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46-Year-Old Airport Firefighter Suffers Fatal Heart Attack

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Executive Summary

On March 20, 2019, at approximately 0058 hours, a 46-year-old career firefighter (FF) failed to 

respond to the apparatus for a call. A fellow firefighter went to find the FF and discovered him 

unconscious on the floor in a hallway leading to the apparatus bay. Crew members initiated 

cardiopulmonary resuscitation (CPR) and notified in-house paramedics, who provided advanced 

cardiac life support (ACLS) and transported the FF. The emergency department (ED) staff continued 

resuscitation efforts for nearly 20 minutes. The FF never regained an organized cardiac rhythm and 

was pronounced dead at 0151 hours. 

The Medical Examiner’s report listed the cause of death as “acute myocardial infarction due to 

hypertensive and atherosclerotic cardiovascular disease.” The autopsy found a large portion of the 

left ventricle wall was damaged due to a heart attack (myocardial infarction). There was severe 

atherosclerotic plaque in several of the major coronary arteries and evidence of prior stenting in the 

descending aorta. National Institute for Occupational Safety and Health (NIOSH) investigators 

concluded that the sympathetic nervous system activation associated with the alarm response likely 

triggered a heart attack in an individual with underlying cardiovascular disease. 

Key Recommendations

NIOSH offers the following recommendations to reduce the likelihood of heart attacks and sudden 

cardiac arrest among firefighters at this and other fire departments across the country.

• Ensure firefighters are cleared for duty by a physician knowledgeable about the physical

demands of firefighting, the personal protective equipment (PPE) and self-contained breathing

apparatus (SCBA) used by firefighters, and the various components of National Fire Protection

Association (NFPA) 1582.

• Develop a tracking system that ensures that firefighters who require follow-up by another

provider receive the follow-up, and that results are reviewed by the physician providing

medical clearance or return to duty.

• Adopt a mandatory comprehensive wellness and fitness program for firefighters.
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The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and Prevention (CDC), is the federal 

agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness. In 1998, Congress 

appropriated funds to NIOSH to conduct a fire fighter initiative that resulted in the NIOSH Fire Fighter Fatality Investigation and Prevention Program, 

which examines line-of-duty deaths or on-duty deaths of fire fighters to assist fire departments, fire fighters, the fire service, and others to prevent similar fire 

fighter deaths in the future. The agency does not enforce compliance with state or federal occupational safety and health standards and does not determine 

fault or assign blame. Participation of fire departments and individuals in NIOSH investigations is voluntary. Under its program, NIOSH investigators 

interview persons with knowledge of the incident who agree to be interviewed and review available records to develop a description of the conditions and 

circumstances leading to the death(s). Interviewees are not asked to sign sworn statements and interviews are not recorded. The agency's reports do not 

name the victim, the fire department or those interviewed. The NIOSH report's summary of the conditions and circumstances surrounding the fatality is 

intended to provide context to the agency's recommendations and is not intended to be definitive for purposes of determining any claim or benefit. 

For further information, visit the program website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636). 
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46-Year-Old Airport Firefighter Suffers Fatal Heart Attack

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Introduction

On March 20, 2019, a 46-year-old career firefighter (FF) suffered a fatal heart attack while responding 

to the apparatus for a rescue call at the airport. The U.S. Fire Administration notified the National 

Institute for Occupational Safety and Health (NIOSH) of this fatality on March 21, 2019. On July 23, 

2019, a contractor for the NIOSH Fire Fighter Fatality Investigation and Prevention Program (the 

NIOSH investigator) conducted an on-site investigation of the incident. 

During the investigation, the NIOSH investigator interviewed the following people:

• Fire Commissioner

• Deputy Chief of Health and Safety

• Deputy Chief of Incident Safety

• Fire Marshal

• Union President

• Captain in Charge of Shift

• Medical Director for City

The NIOSH investigator reviewed the following documents:

• Fire department (FD) incident reports for calls throughout the shift

• Emergency medical service (EMS) (ambulance) report

• Hospital emergency department (ED) records

• Occupational medical records

• Death certificate

• Autopsy report

Investigation

On March 19, 2019, at 0800 hours the 46-year old FF attended roll call for the day shift (12 hour) at 

his airport fire station as part of a mutual exchange of tour. The FF continued on his regularly 

scheduled night shift beginning at 2000 hours. The airport fire station was staffed with two captains 

(one of whom was filling a shift for a lieutenant), 12 firefighters, and 2 paramedics. The FF was part of 

a four-member engine crew and was assigned as the driver. At 1146 hours, the FF and his crew were 
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dispatched on a call for an aircraft that may have difficulty landing, but the aircraft made a normal 

landing and no members dismounted their apparatus.

On the evening of March 19, the FF prepared dinner for crew members at the station, and then most 

members watched a basketball game. It is reported that the FF was in a good mood and his captain 

(CAPT) was not aware of the FF having any issues. 

On March 20, at 0042 hours, the engine crew was dispatched to the airport for a person stuck in an 

elevator. The call was canceled when the crew was notified that everyone was out of the elevator. The 

crew returned to the station and the CAPT and the FF spoke briefly before the CAPT returned to his 

office/bunkroom. There was no indication that the FF was experiencing any symptoms or any distress. 

At 0058 hours, the engine was dispatched again for a person stuck in an elevator. The crew responded 

to the apparatus but the FF failed to respond. The CAPT sent another member to find the missing FF. 

The FF was found unconscious and not breathing in a hallway leading to the apparatus bay. The 

member notified the shift commander that there was a FF down, and the shift commander notified the 

watchman to activate the in-house alarm and announce a code blue. 

The member who went to look for the FF found him in the left side prone position and rolled him over 

on his back. The FF was not breathing, he had no pulse, and his skin was purple. After the member 

called for help, he opened the airway and began cardiopulmonary resuscitation (CPR). Other members 

arrived very shortly. At 0108 hours, dispatch announced a code blue over the public announcement 

(PA) system, and paramedics and firefighters responded to provide care. The FF was attached to a 

cardiac monitor that showed the was in asystole. High-flow oxygen was provided with a nonrebreather mask and oral airway. Oral intubation was unsuccessful due to a difficult airway and a King 

AirwayTM was placed (positive for bilateral breath sounds, confirmed with capnography). The FF 

received 5 rounds of epinephrine with no change in his status. The FF had one brief electrocardiogram

(EKG) change (approximately one minute) where he had a pulseless electrical rhythm, otherwise he 

remained in asystole throughout treatment. The ambulance departed the scene at 0122 hours and 

arrived at the ED at 0133 hours with advanced cardiac care continued en route. Advanced cardiac life 

support (ACLS) protocols were continued in the ED but to no avail. At 0151 hours the FF was 

pronounced dead.

Medical Findings

The FF made no complaints of chest pain, dizziness, or fatigue after he completed a call just 

10 minutes before his collapse. However, based on contemporaneous notes taken after his death, he 

had complained of symptoms of indigestion in the week before the event and was scheduled to see his 

personal physician that day. The Medical Examiner’s report identified the cause of death as acute

myocardial infarction due to hypertensive and atherosclerotic cardiovascular disease. The heart attack

damaged the inferior wall of the left ventricle (4.0 centimeter [cm] x 4.8 cm area of softened 

myocardium). There was severe atherosclerosis noted in the left main, left anterior descending, left 

circumflex, and right coronary arteries. The autopsy also noted a plastic graft in the abdominal aorta 

between the renal arteries and iliac arteries. See Appendix A for a more detailed description of 

autopsy findings.
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The FD and local union have recently begun providing medical evaluations for firefighters through a 

joint labor-management agreement. Through this arrangement, incumbent firefighters receive medical 

evaluations offered through a Contract Provider every other year. The medical evaluations are 

performed at the fire academy, scheduled by the local union, and paid for by the City. FFs who are not 

cleared for duty through this process are referred to their primary care provider (PCP) or a specialist to 

have their condition evaluated further and/or treated. To be cleared for duty, the FFs must bring 

medical records and recommendations from their PCP or specialist to the city medical evaluation unit,

which makes final determination on clearance for duty and return to duty. 

The FF received a medical evaluation for the FD through the Contract Provider on October 23, 2018. 

At that medical exam, he had elevated blood pressure; 160/102 millimeters of mercury (mmHg) for the 

first reading and 170/102 mmHg for a repeat measurement (normal is < 120/80; hypertension is 

considered ≥ 130 systolic and/or ≥ 80 diastolic) [Whelton et al. 2017]. The FF told the Contract 

Provider that he had not taken his blood pressure medication that morning. The FF’s EKG was normal. 

His pulmonary function testing suggested reduced lung function (functional vital capacity [FVC]

78% of age-predicted value). Blood work performed as part of the evaluation indicated the FF had:

• high total cholesterol (215 mg/dL; desirable < 200) 

• high “bad” low-density lipoprotein (LDL) cholesterol (119; optimal < 100) 

• high triglycerides (336 mg/dL; normal < 150)

• low level of “good” high-density lipoprotein (HDL) cholesterol (29; normal > 40)

• high blood sugar and elevated hemoglobin A1C diabetes screening tests (blood glucose = 

128 mg/dL and normal is < 100; A1C = 6.1% and normal is 4.0%–5.6%) [Mayo Clinic 2019]. 

Based on the findings of the medical evaluation, the Contract Provider did not perform the exercise

stress test (EST) that is typically performed as part of the medical evaluation and did not clear the FF 

for duty. The FF was instructed to provide documentation that his blood pressure was controlled. The 

FF was also counseled to quit smoking, lose weight, and lower his hemoglobin A1C. 

On October 24, 2018, the FF visited the physician at the city medical evaluation unit after taking his 

blood pressure medication. At that evaluation his blood pressure was 140/90 mmHg and the FF was

cleared for duty. Because the FF did not have an EST during his periodic FD medical evaluation, he 

was instructed to get an EST (with imaging) through his PCP, and then return to the city’s medical 

evaluation unit. He had a follow-up appointment scheduled for December 6, 2018, but did not show up 

for the appointment due to possible miscommunication or misunderstanding. There are no records 

available to NIOSH to indicate that he ever had the EST.

The FF was 66 inches tall and weighed 164 pounds giving him a body mass index (BMI) of 26.5 (a 

BMI of 25–29.9 is considered overweight, but not obese) [NHLBI no date-a]. He was a smoker. Based 

on his age and modifiable risk factors, and not including diabetes as a risk despite his elevated 

hemoglobin A1C, the American Cardiology Association (ACC) Heart Risk calculator estimated that 

the FF had a 20.6% 10-year risk of heart attack or stroke (0.7% risk with optimal modifiable risk 

factors).
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Fire Department

At the time of the NIOSH investigation, the FD consisted of approximately 2,600 uniformed personnel 

operating out of 63 fire stations. It serves a population of approximately 1,500,000 in a geographic area 

of about 140 square miles. 

Employment and Training

Applicants must be at least 18 years of age, have a high school diploma or equivalent, and possess a 

valid driver’s license. Applicants take a written aptitude (civil service) exam and are ranked based on 

their score and priority points. Successful applicants are then offered conditional employment and must 

pass a criminal background check and a medical evaluation before they are hired. The FF had been 

with the FD for 22 years.

Preplacement, Periodic, and Return to Work Medical Evaluations

The FD requires preplacement medical evaluations for applicants. Components of the medical 

evaluation include the following: 

• Complete medical history

• EKG

• Complete blood count

• Urinalysis

• Urine drug screen

• Audiogram

• Vision test

• Respirator use questionnaire

• Spirometry (pulmonary function testing)

• EST

• Chest x-ray.

The FD and the local FF Union have collaborated to begin offering periodic medical evaluations to 

firefighters. The medical evaluation is provided by a Contract Provider and is based on the National 

Fire Protection Association (NFPA) 1582 Standard. Firefighters over 45 years of age have an EST as 

part of this evaluation. If firefighters are not cleared for duty or are cleared for restricted duty based on 

the periodic medical evaluation, they must follow up with their PCP to address the issue and then be 

cleared for duty by the city’s medical evaluation unit. Firefighters must also be medically cleared by 

the city medical evaluation unit to return to work following a serious injury or illness. 
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Wellness/Fitness Programs

The Fire Department and the Union offer wellness programming through a health plan. There is 

exercise equipment in fire stations and the Union offers fitness programming for members, but the FD 

does not require that firefighters engage in a fitness program. 

Discussion

Sudden Cardiac Events

Sudden cardiac events are most often caused by heart attack or cardiac arrest (fatal arrhythmias). In the 

United States, atherosclerotic coronary heart disease (coronary artery disease) is the most common risk 

factor for cardiac arrest and sudden cardiac death [Myerburg and Castellanos 2008]. Risk for the

development of atherosclerosis is grouped into non-modifiable and modifiable risk factors. Nonmodifiable risk factors include age older than 45 (age > 55 for women), male sex, and family history of 

coronary artery disease. Modifiable risk factors include diabetes, smoking, high blood pressure 

(hypertension), unhealthy blood cholesterol levels, and obesity/physical inactivity [AHA 2016; NHLBI 

no date-b]. The FF had 3 non-modifiable risk factors (male sex, over 45 years of age, and family 

history). The FF had 4 known modifiable risk factors (hypertension, which was being treated;

smoking; high cholesterol; and elevated blood sugar). A structurally enlarged heart (cardiomegaly or 

left ventricle hypertrophy) is also common among many individuals who die of sudden cardiac events 

[Tavora et al. 2012]. High blood pressure is one of the main contributors to an enlarged heart.

Coronary Artery Disease

Coronary artery disease refers to atherosclerotic plaque in the coronary arteries and the complications 

of the plaque. The narrowing of the coronary arteries by atherosclerotic plaques occurs over many 

years, typically decades [Libby 2013]. However, the growth of these plaques probably occurs in a 

nonlinear, often abrupt fashion. Plaque buildup that restricts blood flow and prevents sufficient oxygen 

delivery to the heart muscle (myocardium) causes ischemia and often produces chest pain (angina), 

particularly with exertion. Heart attacks typically occur with the sudden development of complete 

blockage (occlusion) in one or more coronary arteries that have not developed a collateral blood 

supply. This sudden blockage is primarily due to blood clots (thromboses) forming on top of a ruptured 

atherosclerotic plaque [Libby 2013]. 

Heart attacks and sudden cardiac death can be triggered by heavy physical exertion including snow 

shoveling and firefighting activity, including an alarm response and training [Albert et al. 2000; 

Franklin et al. 2001; Kales et al. 2003, 2007; Mittleman et al. 1993; NIOSH 2007; Smith et al. 2019; 

Willich et al. 1993]. The triggering of a heart attack by physical exertion is far more likely in 

individuals who do not regularly engage in strenuous physical activity [Mittleman et al. 1993].

Establishing the occurrence of an acute heart attack requires any of the following: characteristic EKG

changes, elevated cardiac enzymes, coronary artery thrombus/plaque rupture, or evidence of heart 

muscle (myocardial) damage at autopsy. In this case, the FF had evidence of a large area (4.0 cm x

4.8 cm) of damaged tissue in the left ventricle. The autopsy also identified marked atherosclerosis of

the coronary arteries. 
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Occupational Medical Standards for Structural Firefighters

Nearly half of all firefighter duty-related deaths are caused by sudden cardiac death. Firefighting 

results in multiple cardiovascular changes that could lead to plaque rupture or induce arrhythmias in 

individuals with underlying cardiovascular disease [Smith et al. 2016]. Research suggests that the vast 

majority of firefighter duty-related sudden cardiac deaths have underlying atherosclerosis, 

cardiomegaly/left ventricle hypertrophy, or both [Geibe et al. 2008; Kales et al. 2003; Smith et al. 

2018; Yang et al. 2013]. In fact, a study that relied on firefighter autopsy data and was able to verify 

the presence of atherosclerosis (coronary heart disease) and structural heart changes (specifically 

cardiomegaly and left ventricle hypertrophy) found that more than 80% of cardiac fatalities had both 

types of heart disease [Smith et al. 2018]. 

To reduce the risk of sudden cardiac events or other incapacitating conditions among firefighters, the 

NFPA developed 1582, Standard on Comprehensive Occupational Medical Program for Fire 

Departments [NFPA 2018]. Regarding cardiovascular disease (CVD) screening for asymptomatic 

firefighters, NFPA 1582 recommends basing the decision for exercise stress testing on the firefighter’s 

10-year Heart Risk score (which is based on age, blood pressure, cholesterol, and other cardiovascular 

risk factors) [ACC/AHA 2018; NFPA 2018]. Heart Risk should be calculated each year beginning at 

age 40, and firefighters whose risk is 10% to < 20% should receive a symptom-limiting EST (with or 

without imaging) to at least 12 metabolic equivalents (METs) [NFPA 2018].

The FF had a 10-year risk score of 20.6% at his occupational medical evaluation in October of 2018. 

Based on his elevated blood pressure at the time of the evaluation, he did not receive an EST. The FF 

went to see the physician at the city’s medical evaluation unit the following day after taking his 

prescribed blood pressure medication and his blood pressure was 140/90 mmHg. Based on this finding, 

the physician cleared the FF for duty and required that he follow up with his PCP to manage his blood 

pressure and obtain an EST because he had not received it as part of his occupational medical exam. 

The FF was scheduled to return to the city medical evaluation unit to evaluate his follow-up testing on 

December 6, 2018, but the FF did not show up for this evaluation due to possible miscommunication

or misunderstanding. There are no records available to NIOSH that the FF performed the required 

stress test. 

NIOSH offers the following recommendations to reduce the likelihood of heart attacks and sudden 

cardiac arrest among firefighters at this and other fire departments across the country.

Recommendations

Recommendation #1: Ensure firefighters are cleared for duty by a physician knowledgeable about 

the physical demands of firefighting, the personal protective equipment (PPE) and self-contained 

breathing apparatus (SCBA) used by firefighters, and the various components of NFPA 1582.

Discussion: According to NFPA 1582, the FD should require that physicians are familiar with the 

physical demands of firefighting and the risks that firefighters encounter and should guide, direct, and 

advise members with regard to their health, physical fitness, and suitability for duty [NFPA 2018]. The 

physician should review job descriptions and essential job tasks required for all FD positions to 

understand the physiological and psychological demands of firefighting and the environmental 
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conditions under which firefighters perform, as well as the PPE/SCBA they must wear during various 

types of emergency operations. 

Recommendation #2: Develop a tracking system that ensures that FF who require follow-up by 

another provider receive the follow-up and that results are reviewed by the physician providing 

medical clearance or return to work. 

Discussion: Occupational medical evaluations are intended to identify individuals who cannot perform 

the essential job tasks of firefighting without undue risk of sudden incapacitation. Occupational 

evaluations often identify conditions that require additional testing or follow-up with a personal 

physician/PCP. It is critical that any issues that are identified receive the required follow up, and that 

this information is relayed to the physician providing clearance. Clear policies and procedures must be 

in place to track firefighters through this entire system.

Recommendation #3: Phase in a mandatory comprehensive wellness and fitness program for 

firefighters.

Discussion: Guidance for fire department wellness/fitness programs to reduce risk factors for 

cardiovascular disease and improve cardiovascular capacity is found in NFPA 1583, Standard on 

Health-Related Fitness Programs for Fire Fighters [NFPA 2015], and the IAFF/IAFC Fire Service 

Joint Labor Management Wellness-Fitness Initiative [IAFF, IAFC 2018]. Worksite health promotion 

programs have been shown to be cost effective by increasing productivity, reducing absenteeism, and 

reducing the number of work-related injuries and lost work days [Aldana 2001; Stein et al. 2000]. 

Health promotion programs tailored for firefighters have been shown to reduce coronary heart disease 

risk factors and improve fitness levels, with mandatory programs showing the most benefit [Blevins et 

al. 2006; Dempsey et al. 2002; Womack et al. 2005]. 

References

ACC/AHA [2018]. Atherosclerotic cardiovascular disease risk estimator plus. Dallas, TX: American 

Heart Association; Washington, DC: American College of Cardiology, http://tools.acc.org/ASCVDRisk-Estimator-Plus/#!/calculate/estimate/.

AHA [2016]. Understand your risks to prevent a heart attack. Dallas, TX: American Heart Association, 

www.heart.org/HEARTORG/Conditions/HeartAttack/UnderstandYourRiskofHeartAttack/Under 

stand-Your-Risk-of-Heart-Attack_UCM_002040_Article.jsp. 

Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE [2000]. Triggering of 

sudden death from cardiac causes by vigorous exertion. N Engl J Med 343(19):1355–1361, 

http://dx.doi.org/10.1056/NEJM200011093431902. 

Aldana SG [2001]. Financial impact of health promotion programs: a comprehensive review of the 

literature. Am J Health Promot 15(5):296–320, http://dx.doi.org/10.4278/0890-1171-15.5.296. 

Blevins JS, Bounds R, Armstrong E, Coast JR [2006]. Health and fitness programming for fire 

fighters: does it produce results? Med Sci Sports Exerc 38(5):S454. 
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Dempsey WL, Stevens SR, Snell CR [2002]. Changes in physical performance and medical measures 

following a mandatory firefighter wellness program. Med Sci Sports Exerc 34(5):S258, 

https://www.researchgate.net/deref/http%3A%2F%2Fdx.doi.org%2F10.1097%2F00005768-

200205001-01445. 

Franklin BA, George P, Henry R, Gordon S, Timmis GC, O’Neill WW [2001]. Acute myocardial 

infarction after manual or automated snow removal. Am J Cardiol 87(11):1282–1283, 

https://doi.org/10.1016/s0002-9149(01)01520-x. 

Geibe JR, Holder J, Peeples L, Kinney AM, Burress JW, Kales SN [2008]. Predictors of on-duty 

coronary events in male firefighters in the United States. Am J Cardiol 101(5):585–589, 

http://dx.doi.org/10.1016/j.amjcard.2007.10.017. 

IAFF, IAFC [2018]. The fire service joint labor management wellness-fitness initiative. Fourth ed. 

Washington, DC: International Association of Fire Fighters, International Association of Fire Chiefs.

Kales SN, Soteriades ES, Christoudias SG, Christiani DC [2003]. Firefighters and on-duty deaths from 

coronary heart disease: a case control study. Environ health: a global access science source 2(1):14, 

https://doi.org/10.1186/1476-069x-2-14. 

Kales SN, Soteriades ES, Christophi CA, Christiani DC [2007]. Emergency duties and deaths from 

heart disease among fire fighters in the United States. N Engl J Med 356(12):1207–1215, 

http://dx.doi.org/10.1056/NEJMoa060357. 

Libby P [2013]. Mechanisms of acute coronary syndromes and their implications for therapy. N Engl J 

Med 368(21):2004–2013, http://dx.doi.org/10.1056/NEJMra1216063. 

Mayo Clinic [2019]. Diabetes. Rochester, MN: Mayo Foundation for Medical Education and Research 

(MFMER), https://www.mayoclinic.org/diseases-conditions/diabetes/diagnosis-treatment/drc20371451. 

Mittleman MA, Maclure M, Tofler GH, Sherwood JB, Goldberg RJ, Muller JE [1993]. Triggering of 

acute myocardial infarction by heavy physical exertion. N Engl J Med 329(23):1677–1683, 

http://dx.doi.org/10.1056/NEJM199312023292301. 

Myerburg RJ, Castellanos A [2008]. Cardiovascular collapse, cardiac arrest, and sudden cardiac death. 

In: Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J, eds. 

Harrison’s principles of internal medicine. 17th ed. New York: McGraw-Hill. 

NFPA [2015]. NFPA 1583. Standard on health-related fitness programs for fire fighters. Quincy, MA: 

National Fire Protection Association. 

NFPA [2018]. NFPA 1582. Standard on comprehensive occupational medical program for fire 

departments. Quincy, MA: National Fire Protection Association. 

NHLBI [no date-a]. Calculate your body mass index. Bethesda, MD: National Institutes of Health, 

National Heart, Lung and Blood Institute, 

https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmi-m.htm. 
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NHLBI [no date-b]. Who is at risk for coronary heart disease? Bethesda MD: National Institutes of 

Health, National Heart, Lung and Blood Institute, https://www.nhlbi.nih.gov/health-topics/coronaryheart-disease. 

NIOSH [2007]. NIOSH alert: preventing fire fighter fatalities due to heart attacks and other sudden 

cardiovascular events. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for 

Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS 

(NIOSH) Publication No. 2007-133, https://www.cdc.gov/niosh/docs/2007-133/. 

Smith DL, DeBlois JP, Kales SN, Horn GP [2016]. Cardiovascular strain of firefighting and the risk of 

sudden cardiac events. Exerc Sport Sci Rev 44(3):90–97, 

http://dx.doi.org/10.1249/JES.0000000000000081. 

Smith DL, Haller JM, Korre M, Fehling PC, Sampani K, Porto LG, Christophi CA, Kales SN [2018]. 

Pathoanatomic findings associated with duty-related cardiac death in US firefighters: a case-control 

study. J Am Heart Assoc 7(18):e009446, https://doi.org/10.1161/jaha.118.009446. 

Smith DL, Haller JM, Korre M, Sampani K, Porto LG, Fehling PC, Christophi CA, Kales SN [2019]. 

The relation of emergency duties to cardiac death among US firefighters. Am J Cardiol 123(5):736–

741, https://doi.org/10.1016/j.amjcard.2018.11.049. 

Stein AD, Shakour SK, Zuidema RA [2000]. Financial incentives, participation in employer sponsored 

health promotion, and changes in employee health and productivity: HealthPlus health quotient 

program. J Occup Environ Med 42(12):1148–1155, https://doi.org/10.1097/00043764-200012000-

00005. 

Tavora F, Zhang Y, Zhang M, Li L, Ripple M, Fowler D et al [2012]. Cardiomegaly is a common 

arrhythmogenic substrate in adult sudden cardiac deaths, and is associated with obesity. Pathology 

44(3):187–191, https://doi.org/10.1097/PAT.0b013e3283513f54. 

Whelton PK, Carey RM, Aronow WS, Casey Jr DE, Collins KJ, Himmelfarb CD, DePalma SM, 

Samuel Gidding, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith Jr SC, 

Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams Sr KA, Williamson JD, Wright Jr JT [2018]. 

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the 

prevention, detection, evaluation, and management of high blood pressure in adults: a report of the 

American College of Cardiology/American Heart Association Task Force on Clinical Practice 

Guidelines. J Am Coll Cardiol 71(19):e127–e248, https://doi.org/10.1161/hyp.0000000000000066. 

Willich SN, Lewis M, Lowel H, Arntz HR, Schubert F, Schroder R [1993]. Physical exertion as a 

trigger of acute myocardial infarction. N Engl J Med 329(23):1684–1690, 

http://dx.doi.org/10.1056/NEJM199312023292302.

Womack JW, Humbarger CD, Green JS, Crouse SF [2005]. Coronary artery disease risk factors in 

firefighters: effectiveness of a one-year voluntary health and wellness program. Med Sci Sports Exerc 

37(5):S385. 
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Yang J, Teehan D, Farioli A, Baur DM, Smith D, Kales SN [2013]. Sudden cardiac death among 

firefighters ≤ 45 years of age in the United States. Am J Cardiol 112(12):1962–1967, 

http://dx.doi.org/10.1016/j.amjcard.2013.08.029. 

Investigator Information

This incident was investigated by the NIOSH Fire Fighter Fatality Investigation and Prevention 

Program, Cardiac and Medical Line-of-Duty Deaths (LODD) Investigations Team, located in 

Cincinnati, Ohio. Denise L. Smith, Ph.D., led the investigation and authored the report. Dr. Smith is 

Professor of Health and Human Physiological Sciences, and Director of the First Responder Health 

and Safety Laboratory at Skidmore College, where she holds the Tisch Family Distinguished 

Professorship. She is also a member of the NFPA Technical Committee on Occupational Safety and 

Health. Dr. Smith was working as a contractor with the NIOSH Fire Fighter Fatality Investigation and 

Prevention Program, Cardiac and Medical LODD Investigations Team, during this investigation. 

Wendi Dick, MD, MSPH, provided medical consultation and contributed to the report. Dr. Dick is 

Medical Officer for the Cardiac and Medical LODD Investigations Team in Cincinnati. 

Disclaimer

Mention of any company or product does not constitute endorsement by the National Institute for 

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Page 11 

Report # F2019-14

46-Year-Old Airport Firefighter Suffers Fatal Heart Attack 

Responding to Call—Pennsylvania

Appendix A 

Autopsy Findings

Coronary arteries

• Atherosclerotic stenosis in coronary arteries:

o Left main – 95% 

o Left anterior descending – 95% 

o Left circumflex – 90% 

o Right coronary artery – 95% 

• No recent thrombus

• 4.8 cm x 4.0 cm area of mottled and slightly softened myocardium within inferior wall of left 

ventricle

Structural 

• Heart weight = 330 grams

• Left ventricle wall = 1.3 cm thick

• Right ventricle wall = 0.2 cm thick

Other Significant Cardiovascular Findings

• Marked atherosclerosis in aorta 

• Plastic graft in descending aorta distal to renal arteries

Toxicology 

• Negative for drugs of abuse 

Author’s Discussion:

Left ventricle thickness of 1.3 cm is normal on the basis of postmortem studies by Kitzman et al. 

[1988] (normal range 1.07 cm–1.39 cm, average 1.23 cm).

Kitzman DW, Scholz DG, Hagen PT, Ilstrup DM, Edwards WD [1988]. Age-related changes in 

normal human hearts during the first 10 decades of life. Part II (Maturity): a quantitative anatomic 

study of 765 specimens from subjects 20 to 99 years old. Mayo Clin Proc 63(2):137–146, 

https://doi.org/10.1016/s0025-6196(12)64946-5.