Downloaded from http://journals.lww.com/joem by BhDMf5ePHKbH4TTImqenVOxbUnPuOlhi5EeCea+sVQ32t18KlPvJYpm/AAFA7x2c on 10/11/2018 Copyright © 2018 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited Volunteer and Career French Firefighters With High Cardiovascular Risk Epidemiology and Exercise Tests Ange ´lique Savall, MD, Rodolphe Charles, MD, Jeremy Binazet, MD, Fre ´de ´ric Frey, MD, Be ´atrice Trombert, PhD, Luc Fontana, PhD, Jean-Claude Barthe ´le ´my, PhD, and Carole Pelissier, PhD Objective: We aim to identify cardiovascular risk factors in firefighters of Loire (French district) with a high cardiovascular risk and report results of a screening program using exercise tests. Methods: A retrospective descriptive study was performed in a cohort of 158 career and 400 volunteer firefighters with a high cardiovascular risk who had undergone an exercise test. Results: Five hundred fifty-eight exercise tests and cardiovascular profiles were analyzed. Prevalence was 18% for high blood pressure, 19% for dyslipidemia, and 48% for overweight. Exercise tests were positive in 91 cases (16.3%): sensitivity, 53%; specificity, 74%. Risk of onset of a predictive event was higher in the high-risk group: odds ratio, 3.2 (95% confidence interval 2.0 to 5.1). There were more events on exercise test in volunteer firefighters. Conclusion: Prevalence of cardiovascular risk factors in the cohort of firefighters was acceptable in comparison to French general population and other firefighters’ cohort. Physical training of volunteer firefighters needs reinforcing. Keywords: cardiovascular risk, exercise test, firefighters, occupational health I n 2007, the New England Journal of Medicine reported that 39% of on-duty deaths in US firefighters concerned myocardial infarction (MI), compared with 11% in emergency medical services workers. 1 In Australia, volunteer wildland firefighters have a greater risk of coronary heart disease (CHD) than levels observed in other emergency services based in different countries (eg, the USA). 2 A literature review confirmed this elevated cardiovascular (CV) risk of firefighters. 3 These deaths from CV events occur most often between noon and midnight, during firefighting or intense physical training, or in the minutes following an alarm. 4,5 Specific risks come on top of the stress of the situation: the physical load carried during intervention, and inhalation of combustion products (carbon mon- oxide). 6 Certain occupational tasks incur a higher risk of MI: actual firefighting, the departure and return from intervention, physical training (including all job-related physical-fitness activities, physi- cal-abilities testing, simulations, and exercises), and victim rescue. 1 In 2007, the National Institute for Occupational Safety and Health published a review of the various risks inherent to the work of firefighters. Analysis of heart rate (HR) during the various tasks involved in the work found that the alarm signal induced a very rapid increase in HR, sometimes reaching the theoretical maximum. In putting out fires, hose positioning and excavation are the phases that most tax the heart; the type of gear worn (mask, helmet, jacket) is also a factor. 7 In 2003, Kales et al found a higher prevalence of CV risk factors associated with on-duty death: age > 45 years, smoking, hypertension. 4 There now seems no doubt that CV risk factors are more frequent in firefighters. Between 1996 and 2001, the rate of overweight and obesity increased from 77% to 90% in American firefighters, 8–10 20% to 30% suffered from high blood pressure (HBP), 1,4,8 and dyslipidemia rates increased by 20%. 11,12 A recent study documents the prevalence of CV risk factors in Que ´bec firefighters with a prevalence of obesity, hypertension, and dysli- pidemia about 23.6%, 12.2%, and 17.4%, respectively. 13 There are currently no French national data for the prevalence of CV risk factors in firefighters, and no guidelines for assessing CV risk. In France, an aptitude assessment is mandatory every 2 years up to 38 years of age, then every year, and provides the best opportunity to assess CV risk. It comprises interview, clinical examination, visual and auditory acuity tests, and a respiratory function test. As frequently as necessary, and at least every 3 years after 40 years of age, biological assessment and electrocardiography (ECG) are performed. This was laid out in the official modified guidelines on May 6, 2000 (Ministry of Defense and Civil Security), which determined medical aptitude for firefighters and the role of preventive and occupational medicine in the departmental fire and emergency services. Article 18 specifies that ECG at rest should be supplemented by an exercise test (ET) in case of CV risk factors. ET quantify endurance and reveal cardiac anomalies that may not be apparent at rest. They are performed under clearly defined conditions, ensuring safety. 14 They are highly discriminating, with 68% sensitivity and 77% specificity in detecting subjects at CHD risk. They are of diagnostic interest within an at-risk population (athletes aged over 30 years). The Loire departmental fire and emergency service (DFES42) comprises 550 career and 2300 volunteer firefighters. These firefighters complete urban and wildland firefighting. ET are used in assessing aptitude, according to the subject’s age and a CV risk factor scale, that is assessed at the annual aptitude check-up. The results of these ET are recorded in the DFES42 medical register of occupational medicine. The main objective of the present study was to identify CV risk factors of Loire (French district, prefecture Saint Etienne) firefighters with a high CV risk that had led to an ET being required. Secondary objectives comprised comparison of CV risk factors and ET data between career and volunteer firefighters, and analysis of the ade- quacy of the selection criteria for firefighters monitored by ET. From the Department of Education and Research in General Practice, Saint- Etienne Jean Monnet University, Saint Priest en Jarez, France (Drs Savall, Charles); SDIS 42, Fire and Rescue Department of Saint Etienne, Saint Etienne cedex, France (Drs Charles, Frey); Public Health, University Hospi- tal, Saint-Priest-en-Jarez cedex, France (Dr Trombert); Department of Occu- pational Health, University Hospital, Saint-Priest-en-Jarez cedex, France (Drs Fontana, Pelissier); University Lyon 1, University of St Etienne, IFSTTAR, UMRESTTE, UMR-T9405, Saint Etienne, France (Drs Fontana, Pelissier); and Clinical and Exercise Physiology, EA 4607 SNA EPIS, University Hospital and Jean Monnet University, PRES Lyon, Saint-Etienne, France (Drs Savall, Trombert, Barthe ´le ´my). CR, BJ, and FF participated in the planning and conduct of this study. BT analyzed the data. AS, CR, BJ, and CP contributed to the interpretation of results and writing for the paper. AS, LF, and CP drafted the manuscript. All authors contributed to the revision of the manuscript and approved it for submission. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors have no competing interests. Address correspondence to: Ange ´lique Savall, MD, Research fellow, Department of Education and Research in General Practice, Saint-Etienne Jean Monnet University, Po ˆle Sante ´ Nord, 10 Rue de la Marandie `re, 42270 Saint Priest en Jarez, France (a.savall@univ-st-etienne.fr). Copyright ß 2018 American College of Occupational and Environmental Medicine DOI: 10.1097/JOM.0000000000001426 e548 JOEM  Volume 60, Number 10, October 2018 ORIGINAL ARTICLE