Fire Fighter Cardiovascular Screening and
Heart Disease Prevention Program
Franklin D. Pratt, M.D.
Matthew Budoff, M.D.
Fire Captain George A. Cruz
Robert Karwasky, M.S.
History of LA County Wellness/Fitness
Program
 Administered by LA County Occupational Health
Service
 40,000 + exercise tests administered 1970-1992.
 Several landmark research papers published.
“ Physical Fitness and Subsequent MI in Healthy
Workers”, Peters.RK, et.al., JAMA 1983; 249:30523056.
3400 FFs followed for 4.8 years found 36 MI.

1970- mandatory pre-employment and periodic
medical exams for all LA county safety personnel
Risk associated with low physical work capacity
evident primarily in subjects with other risk factors.
History of LA County Wellness/Fitness
Program

1998- LA County joins 9 other FDs to form
IAFF/IAFC Wellness/Fitness
Initiative

2000- Medical Exams resume at 6 contracted
clinics

2000-2005 Approx 2000 Medical exams/ year
Disappointing ~70% compliance.
Cost Components for Follow-up of Abnormal
Stress Tests

Initial Cardiologist’ Consult (~$150)

Additional diagnostic tests
– Ex. Echo (~$800), or Thallium (~$1800)

Salary of employee and replacement

Administrative costs of Worker’s Comp claim
– $2300 average for cardiac claim, skewed by a few expensive litigations

Additional diagnostic tests
– Cardiac catheterization (~$5000)
– Electrophysiological Studies

Salary for additional time off pending clearance

Final Cardiologist Consultation (~$250)

Potential cost of 184 follow-ups = $275,000 to $775,000
Cost Components for Follow-up of
Abnormal Stress Tests

Cardiac events prevented by early
diagnosis and treatment of 22 mild or
moderate CAD cases…….
Staying Alive
Why is this soooo….
IMPORTANT???
Firefighter Cardiovascular
Disease Screening and Heart
Disease Prevention
The history of our Program
 The mechanics of Program
 The science and medicine of our program

Origins of this partnership

Disagreement between Labor and
Management on financial responsibility for
evaluation after Wellness-Fitness Exam
– When did W/F exam end and “private medical
care” begin?
Origins of this partnership

Too much time lapsed between
abnormalities discovered at WellnessFitness Exam and further evaluation
– Firefighter anxious
– Mediocre medical care on occasion
Los Angeles County Fire
Department and Harbor-UCLA
Medical Center
Worked together to provide quicker, better
screening
 Working toward a future of all inclusive
prevention and screening strategies

Origins of this partnership

Availability of cutting edge diagnostic tools
in a major medical center

Academic facility with interest in firefighter
health
Product of the Partnership

Electron Beam Cardiac Scanning for early
diagnosis

Intravenous coronary artery imaging

Integration of diagnosis and treatment
with prevention, risk factor modification
Purpose of Program

May 2000 to October 2001, 38 Workers’ Compensation
claims were filed for questionable ECG tracings that
were discovered during a cardiac exercise stress test.

As a result of the 38 claims filed, the Department
Medical cost amounted to $96,463.

36 of the 38 claims were false-positive ECG traces
Purpose of program

Prior to Cardiology program
 January 1 - December 31, 2001, 19 cardiac claims were filed as
a result of a wellness exam.
 January 1 - December 31, 2002, 18 cardiac claims were filed as
a result of a wellness exam.

Implementation of Cardiology program
 January 1 - December 31, 2003, 8 cardiac claims were filed as a
result of a wellness exam.
 January 1 - September 30, 2004, 6 cardiac claims were filed as a
result of a wellness exam
Program Overview





Program implemented in 11/01/03.
Data captured from 11/01/03 to 09/19/05
3413 Annual medical exams conducted
6 contracted medical facilities conduct annual
medical and fitness exams in the AM hours.
During the fitness exam a Maximal exercise test
is conducted
Rationale for Maximal Effort
Medical Screening
♥
FF tasks or fitness testing commonly elicit sustained HRs exceeding
85% of predicted maximum
♥ LA County Recruits HR exceed age-predicted max HR by ~4 bpm
during 1.5 mile run
♥
39% of first abnormalities would have been
missed if test terminated at 85% predicted Max.
HR*
♥
A maximal effort test ensures an accurate measure of
Cardiovascular fitness
Doing a Max test and measuring fitness periodically is
MOTIVATIONAL
♥
♥ Dr. Robert Bruce….63% of men having an exercise test changed at least
one other risk factor
*
Based on 552 abnormal tests on men at the Cooper Clinic
Program Components

If a undetermined ECG trace is discovered then
Fire Fighter is advised of the volunteer cardiology
program

Step 1: Re-read of ECG by a Board Certified
cardiologist within one hour.

Step 2: Electron Beam Coronary Calcium
Tomography (EBCT)

Step 3: Electron Beam Coronary Angiography
3413 Wellness/Fitness
Medical Exams
Suspected
Pos.
Normal
ECG
3229
(95%)
184
(5%)
Note:11/01/03 to 09/19/05 n=3413
184 Suspected Positive ECG’s
Step1: ECG Re-read
146 (79%)
38 (21%)
38 (21%)
146
Confirmed
Pos.
38 ECG's
Negative

146
confirmed
positive

38 ECG’s
were
negative
and RTW
146 Confirmed positive ECG’s
Step 2: EBCT

145 EBCT Scans
were performed to
determine the
presence of
coronary calcium
and extent of CAD.

1 case required an
arrhythmia
evaluation
Confirm
Positive
146 (79%)
RTW
38 (38%)
145 EBCT conducted
Calcium
detected,
CAD?
35 (24%)
110 (76%)
110 (76%)
Note: 1 Arrhythmia
No Calc.
=no sig.CAD,
= RTW
35 Positive EBCT scans
22 (63%)
Confirmed true
positive, CAD
12 (34%)
CAD
No
CAD
1 (3%)
False Positive, no
Sig.CAD,RTW
Arrhythmia,no
CAD
22 Confirmed True Positives on
EBA Indicate Mild to Moderate
CAD
7 (32%)
15 (68%)
Note:, 1 Arrhythmia, Light duty, 1 Arrhythmia, RTW
Temporary
light duty
RTW, full
duty
Coronary Artery Scanning
SEVERE CALCIFICATION
Pathway for Coronary
Calcium
146 Scans
35 with Coronary
Calcium Present
13 –
no significant
disease
15 - mild
Or moderate
Disease
7 with significant
Disease
3 required
Angioplasty
or Bypass
4 treated
medically
High Specificity for
Obstruction
Exquisite Detail of Anatomy
Lumen + Plaque Burden
CONCLUSIONS
Able to rapidly
screen and
triage
firefighters
(almost always
same day) back
to work or light
duty
Safety of Maximal Exercise Testing

Cooper Clinic – 170,000 tests since 1971




11 Complications
1 Death, 1 death 10 days later
Rate= 0.65 Complications/ 10,000 tests
ACSM and ACC Guidelines for Exercise Testing
strictly adhered to !
Comparison of Present Versus Former Cardiology Follow-up Programs
N
% Total
Procedure
Present Program
Former Program
3413*
100
Maximal Effort treadmill test
Clinic MD review
Clinic MD review
Suspected Positive ECG
184
5.4
Initial ECG re-read
Card. review within hour,
38 RTW w/o further eval.
OHP MD review ( 1 hour-2 weeks),
Cardiologist review?
Conformed Positive ECG
146
4.3
After ECG re-read, EBCT
recommended
EBCT same day, 110 negative and
RTW
Ex Echo? Thallium ? Off-duty pending
eval? Work comp?
Coronary Calcium present
35
1
After EBCT, EBA recommended
EBA next day or shift
Ex Echo or Thallium. Possible Cath.
Off-duty pending eval. Work comp.
Confirmed CAD
22
0.6
After EBA
Final review same day.
12 No sig. CAD -RTW- no time lost
Status pending final review
CAD requiring light duty
7
0.2
After final review
15 RTW w/o restrictions.
7 temporary light duty pending
Status pending final review
Arrhythmia requiring evaluation
2
0.06
After initial review
Cardiologist review within hour.
Consider EP study.
OHP MD (1 hour-2 weeks).
Consider EP study
Arrhythmia requiring light duty
1
0.03
After EP study
EP study evaluated.
Status determined by OHP MD.
EP study evaluated.
Status determined by OHP MD.
Total Cardiac requiring light duty
8
0.23
After final review
All Exams (11/1/03 to 9/19/05)
* Estimate calculated from average of 151.7 exams/ month
from 11/1/03 to 12/31/04, extrapolated to 22.5 months.
Cost Components for Follow-up of
Abnormal Stress Tests

Initial Cardiologist’ Consult (~$150)

Additional diagnostic tests
– Ex. Echo (~$800), or Thallium (~$1800)

Salary of employee and replacement

Administrative costs of Worker’s Comp claim
– $2300 average for cardiac claim, skewed by a few expensive litigations

Additional diagnostic tests
– Cardiac catheterization (~$5000)
– Electrophysiological Studies

Salary for additional time off pending clearance

Final Cardiologist Consultation (~$250)