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47-Year-Old Captain Suffers Fatal Heart Attack at Fire Station – 

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Executive Summary

On July 14, 2022, a 47-year-old Captain (CAPT) suffered a fatal heart attack while sleeping at the fire 

station on the last day of a 72-hour shift. Earlier that day at 0717 hours, the fire station crew was 

dispatched to a medical aid call. When the CAPT did not show up at the engine for the call, the engineer 

knocked on his door. When the CAPT did not answer, the engineer opened his bedroom door and found 

the CAPT in his bed showing obvious signs of death. No medical interventions were initiated. 

The medical examiner’s report determined the CAPT had atherosclerotic heart disease (ASCVD). 

There was severe coronary atherosclerosis with near total occlusion of the left anterior descending 

artery. Other significant conditions included mild aortic atherosclerosis and mild cerebral 

atherosclerosis. The medical examiner listed cause of death as ASCVD.

Key Recommendations

NIOSH investigators offer the following recommendations to reduce the risk of heart attacks and sudden 

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

• Key Recommendation #1: Implement comprehensive annual medical evaluations consistent with 

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

which should include a baseline EKG in all individuals prior to engagement in any strenuous 

physical activity to rule out any underlying cardiac abnormalities [NFPA 2022]. 

• Key Recommendation #2: Implement an annual fitness evaluation consistent with NFPA 1582 

Standard on Comprehensive Occupational Medical Program for Fire Departments to ensure 

personnel are physically fit to perform job expectations at emergencies [NFPA 2022]. 

• Key Recommendation #3: Employers and employees should be aware of the early warning 

symptoms of heart attack that could result in SCD. 

The National Institute for Occupational Safety and Health (NIOSH) initiated the Fire Fighter Fatality Investigation and Prevention Program to examine 

deaths of fire fighters in the line of duty so that fire departments, fire fighters, fire service organizations, safety experts and researchers could learn from these 

incidents. The primary goal of these investigations is for NIOSH to make recommendations to prevent similar occurrences. These NIOSH investigations 

are intended to reduce or prevent future fire fighter deaths and are completely separate from the rulemaking, enforcement and inspection activities of any 

other federal or state agency. Under its program, NIOSH investigators interview persons with knowledge of the incident and review available records to 

develop a description of the conditions and circumstances leading to the deaths in order to provide a context for the agency’s recommendations. The NIOSH 

summary of these conditions and circumstances in its reports is not intended as a legal statement of facts. This summary, as well as the conclusions and 

recommendations made by NIOSH, should not be used for the purpose of litigation or the adjudication of any claim.

For further information, visit the program Web site at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).

F2022-08 • February 2024
47-Year-Old Captain Suffers Fatal Heart Attack at Fire Station – 

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F2022-08 • February 2024

Introduction

On July 14, 2022, a fire captain (CAPT) suffered a fatal heart attack during his sleep at his assigned 

fire station. The U.S. Fire Administration notified the National Institute for Occupational Safety and 

Health (NIOSH) of this fatality on July 18, 2022. NIOSH contacted the affected department to gather 

additional information and initiate the investigation.

A medical officer and a contractor firefighter safety specialist with the NIOSH Fire Fighter Fatality 

Investigation and Prevention Program (FFFIPP) conducted the investigation. In November 2022, the 

firefighter safety specialist conducted a series of telephone, email, and in-person interviews to 

investigate the incident.

During the investigation, the NIOSH investigators interviewed family members and the following 

agency personnel: 

• Fire Chief

• Chief Deputy 

• Battalion Chief 

• Firefighter

The NIOSH investigator reviewed the following documents:

• Fire Department (FD) incident records

• FD hiring requirements and standard operating procedures 

• Crew statements

• FD medical examination policies 

• FD biennial medical records for CAPT 

• Autopsy and toxicology reports 

Fire Department

At the time of the NIOSH investigation, this career FD conducted both structural and wildland 

firefighting responses and consisted of 47 fire stations with 58 engines, 6 ladder trucks, 

54 wildland patrols, and 521 uniformed personnel. The FD serves a population of approximately 
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500,000 citizens in a geographic area of about 8,000 square miles and responds to approximately 

62,000 calls annually.

Employment and Training

The employment selection process is open to individuals at least 18 years of age. New employees must 

have a U.S. high school diploma or an equivalency certificate (e.g., G.E.D. or equivalent from a U.S. 

institution) and a valid California Driver’s License at time of appointment. Captains must have two 

years minimum experience as a firefighter and two additional years of experience as an engineer within 

the department to be eligible for promotion to captain.

The CAPT had been with the department since April 2002, working as a firefighter and engineer. He 

worked at the rank of captain since November 2008.

Preplacement/Periodic/Return to Work Medical Evaluations

Preplacement Physical Examination: Per FD policy a medical examination by the County Physician is 

required for all applicants and includes spine and chest x-rays; blood tests, and urine drug screening. 

A resting electrocardiogram (EKG) is required starting at age 40 and those who are considered at 

intermediate risk or higher as per the American College of Cardiology /American Heart Association 

(ACC/AHA) 10-year Heart Risk Calculator are advised to obtain an exercise stress test [NFPA 2022]. 

All fire members must meet a minimum fitness level of 10 metabolic equivalents (METs) on a cardiac 

treadmill stress test, also known as an exercise stress test (EST), without showing signs of myocardial 

ischemia to actively work in the field. Weight must be proportionate to height and age, and the 

applicant must meet county physical fitness requirements.

Periodic Medical Examination: Per FD policy, thorough medical examinations (“physicals”) are 

required annually of all employees over age 50 and every other year for those under 50 years of age. 

The exam includes a fitness assessment, also known as a work capacity test, that may be done on either 

a treadmill or stationary bicycle and results expressed in METs.

Minimum Fitness Level Standard: The medical examination is the only process to determine an 

employee’s minimum fitness level. Members who fail to obtain 10 METs on the regularly scheduled 

medical examination will require additional medical consultation. Members assigned to rural stations 

in the wildland are required to meet 12 METs as outlined in the National Fire Protection Association

(NFPA) 1582 and the state mutual aid guidelines under the California Incident Command Certification 

System [CICCS 2022]. The stress test results are reviewed by a contract physician and the employee is 

notified in writing of their results, including clearance to work. At the direction of the physician, the 

member will be provided an improvement plan in an attempt to obtain the desired fitness level. The 

CAPT obtained a fitness level of 12.4 METs in his last physical evaluation in November of 2020. He 

was scheduled for his next biennial physical in November of 2022.

Return to Work: Members who have been off-duty or assigned to temporary light duty because of an 

injury or illness in excess of 60 calendar days, are required to consult with the Administrative Duty 

Chief prior to returning to active duty. A fit for duty medical evaluation may be required.
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Wellness/Fitness Programs

The FD has a wellness/fitness program for all members and encourages participation. It is the company 

officer or immediate supervisor’s responsibility to make a reasonable effort to allocate sixty minutes of 

physical fitness each on-duty day. Sufficient fitness equipment is provided at each fire station. The FD 

does not mandate that firefighters participate in the fitness program at work, but they must meet the 

physical fitness requirements. Some members utilize local gyms to conduct their physical fitness 

program. The CAPT participated in some physical training and weightlifting at the station, but he was 

inconsistent.

Investigation

On July 11, 2022, at approximately 0800 in the morning, the CAPT arrived for work at his station for 

his regularly scheduled 48-hour shift. The station serves a small rural community. It is a single engine 

station staffed by a captain, engineer, and a firefighter. During the first day of his shift, the CAPT and 

his crew responded to two outside rubbish fires and a building fire. There was nothing remarkable 

about either of these incidents. There were no responses on the second day of his 48-hour shift.

On July 13th the CAPT worked an overtime shift at his normally assigned station. At approximately 

0400 hours that morning, the CAPT and crew responded to a structure fire but were placed on standby 

and did not actively suppress the fire. At approximately 0830 the CAPT told the Firefighter he was 

tired, but the Firefighter assumed it was due to the early morning call. At approximately 1700 hours, 

the shift Battalion Chief stopped by the station on his rounds and spoke to the CAPT as he was doing a 

light workout in the engine bay. The Battalion Chief said the CAPT did not appear to be sweaty and 

did not voice any complaints about how he was feeling. The Engineer spoke with the CAPT around 

1830 hours as they cooked dinner, and at that time he appeared to be feeling fine. At approximately 

2100 hours that night, the Firefighter went to the kitchen to get water and spoke to the CAPT briefly. 

The Firefighter noticed that the CAPT was extremely sweaty but did not express any complaints.

The crew was dispatched to a medical aid call at 0717 on July 14, 2022. When the CAPT failed to 

emerge from his sleeping quarters, the Engineer went to his room and knocked on the door. When he 

did not answer, the Engineer entered the room and found the CAPT laying supine in his bed and 

unresponsive. No medical intervention was initiated because he had no pulse and was cold to the 

touch. The crew advised dispatch that they were unable to respond to the medical aid call, and then 

they notified the Battalion Chief by landline.

Medical Findings

The medical examiner’s report determined the CAPT had atherosclerotic cardiovascular disease 

(ASCVD). There was severe coronary atherosclerosis with near total occlusion of the left anterior 

descending artery. Other significant conditions included mild aortic atherosclerosis, mild cerebral 

atherosclerosis, and obesity with a body mass index (BMI) of 37.6. The toxicology report was 

negative.

Cause of Death

The medical examiner listed cause of death as atherosclerotic heart disease.
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Discussion 

Sudden Cardiac Events

Sudden cardiac arrest (SCA) is when the heart suddenly fails to pump blood. If the individual does not 

survive, the term sudden cardiac death (SCD) is used. These events mostly occur in patients with 

structural heart disease (that may not have been previously diagnosed), particularly coronary heart 

disease (CHD). 

SCD accounts for 300,000–400,000 deaths annually in the United States. Most sudden deaths are 

cardiac, and most SCDs are related to arrhythmias secondary to structural heart disease or primary 

electrical abnormalities of the heart [Isbister and Semsarian 2019; Jazayeri and Emert 2019; Kuriachan 

et al. 2015]. SCA usually occurs in people with some form of underlying structural heart disease, and 

as much as 70 percent of SCAs have been attributed to CHD. The risk of experiencing SCA increases 

dramatically with age and with underlying cardiac disease. Men are two to three times more likely to 

experience SCA than women. SCD is the mechanism of death in over 60 percent of patients with 

known CHD. In addition, SCA is the initial clinical manifestation of CHD in approximately 

15 percent. Even among the young, CHD is a relatively common cause of SCD. In one study, CHD 

was the second most common condition (22%) underlying SCD among subjects aged 5 to 34 years. 

In this study, the most common SCA-related conditions were sudden arrhythmic death syndrome 

(31%), coronary artery disease (22%), and hypertrophic cardiomyopathy (14%). There was a high 

overall prevalence of established cardiovascular risk factors (obesity, diabetes mellitus, hypertension, 

elevated blood cholesterol, smoking) with ≥1 risk factor present in 58% of persons with SCA

[Jayaraman et al. 2018]. 

Risk factors for SCA include elevated blood cholesterol, hypertension, cigarette smoking, physical 

inactivity, obesity, diabetes mellitus, and a family history of premature CHD or myocardial infarction. 

There is also some evidence that acutely stressful situations increase the risk of SCA. Individuals of 

African American descent appear to have a higher rate of SCD and poorer outcomes compared to those 

of Caucasian or Hispanic descent [Wong et al. 2019]. 

Prevention of SCA and SCD is focused on identifying underlying risk factors. Some risk factors are 

modifiable such as reducing cholesterol and blood pressure, quitting smoking, increasing physical 

activity, losing weight, and controlling diabetes. Other risk factors are not modifiable such as age or 

family history of CAD. Several risk factors can be used to calculate a risk score for CHD (Table 1); 

these factors include BMI, blood pressure, serum lipids and glucose. Based on age and other risk 

factors, the ACC/AHA atherosclerotic cardiovascular disease (ASCVD) risk calculator can estimate 

the percent 10-year risk of heart attack or stroke [Andrus and Lacaille 2013]. 
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Table 1. Cardiovascular disease risk factors and associated category of risk

Risk Factor Interpretation Category Guidelines

Systolic BP* Normal

Elevated

Stage 1 Hypertension

Stage 2 Hypertension

< 120 mmHg

120–129 mmHg

130–139 mmHg

≥ 140 mmHg

Diastolic BP* Normal

Elevated

Stage 1 Hypertension

Stage 2 Hypertension

< 80 mmHg

> 80 mmHg

80–89 mmHg

≥ 90 mmHg

Total 

Cholesterol†

Desirable

Borderline high

High

< 200 mg/dL

200–239 mg/dL

≥ 240 mg/dL

HDL† Low

High (Desirable)

< 40 mg/dL

≥ 60 mg/dL

LDL† Optimal

Above normal

Borderline high

High

< 100 mg/dL

100–129 mg/dL

130–159 mg/dL

> 160 mg/dL

Triglycerides‡ Normal

Hypertriglyceridemia

Severe hypertriglyceridemia

> 175 mg/dL

175–499 mg/dL

≥ 500 mg/dL

Blood 

Glucose§

Normal

Prediabetes

Diabetes

< 100 mg/dL

100–125 mg/dL

≥ 126 mg/dL

BMI¶ Underweight

Normal weight

Overweight

Obesity

< 18.5 kg/m2

18.5–24.9 kg/m2

25–29.9 kg/m2

≥ 30 kg/m2

*Whelton et al. 2018, †Kratz et al. 2004, ‡Grundy et al. 2019, §ADA 2014, ¶CDC 2022a

The CAPT in this case was obese and based on his 2020 medical examination results his ASCVD 

10-year risk was considered low at 4.2%.

The presence of severe coronary atherosclerosis with near total occlusion of the left anterior 

descending artery on autopsy suggests that the atherosclerotic plaques in the CAPT’s coronary arteries 

had been building up over several years. The Duke Treadmill Score is a point system to predict 5-year 

mortality based on treadmill ECG stress testing in patients without known coronary artery disease

[Shaw et al. 1998]. A Low risk (score > 5) indicates a 5-year survival of 97%; an Intermediate risk 

(score between 4 and -11) indicates 5-year survival of 90%; and a High risk (score < -11) indicates 

5-year survival of 65%. The CAPT had a Duke Treadmill Score in 2020 of -20, but on review of the 

EKG tracing with a cardiac specialist, it was determined that this was likely due to an artifact (possible 

loose EKG lead). 
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In most cases, an EST can identify the presence of CHD that increases the risk of fatal and non-fatal 

cardiac events. An abnormal EKG that shows myocardial ischemia (areas of the heart where the blood 

supply is not adequate) with exercise increases the risk of future CHD events, especially in those 

individuals with other risk factors for heart disease such as high blood pressure, high lipid levels, 

elevated blood sugar or obesity [Balady et al. 2004; Bruce et al. 1980; Mégnien and Simon 2009; 

Michaelides et al. 1990; Michaelides et al. 1995; Michaelides et al. 2005; Sumanen et al. 2005; 

Van Campen et al. 1996]. As recommended by NFPA 1582, the EST in general is one of the best ways 

to assess cardiovascular disease and the ability to engage in activities that place a high demand on 

the heart.

In this case, the CAPT had severe coronary atherosclerosis with near total occlusion of the left anterior 

descending artery, but his EST did not show that he had ischemia and so was not predictive of the 

CAPT’s sudden cardiac death. A meta-analysis of 34 studies of EST and coronary artery disease found 

that although a positive EST is often accurate at confirming the presence of significant blockages of 

the coronary arteries, “a negative exercise test result is not as good at excluding CAD and the clinical 

challenge of knowing which of these test-negative patients benefit from urgent coronary angiography 

and treatment remains” [Banerjee et al. 2012]. Therefore, it is important for patients to understand that 

a negative EST (or the ability to achieve high METS on the EST without signs or symptoms of 

ischemia) does not guarantee clear coronary arteries so any potential heart attack signs or symptoms 

should still be taken seriously.

In this incident, the Firefighter had noticed that the CAPT was extremely sweaty. Sweating is among 

the symptoms of a heart attack that could result in SCD. Other heart attack symptoms may also include 

chest pain/discomfort, shortness of breath, lightheadedness, and pain/discomfort in the jaw, neck, back,

arms or shoulders [American Heart Association 2021; CDC 2022b].

Recommendations

Recommendation #1: Implement comprehensive annual medical evaluations consistent with 

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

which includes a cardiac exercise stress test for all individuals prior to engagement in any strenuous 

physical activity to rule out any underlying cardiac anomalies [NFPA 2022].

Discussion: NIOSH recommends that all new and incumbent personnel participate in annual medical 

evaluations to determine that members are healthy enough to participate in strenuous activity and to 

identify potential injuries or illnesses. Guidance regarding the content and frequency of the medical 

evaluations for firefighters can be found in Chapter 7 of NFPA 1582. At the time of the incident, the 

department required biennial medical examination for members under 50 years of age, and annual 

exams for members 50 years of age and over [NFPA 2022].

Recommendation #2: Implement an annual fitness evaluation consistent with NFPA 1582 Standard 

on Comprehensive Occupational Medical Program for Fire Departments to ensure personnel are 

physically fit to perform job expectations at emergencies [NFPA 2022].

Discussion: NIOSH recommends that fire departments phase in an annual fitness evaluation program 

that is consistent with NFPA 1582-Chapter 8-Annual Occupational Fitness Evaluation of Members to 

ensure personnel can meet state and job requirements, NFPA 1582 [NFPA 2022]. The department 
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medical exams do include a stress EKG to determine capacity for physical exertion and decrease the 

risk of sudden cardiac death. The stress EKG required all members to meet a minimum level of 

10 MET’s. In addition, members assigned to wildland fire response and the state mutual aid system 

must meet a minimum of 12 METs, or successfully complete the Wildland Firefighting Work Capacity 

Test (Pack Test) annually. The California Incident Command Certification System [CICCS 2022] 

requires all fire departments in California that participate in statewide mutual aid to certify their 

members meet the “arduous” fitness level requirement as defined in the National Wildland 

Coordinating Group (NWCG) fitness requirements [NWCG Fitness and Work Capacity 2009]. 

NIOSH recommends all firefighters assigned to arduous work be capable of meeting a minimum of 

12 METs annually, as outlined in NFPA 1582-Chapter 8 [NFPA 2022].

An exercise stress test can detect areas of the heart that show ischemia only during exertion; the 

presence of these areas increases the risk of fatal and non-fatal cardiac events. If the stress EKG 

indicates ischemia, the individual should be referred to a heart specialist for additional evaluation to 

determine if there may be an increased risk for SCA and SCD while performing firefighter job tasks. 

However, it is important to keep in mind that a negative EST does not rule out the presence of 

underlying blockages in the coronary arteries so any signs or symptoms consistent with a heart attack 

even in someone who had a negative EST should prompt immediate medical evaluation.

Recommendation #3: Employers and employees should be aware of the early warning symptoms of 

a heart attack that could result in SCD.

If you or someone you work with experience symptoms that could be a heart attack, immediate 

medical attention can save lives by making a prompt diagnosis and starting life-saving interventions. If 

you see possible heart attack symptoms in someone else or hear them report symptoms consistent with 

a heart attack, encourage them to do the same.

References

American Diabetes Association (ADA) [no date]. Diabetes overview: prediabetes. Arlington, VA. Date 

accessed: November 2023.

American Heart Association (AHA) [2021]. Warning signs of a heart attack. Dallas, TX: American 

Heart Association.

Andrus B, Lacaille D [2014]. 2013 ACC/AHA guideline on the assessment of cardiovascular risk. J 

Am Coll Cardiol 63(25 Pt A):2886. 

Balady GJ, Larson MG, Vasan RS, Leip EP, O'Donnell CJ, Levy D [2004]. Usefulness of exercise 

testing in the prediction of coronary disease risk among asymptomatic persons as a function of the 

Framingham risk score. Circulation 110(14):1920–1925.

Banerjee A, Newman DR, Van den Bruel A, Heneghan C [2012]. Diagnostic accuracy of exercise 

stress testing for coronary artery disease: a systematic review and meta-analysis of prospective studies. 

Int J Clin Pract 66(5):477–492.

Bruce RA, DeRouen TA, Hossack KF, Blake B, Hofer V [1980]. Value of maximal exercise tests in 

risk assessment of primary coronary heart disease events in healthy men: five years' experience of the 

Seattle heart watch study. Am J Cardiol 46(3):371–378.
Page 8

47-Year-Old Captain Suffers Fatal Heart Attack at Fire Station – California

Report # F2022-08

CICCS [2022]. California incident command certification system 2022 qualifications guide. 

Centers for Disease Control and Prevention (CDC) [2022a]. About adult BMI.

Centers for Disease Control and Prevention (CDC) [2022b]. Heart attack symptoms, risk, and 

recovery.

Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Braun LT, de Ferranti S, 

Faiella-Tommasino J, Forman DE, Goldberg R, Heidenreich PA, Hlatky MA, Jones DW, Lloyd-Jones 

D, Lopez-Pajares N, Ndumele CE, Orringer CE, Peralta CA, Saseen JJ, Smith SC Jr, Sperling L, 

Virani SS, Yeboah J [2019]. 2018 

AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the 

management of blood cholesterol: executive summary: a report of the American College of 

Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol 

73(24):3168–3209. 

Isbister J, Semsarian C [2019]. Sudden cardiac death: an update. Intern Med J 49(7):826–833.

Jayaraman R, Reinier K, Nair S, Aro AL, Uy-Evanado A, Rusinaru C, Stecker EC, Gunson K, Jui J, 

Chugh SS [2018]. Risk factors of sudden cardiac death in the young: multiple-year community-wide 

assessment. Circulation 137(15):1561–1570.

Jazayeri MA, Emert MP [2019]. Sudden cardiac death: who is at risk? Med Clin North Am 

103(5):913–930.

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.

Kuriachan VP, Sumner GL, Mitchell LB [2015]. Sudden cardiac death. Curr Probl Cardiol 40(4):133–

200. 

Mégnien JL, Simon A [2009]. Exercise tolerance test for predicting coronary heart disease in 

asymptomatic individuals: a review. Atherosclerosis 205(2):579–583.

Michaelides AP, Triposkiadis FK, Boudoulas H, Spanos AM, Papadopoulos PD, Kourouklis KV, 

Toutouzas PK [1990]. New coronary artery disease index based on exercise-induced QRS changes. Am 

Heart J 120(2):292–302.

Michaelides A, Ryan JM, Bacon JP, Pozderac R, Toutouzas P, Boudoulas H [1995]. Exercise-induced 

QRS changes (Athens QRS score) in patients with coronary artery disease: a marker of myocardial 

ischemia. J Cardiol 26(5):263–272.

Michaelides AP, Aigyprladou MN, Andrikopoulos GK, Richter DJ, Kartalis A, Tapanlis E, Fourlas CA, 

Stefanadis CI [2005]. The prognostic value of a QRS score during exercise testing. Clin Cardiol 

28(8):375–380.

NFPA [2022]. NFPA 1582. Standard on comprehensive occupational medical program for fire 

departments. Quincy, MA: National Fire Protection Association. 

NWCG [2009]. Fitness and work capacity, PMS 304-2. National Wildfire Coordinating Group. 
Page 9

47-Year-Old Captain Suffers Fatal Heart Attack at Fire Station – California

Report # F2022-08

Shaw LJ, Peterson ED, Shaw LK, Kesler KL, DeLong ER, Harrell FE Jr, Muhlbaier LH, Mark DB 

[1998]. Use of a prognostic treadmill score in identifying diagnostic coronary disease subgroups. 

Circulation 98(16):1622–1630.

Sumanen M, Jussila M, Mattila K [2005]. Exercise treadmill test may predict clinical outcome among 

working-aged patients suspected of coronary heart disease in general practice. Scand J Prim Health 

Care 23(1):47–51.

van Campen CM, Visser FC, Visser CA [1996]. The QRS score: a promising new exercise score for 

detecting coronary artery disease based on exercise-induced changes of Q-, R- and S-waves: a 

relationship with myocardial ischaemia. Eur Heart J 17(5):699–708.

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. 

Wong CX, Brown A, Lau DH, Chugh SS, Albert CM, Kalman JM, Sanders P [2019]. Epidemiology of 

sudden cardiac death: global and regional perspectives. Heart Lung Circ 28(1):6–14. 

Investigator Information

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

Program, Cardiac/Medical Team, in Cincinnati, Ohio. Co-author TJ Welch is a Firefighter Safety 

Specialist that has worked in volunteer, industrial and municipal fire departments. Mr. Welch is a State 

Certified Fire Officer, founding member of the California Incident Command Certification System, 

and chaired the CICCS committee on Physical Fitness Standards. Dr. Robert Harrison MD, MPH 

(California Department of Public Health) provided medical consultation, and Laura Styles, MPH 

(Public Health Institute) also contributed to this report.

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 Web sites 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 Web sites.