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67-Year-Old Volunteer Lieutenant Suffers Sudden Cardiac Death

Following Training—Florida

Executive Summary

On May 07, 2019, a 67-year-old volunteer Lieutenant (LT) complained of pain in his pectoralis muscle 

after completing departmental rapid intervention team training. The LT initially denied that the pain 

could be related to cardiac issues and refused to be evaluated, but as symptoms of increasing pressure 

and shortness of breath appeared, the LT agreed to be evaluated by paramedics in the station. The LT

was escorted into the station by a fellow firefighter who requested that the paramedics evaluate the LT.

The paramedic in the room asked the LT to sit down while he notified dispatch (2125 hours) that there 

was a walk-in. The LT was now pale and he suffered a syncopal episode within a minute of being 

seated and had to be lowered to the floor with the help of two other members. Another paramedic 

entered the room as the firefighter was being lowered to the floor. Paramedics evaluated for a pulse, 

and finding none, initiated cardiopulmonary resuscitation. After approximately one minute, the LT 

briefly regained consciousness and fought efforts to provide care. Approximately 30 seconds later, he 

lost consciousness and had no pulse. The cardiac monitor revealed pulseless electrical activity (PEA). 

Advanced cardiac life support (ACLS) protocols were continued. The LT was intubated and received

cardiac medications, but he never had a shockable rhythm. The LT was transferred to a nearby

emergency department where ACLS protocols were continued for approximately 20 minutes to no 

avail. The LT never regained an organized cardiac rhythm and cardiac ultrasound revealed no cardiac 

activity. The LT was pronounced dead at 2203 hours. 

The Medical Examiner’s report listed the cause of death as “hypertensive atherosclerotic 

cardiovascular disease”, and offered the opinion that this likely resulted in a myocardial infarction 

(heart attack). The autopsy found 75% luminal narrowing of the left main artery due to atherosclerotic

plaque. There was no intracoronary thrombosis (blood clot) noted. National Institute for Occupational 

Safety and Health (NIOSH) investigators concluded that the physical activity associated with the 

training drill triggered a sudden cardiac event in an individual with undiagnosed underlying 

cardiovascular disease. 

Key Recommendations

NIOSH, as a federal agency whose focus is prevention, offers the following recommendations to lower

the risk of sudden cardiac events and other incapacitating medical conditions among firefighters at this 

and other fire departments across the country.

• Phase in a comprehensive wellness and fitness program for all firefighters.

• Ensure that all firefighters are aware of the warning signs of a cardiovascular event and the

atypical ways it can present.
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NIOSH also provides the following as a general recommendation for the fire service: 

In addition to fire department fitness-wellness programs and occupational medical exams, firefighters 

can enhance their heart health and overall health by following a heart-healthy lifestyle away from the 

firehouse and having regular checkups with their family doctor. 

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 firefighter initiative that resulted in the NIOSH Fire Fighter Fatality Investigation and Prevention Program

(FFFIPP), which examines line-of-duty deaths or on-duty deaths of firefighters to assist fire departments, firefighters, the fire service, and others to prevent 

similar firefighter 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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December 1, 2019

67-Year-Old Volunteer Lieutenant Suffers Sudden Cardiac Death

Following Training—Florida

Introduction

On May 7, 2019, a 67-year-old voluteer Lieutenant (LT) collapsed after rapid intervention team (RIT) 

training and suffered sudden cardiac death despite immediate resuscitative efforts. The U.S. Fire 

Administration notified the National Institute for Occupational Safety and Health (NIOSH) of this 

fatality on May 22, 2019. On August 8, 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:

• Deputy Chief

• Battalion Chief (BC), Health Safety Officer

• Firefighters who participated in training and rendered care

• Paramedics who provided care

• Wife of the LT

The NIOSH investigator reviewed the following documents:

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

• Law enforcement report of fatality

• EMS (ambulance) report

• Hospital emergency department (ED) records

• Occupational medical records

• Death certificate

• Autopsy report

Investigation

On May 7, 2019, at 1900 hours, a 67-year-old volunteer LT reported to the fire station for departmental 

training along with 8 other members of his station. The training drills were designed to increase 

knowledge of skills needed to locate, package, and remove a downed firefighter as part of a rapid 

intervention crew (RIC). 
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The drill was conducted in the fire station and was designed to simulate a collapsed building with wire 

entanglements. Groups of 3 firefighters performed the drill together. One firefighter stayed at the 

window to assist with removing the victim, while two firefighters entered the prop through a simulated 

window. The two firefighters who entered the window followed a charged hose line for about 10 feet 

to the entrapment section. One firefighter remained at the entrance to the entrapment prop while the 

other navigated his way through the prop (about 6 feet), then proceeded through a narrow tunnel (about 

3 feet), and then continued along the hose line for another 15 feet until they found a rescue mannequin 

(60 pounds). The firefighter radioed that he had found the victim and was returning and made his way 

back to the entrapment prop. The firefighter who had remained at the entrapment prop entrance met the 

firefighter who was returning with the rescue mannequin in the entanglement prop and and then both 

firefighters dragged the mannequin to the window, where the 3 firefighters in the crew assisted in 

passing the mannequin out the window. 

The firefighters estimated that it took 6–10 minutes to complete each evolution depending on how long 

it took to navigate the entrapment section. Firefighters critiqued the performance of fellow firefighters 

and discussed different approaches to the obstacles so the duration of the evolutions seemed to get 

shorter each time the drill was performed. There were 3 groups of 3 firefighters, and each group 

performed the drill two times. The LT was in the third group. The first time he performed the evolution 

he was stationed at the window, the second time that he performed the drill, he entered the window and 

then remained at the entrance of the entanglement section while the other firefighter continued on the 

course and retrieved the mannequin. The LT then met the firefighter and helped return the mannequin 

to the window where it was lifted and removed. The entire training drill lasted about 2 hours. This 

included the safety briefing, 6 evolutions, short debriefing after each group went through the course, a 

period of rehab and formal critique after everyone finished their first evolution, and time to clean up 

the area after training. 

After the drills had ended, some firefighters put air bottles on an apparatus to go to another station to 

fill them, and some members met in a small office area to enter their training time. The LT asked two 

fellow firefighters what would cause his pectoral muscles to hurt. As he asked, he had his thumbs in 

his underarm area and was rubbing his chest. One of the firefighters asked if the pain could be cardiacrelated. The LT responded that it was not cardiac, it was muscular and it had been happening after his 

workouts. The firefighters asked more about his workout and he described a heavy, upper body 

workout routine that involved calisthenics, including push-ups, hand weights and a rowing machine. 

Another firefighter entered the room and heard part of the conversation, and he too asked if the pain 

could be cardiac. Again, the LT strongly denied the possibility and insisted it was muscular. He had no 

other pain and no signs of distress. After multiple suggestions to go into the station and have the 

paramedics there do an evaluation, and consistent assurances from the LT that the pain was muscular, 

everyone left the station (several members had already left). 

As one of the last firefighters was walking to his car in back of the station, he saw the LT leaning over 

with his hands on his knees and spitting. The firefighter went to the LT and asked again for him to 

come into the station and have the paramedics do an evaluation. The LT agreed and walked a short 

distance into the dayroom and was seated at the table. At this point he was diaphoretic and was in some 

distress. The firefighter who had escorted him into the station asked the paramedic in the dayroom to 
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do an evaluation; the paramedic agreed and said he needed to call it in as a “walk-in.” The paramedic 

notified dispatch at 2125 hours and the other paramedic in the station heard this radio transmission and 

came to the dayroom. A set of vitals was obtained and the LT had a slow heart rate (40 beats per 

minute) and rapid breathing (20 breaths per minute). As the paramedic was making the call, the LT 

slumped in his chair. The firefighter and paramedic helped ease him to the floor. The call was 

upgraded to a cardiac arrest call and firefighters who had just left the station heard the call and returned 

to assist with care. Another set of vitals was obtained immediately as the LT was helped to the floor. 

An electrocardiogram (EKG) revealed the LT had a heart rate of 45 beats per minute; his respiration 

rate was 10 breaths per minute. 

Within moments of being assisted to the floor the LT became unresponsive, pulseless, and apneic. At 

2128 hours, cardiopulmonary resuscitation (CPR) was initiated and the LT was provided oxygen via 

bag-valve mask (BVM). After approximately one minute of CPR, the LT regained responsiveness and 

a pulse, and stated that he was fine and wanted help removing the mask. After about 30 seconds, the 

LT then became unresponsive, pulseless and apneic. CPR was provided with the Lucas® mechanical 

chest compression device. The EKG revealed pulseless electrical activity (PEA). The LT received his 

first round of epinephrine at 2128 hours and was intubated at 2133 hours. The ambulance left the scene 

at 2143 hours and continued cardiac life support protocols en route with no change in status. 

The ambulance arrived at the ED at 2147 hours. The rhythm continued to be PEA. CPR was continued, 

ventilation was confirmed, two more rounds of epinephrine were administered and bicarbonate was 

given but the LT remained in PEA. Cardiac ultrasound revealed that there was no cardiac activity. At 

2203 hours, the LT was pronounced dead. 

Medical Findings

The Medical Examiner’s report identified the cause of death as hypertensive atherosclerotic 

cardiovascular disease. The heart was normal size (350 grams). There was atherosclerosis in the left 

main coronary artery resulting in 75% lumen stenosis (i.e., the diameter of the artery was narrowed by 

75%). There was no thrombus noted and there were no focal lesions in the myocardium (heart muscle). 

The autopsy revealed granular kidneys, consistent with nephrosclerosis, which is often found in 

individuals with long standing hypertension (i.e., target-organ damage). 

The FF received a medical evaluation for the fire department in September of 2018. Cardiovascular 

disease risk factors are provided in Table 1. The LT was a non-smoker, physically active (defined as 

150–300 min/week moderate intensity or 75–150 min/week high intensity exercise [HHS 2019]), not 

obese, and had normal blood sugar (no diabetes). His blood pressure was elevated; although his total 

and low-density lipoprotein (LDL) (“bad”) cholesterol levels were normal, further analysis revealed 

unhealthy levels of high-density lipoprotein (HDL) (“good”) cholesterol and triglycerides. Based on 

his age and risk factors, the American Cardiology Association/American Heart Association 

(ACC)/AHA atherosclerotic cardiovascular disease (ASCVD) risk calculator estimated that the FF had 

a 19.8% 10-year risk of heart attack or stroke.
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Table 1 Cardiovascular (CVD) Risk Factors (RFs) 

References for table 1: 1Whelton et al. 2017; 2Kratz et al. 2004, Mayo Clinic 2019a; 3Grundy et al. 

2018; 4ADA 2014; 5CDC 2020. 

Risk Factor Interpretation Category Guidelines 

Systolic BP1 Normal

Elevated

Stage 1 Hypertension 

Stage 2 Hypertension 

< 120 mmHg 

120–129 mmHg 

130–139 mmHg 

≥ 140 mmHg 

Diastolic BP1 Normal

Elevated

Stage 1 Hypertension 

Stage 2 Hypertension 

< 80 mmHg

>80 mmHg

80–89 mmHg 

≥ 90 mmHg 

Total 

Cholesterol2

Desirable

Borderline High

High

< 200 mg/dL 

200–239 mg/dL 

≥ 240 mg/dL 

HDL2 Low

High (Desirable)

< 40 mg/dL 

≥ 60 mg/dL 

LDL2 Optimal

Above normal 

Borderline high 

High

< 100 mg/dL 

100–129 mg/dL 

130–159 mg/dL 

> 160 mg/dL

Triglycerides3 Normal

Hypertriglyceridemia

Severe hypertriglyceridemia

> 175mg/dL

175–499mg/dL 

≥ 500mg/dL

Blood 

Glucose4

Normal

Prediabetes

Diabetes

< 100 mg/dL 

100–125 mg/dL 

≥ 126 mg/dL

BMI5 Underweight 

Normal weight 

Overweight 

Obesity

< 18.5 kg/m2

18.5–24.9 kg/m2 

25–29.9 kg/m2

≥ 30 kg/m2
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Fire Department

At the time of the NIOSH investigation, the FD consisted of approximately 200 uniformed personnel 

operating out of 6 fire stations. It serves a population of approximately 88,000 in a geographic area of 

about 22 square miles. 

Membership and Training

The FD actively recruits for new members. Applicants must be at least 18 years of age, have a high 

school diploma or equivalent, and possess a valid driver’s license. They must also live within the city 

or be with 2.5 miles or 5 minutes. Potential members complete an application and a background check 

is performed. The FD hosts an orientation for potential candidates who have cleared the background 

check that includes rules, regulations and expectations. Potential members are then invited to make a 

commitment to the FD. Applicants who affirm they want to join are required to pass a medical 

evaluation provided by the City. New members receive departmental training based on the State’s 

curriculum and are certified as Firefighter I. New members are then required to become familiar with 

department policies and procedures, equipment and apparatus, and to attend on-going training. The FF 

had been with the FD for 13 years and was actively involved.

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

• Exercise stress test

• Chest x-ray

The FD provides periodic medical evaluations that include the same components listed above. 

Firefighters must be medically cleared by their primary care physician for return to work following a 

serious injury or illness by the treating physician. 
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Wellness/Fitness Programs

The Fire Department does not offer a formal wellness program. There is exercise equipment in 

fire stations and the FD for members to use. The LT was an avid exerciser and worked out almost 

every day. 

Discussion 

Sudden Cardiac Events

Sudden cardiac events are most often caused by myocardial infarction (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. Non-modifiable risk factors include older age (> 45 for men, > 55 for women), 

male sex, and family history of coronary artery disease. Modifiable risk factors include diabetes, 

smoking, high blood pressure (hypertension), unhealthy cholesterol levels, and obesity/physical 

inactivity [AHA 2016; CDC 2020]. The LT had 2 non-modifiable risk factors (male sex, age over 45) 

but had not been diagnosed with any modifiable disease risk factors. A structurally enlarged heart 

(cardiomegaly or left ventricular hypertrophy) is also common among many individuals who die of 

sudden cardiac events [Tavora et al. 2012]. 

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 myocardium (heart muscle) causes ischemia and often chest pain (angina), particularly 

with exertion. Heart attacks or myocardial infarctions 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 [Albert et al. 2000; Mittleman et al. 1993; Willich et al. 1993], including 

snow shoveling [Franklin et al. 2001] and firefighting activity, including an alarm response and 

training [Kales et al. 2003, 2007; NIOSH 2007; Smith et al. 2019]. 

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 

myocardial damage at autopsy. In this case, there was no definitive evidence of a heart attack, but the 

autopsy identified severe atherosclerosis (75% stenosis) in the left main (main blood supply for left 

ventricle/pumping chamber), and tissue damage may not be clearly visible in infarcts < 24 hours old 

[Siegel 1997]. 

Heart Attack Symptoms
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An individual who is experiencing a heart attack may experience a range of signs and symptoms. The 

American Heart Association provides a partial list, including [AHA 2016]: 

• Uncomfortable pressure, squeezing, fullness or pain in the chest

• Pain or discomfort in one or both arms, the back, neck, jaw, or stomach

• Shortness of breath

• Sweating (diaphoresis)

• Nausea or vomiting

• Dizziness or lightheadedness

The signs and symptoms of a heart attack vary greatly in how they present and in their severity. Some 

individuals experience the sensation of “an elephant on their chest”, others may experience shortness 

of breath or fatigue, and in some individuals, sudden cardiac death is the first sign of a myocardial 

infarction. Some of the variability in the signs and symptoms occur because of the location of the 

blockage. There is also evidence that the symptoms of a heart attack vary by age and gender [AHA 

2016]. Although the most common symptom in women is some type of chest pain, pressure or 

discomfort in the chest, it is not always severe or even the most prominent symptom. Women are more 

likely than men to have heart attack symptoms that are different than chest pain, such as neck, jaw, 

shoulder, upper back or abdominal discomfort; shortness of breath; pain in one or both arms; nausea or 

vomiting; sweating; lightheadedness or dizziness [Mayo Clinic 2019b]. 

Importantly, symptoms of a heart attack are widely varied, and many symptoms may be mistaken for 

other problems. Table 2 presents recent investigative reports where the symptoms that preceded the 

sudden cardiac event would not have been considered “classic symptoms.” In many cases, the 

symptoms were plausibly attributed to a cause other than cardiac problems.
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Table 2. NIOSH firefighter fatality investigation reports involving sudden cardiac events 

Report Brief Description

F2009-16 A 42-yr old Lieutenant died of a cardiac arrhythmia after completing live fire 

training drills and reporting weakness and shortness of breath which he blamed on 

his recent cold. Symptoms seemed relatively mild and did not affect his drill 

performance. 

F2010-03 A 43-yr old career firefighter sudden cardiac death after completing overhaul. He 

complained of extreme back pain and then loss of vision. 

F2010-34 56-yr old male career firefighter/paramedic died of a sudden cardiac event after

rescue training while complaining of chronic chest pain over the past couple

weeks that he attributed to a cold.

F2013-10 A 44-yr old volunteer fire chief died of cardiac arrest while functioning as incident 

commander of a brush fire, showing symptoms of coughing and sweating. The 

chief said he was getting over a cold. Coughing escalated to gasping for air and 

vomiting, sweating profusely. 

F2014-04 53-yr old male career fire chief died of heart attack after responding to grass fire

and complaining of symptoms of indigestion with excessive burping and

heart burn.

F2014-05 57-yr old career FF died of a heart attack after responding to an alarm that

required him to climb 5 flights of stairs. He had symptoms of burping and blamed

it on indigestion

F2015-10 54-yr old male career firefighter experienced a cardiac event after fighting a

residential fire and complaining of shoulder pain that spread to his back. He

explained that it felt like a “pulled muscle”. He later complained of shortness of

breath.

F2015-12 44-yr old male career captain responded to CO call, played basketball for 30 min,

and then complained of leg pain and leg cramping before experiencing sudden

cardiac death.

F2018-01 47-yr old male career FF died of cardiac arrest after a light workout, with no

symptoms, but reported back pain from incident where he “torqued his back”

during medical response call during the same shift.

F2018-05 44-yr old female career FF died of sudden cardiac arrest after reporting a burning

sensation in her throat which she attributed to breathing in cold air during a

physical ability test. The burning sensation intensified and was accompanied with

heavy sweating and eventually chest pain and shortness of breath.

Source: NIOSH FFFIPP http://www.cdc.gov/niosh/fire/investigations/investigations.html
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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 arrhythmogenic changes 

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

vast majority of firefighter duty-related sudden cardiac deaths have atherosclerosis, cardiomegaly/left 

ventricular 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 autopsy data and was able to verify the presence of atherosclerosis 

(coronary heart disease) and structural heart changes (specifically cardiomegaly and left ventricular 

hypertrophy) found that over 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 CVD screening for asymptomatic firefighters, NFPA 1582 

recommends basing the decision for exercise stress testing (EST) on the firefighter’s 10-year Heart

Risk score (which is based on age, blood pressure, cholesterol, and other CVD 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 METs [NFPA 2018]. The FF had a 10-year risk score of 19.8% at his

occupational medical evaluation in September of 2018. 

NIOSH, as a federal agency whose focus is prevention, offers the following recommendations to lower

the risk of sudden cardiac events and other incapacitating medical conditions among firefighters at this 

and other fire departments across the country.

Recommendations

Recommendation #1: Phase in a 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 International Association of 

Fire Fighters; Fairfax, VA: International Association of Fire Chiefs (IAFF/IAFC) Fire Service Joint 

Labor Management Wellness-Fitness Initiative [IAFF and 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 workdays [Aldana 2001; Stein et al. 2000]. 

Health promotion programs 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]. 

Recommendation #2: Ensure that all firefighters are aware of the warning signs of a cardiovascular 

event and the atypical ways it can present.

Discussion: Most firefighters are aware of classic symptoms of a heart attack. FDs could include a

review of classic symptoms and the wide variety of symptoms at required departmental training.
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Personnel should have a high level of suspicion that symptoms in the chest, upper abdomen, shoulder, 

back and neck can be related to cardiac issues. Even if these symptoms could be attributed to other 

possible causes does not mean they are not related to cardiac issues.

NIOSH also provides the following as a general recommendation for the fire service:

In addition to fire department fitness-wellness programs and occupational medical exams, firefighters 

can enhance their heart health and overall health by following a heart-healthy lifestyle away from the 

firehouse and having regular checkups with their family doctor. 

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/. 

ADA [2014]. Diagnosing diabetes and learning about prediabetes. Arlington, VA: American Diabetes 

Association, http://www.diabetes.org/are-you-at-risk/prediabetes/. 

AHA [2016]. Warning signs of a heart attack. Dallas, TX: American Heart Association, 

http://www.heart.org/HEARTORG/Conditions/HeartAttack/WarningSignsofaHeartAttack/WarningSigns-of-a-Heart-Attack_UCM_002039_Article.jsp. 

AHA [2019]. Cardiac arrest vs. heart attack. Dallas, TX: American Heart Association, 

https://cpr.heart.org/-/media/cpr-files/resources/ca-vs-ha/cardiac-arrest-vs-heart-attack-2019-

ucm_493943.pdf?la=en&hash=CCB6EE0A8B7EDEC8F06BD690D8B77CFFC0B84D39. 

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. 

CDC [2020]. About adult BMI. 

https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html. 

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. 
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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. 

HHS [2019]. Physical activity guidelines for Americans. Washington, DC: U.S. Department of Health 

and Human Services, https://www.hhs.gov/fitness/be-active/physical-activity-guidelines-foramericans/index.html. 

IAFF, IAFC [2018]. The fire service joint labor management wellness/fitness initiative. 3rd ed. 

Washington, DC: International Association of Fire Fighters; Fairfax, VA: International Association of 

Fire Chiefs, https://www.iafc.org/topics-and-tools/safety-health/wellness-fitness-task-force/wellnessfitness-program-summary. 

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

coronary heart disease: a case-control study. Environ Health 2(1):14, 

https://dx.doi.org/10.1186%2F1476-069X-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. 

Kratz A, Ferraro M, Sluss PM, Lewandrowski KB [2004]. Case records of the Massachusetts General 

Hospital. Weekly clinicopathological exercises. Laboratory reference values. N Engl J Med 

351(15):1548–1563, https://doi.org/10.1056/nejmcpc049016. 

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 [2019a]. Clinical laboratories test catalog. Rochester, MN: Mayo Foundation for Medical 

Education and Research (MFMER), http://www.mayocliniclabs.com/test-catalog/. 

Mayo Clinic [2019b]. Heart disease in women: understand symptoms and risk factors. Rochester, MN: 

Mayo Foundation for Medical Education and Research (MFMER), 

https://www.mayoclinic.org/diseases-conditions/heart-disease/in-depth/heart-disease/art-20046167. 

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. 
Page 12 

Report # F2019-15

67-Year-Old Volunteer Lieutenant Suffers Sudden Cardiac Death

Following Training—Florida

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/. 

NIOSH [2019]. FFFIPP completed investigations. Cincinnati, OH: Department of Health and Human 

Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and 

Health, https://www.cdc.gov/niosh/fire/investigations/investigations.html. 

Siegel RJ [1997]. Myocardial infarct, acute. In: Bloom S, ed. Diagnostic criteria for cardiovascular 

pathology acquired diseases. Philadelphia, PA: Lippencott-Raven. 

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, Burke A [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. 

Weather Underground [no date]. Historical Weather. Weather Underground, The Weather Company, 

http://www.wunderground.com/history. 

Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, DePalma 

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

Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA Sr, Williamson JD, Wright JT Jr [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://www.sciencedirect.com/science/article/pii/S0735109717415191?via%3Dihub. 

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.
Page 13 

Report # F2019-15

67-Year-Old Volunteer Lieutenant Suffers Sudden Cardiac Death

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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. 

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/Medical Fatality Component, 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/ 

Medical Fatality Component, during this investigation. Wendi Dick, MD, MSPH, provided medical 

consultation and contributed to the report. Dr. Dick is Medical Officer for the Cardiac/Medical 

Fatalities Component in Cincinnati. 

Disclaimer

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

Occupational Safety and Health (NIOSH). In addition, citations to websites external to NIOSH do not 

constitute NIOSH endorsement of the sponsoring organizations or their programs or products. 

Furthermore, NIOSH is not responsible for the content of these websites. 
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Appendix A 

Autopsy Findings

Coronary arteries 

• 75% stenosis in left main coronary artery

• Other coronary arteries unremarkable

• No thrombus identified in coronary arteries

Structural 

• Heart weight = 350 grams

• Myocardium is firm with no focal lesions

Additional 

• Granular kidneys, consistent with nephrosclerosis, suggesting hypertension