        • Lee J.W.
        • Sung J.K.
        • Ahn S.G.
        • You B.S.
        • Lee S.H.
        • Yoon J.
        • Choe K.H.
        • Koh S.B.
        • Park J.K.
        Normative values and correlates of mean common carotid intima-media thickness in the Korean rural middle-aged population: the Atherosclerosis RIsk of Rural Areas iN Korea General Population (ARIRANG) study.
        J Korean Med Sci. 2011; 26: 365-371
        • Turner R.C.
        • Holman R.R.
        • Matthews D.
        • Hockaday T.D.
        • Peto J.
        Insulin deficiency and insulin resistance interaction in diabetes: estimation of their relative contribution by feedback analysis from basal plasma insulin and glucose concentrations.
        Metabolism. 1979; 28: 1086-1096
        • Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults
        Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III).
        JAMA. 2001; 285: 2486-2497
      1. Accessed August 1, 2013.

        • Ridker P.M.
        • Paynter N.P.
        • Rifai N.
        • Gaziano J.M.
        • Cook N.R.
        C-reactive protein and parental history improve global cardiovascular risk prediction: the Reynolds Risk Score for men.
        Circulation. 2008; 118: 2243-2251
        • D'Agostino Sr, R.B.
        • Vasan R.S.
        • Pencina M.J.
        • Wolf P.A.
        • Cobain M.
        • Massaro J.M.
        • Kannel W.B.
        General cardiovascular risk profile for use in primary care. The Framingham Heart Study.
        Circulation. 2008; 117: 743-753
        • Goff Jr., D.C.
        • Lloyd-Jones D.M.
        • Bennett G.
        • Coady S.
        • D'Agostino Sr., R.B.
        • Gibbons R.
        • Greenland P.
        • Lackland D.T.
        • Levy D.
        • O'Donnell C.J.
        • Robinson J.
        • Schwartz J.S.
        • Shero S.T.
        • Smith Jr., S.C.
        • Sorlie P.
        • Stone N.J.
        • Wilson P.W.
        2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        Circulation. 2013 Nov 12;
        • Grundy S.M.
        • Cleeman J.I.
        • Daniels S.R.
        • Donato K.A.
        • Eckel R.H.
        • Franklin B.A.
        • Gordon D.J.
        • Krauss R.M.
        • Savage P.J.
        • Smith Jr., S.C.
        • Spertus J.A.
        • Costa F.
        • American Heart Association; National Heart, Lung, and Blood Institute
        Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement.
        Circulation. 2005; 112: 2735-2752
      2. Accessed December 11, 2013.

      3. Accessed July 24, 2013.

        • Yang J.
        • Teehan D.
        • Farioli A.
        • Baur D.M.
        • Smith D.
        • Kales S.N.
        Sudden cardiac death among firefighters ≤45 years of age in the United States.
        Am J Cardiol. 2013; 112: 1962-1967
        • Burgess J.L.
        • Kurzius-Spencer M.
        • Gerkin R.D.
        • Fleming J.L.
        • Peate W.F.
        • Allison M.
        Risk factors for subclinical atherosclerosis in firefighters.
        J Occup Environ Med. 2012; 54: 328-335
        • Superko H.R.
        • Momary K.M.
        • Pendyala L.K.
        • Williams P.T.
        • Frohwein S.
        • Garrett B.C.
        • Skrifvars C.
        • Gadesam R.
        • King 3rd, S.B.
        • Rolader S.
        • Meyers B.
        • Dusik D.
        • Polite S.
        Firefighters, heart disease, and aspects of insulin resistance.
        J Occup Environ Med. 2011; 53: 758-764
        • Santora L.J.
        • Pillutla P.
        • Norris T.
        • Santora R.
        • Brandt R.
        • Jenkins M.
        • Robinson M.
        • Santora N.
        • Budoff M.J.
        Coronary calcium scanning independently detects coronary artery disease in asymptomatic firefighters: a prospective study.
        J Cardiovasc Comput Tomogr. 2013; 7: 46-50
        • Peters S.A.E.
        • den Ruijter H.M.
        • Bots M.L.
        • Moons K.G.M.
        Improvements in risk stratification for the occurrence of cardiovascular disease by imaging subclinical atherosclerosis: a systematic review.
        Heart. 2012; 98: 177-184
        • Barth A.S.
        • Abd T.T.
        • Blumenthal R.S.
        • Blaha M.J.
        Comparative effectiveness of risk markers for cardiovascular risk assessment in intermediate-risk individuals: coronary artery calcium vs “the rest”.
        Curr Cardiovasc Imaging Rep. 2013; 6: 203-210
        • Folsom A.R.
        • Kronmal R.A.
        • Detrano R.C.
        • O'Leary D.H.
        • Bild D.E.
        • Bluemke D.A.
        • Budoff M.J.
        • Liu K.
        • Shea S.
        • Szklo M.
        • Tracy R.P.
        • Watson K.E.
        • Burke G.L.
        Coronary artery calcification compared with carotid intima-media thickness in prediction of cardiovascular disease incidence: the Multi-Ethnic Study of Atherosclerosis (MESA).
        Arch Intern Med. 2008; 168: 1333-1339
        • Blaha M.
        • Budoff M.J.
        • Shaw L.J.
        • Khosa F.
        • Rumberger J.A.
        • Berman D.
        • Callister T.
        • Raggi P.
        • Blumenthal R.S.
        • Nasir K.
        Absence of coronary artery calcification and all cause mortality.
        JACC Cardiovasc Imaging. 2009; 2: 692-700
        • Doneen A.L.
        • Bale B.F.
        Carotid intima-media thickness testing as an asymptomatic cardiovascular disease identifier and method for making therapeutic decisions.
        Postgrad Med. 2013; 125: 108-123
        • Kavousi M.
        • Elias-Smale S.
        • Rutten J.H.
        • Leening M.J.
        • Vliegenthart R.
        • Verwoert G.C.
        • Krestin G.P.
        • Oudkerk M.
        • de Maat M.P.
        • Leebeek F.W.
        • Mattace-Raso F.U.
        • Lindemans J.
        • Hofman A.
        • Steyerberg E.W.
        • van der Lugt A.
        • van den Meiracker A.H.
        • Witteman J.C.
        Evaluation of newer risk markers for coronary heart disease risk classification: a cohort study.
        Ann Intern Med. 2012; 156: 438-444
        • Yeboah J.
        • McClelland R.L.
        • Polonsky T.S.
        • Burke G.L.
        • Sibley C.T.
        • O'Leary D.
        • Carr J.J.
        • Goff D.C.
        • Greenland P.
        • Herrington D.M.
        Comparison of novel risk markers for improvement in cardiovascular risk assessment in intermediate-risk individuals.
        JAMA. 2012; 308: 788-795