Authors' objectives: To determine whether there is any evidence to support a causal association between firefighting as an occupation and the development of coronary artery disease.

Authors' results and conclusions: 239 citations were identified from the literature searches. With the observed increased trend on the research topic after 2010, the decision was made to focus on the literature from 2010 onwards bringing the total to 173. The tasks a firefighter attends vary by jurisdiction, work setting, and different time points during shiftwork (e.g., active firefighters may attend wildfires, industrial zone fires, or house fires). The literature suggests an increased risk of on-duty sudden cardiac death (SCD) and being an active firefighter (i.e., engaged in alarm response/fire suppression– mitigating/extinguishing fires). On-duty deaths attributable to cardiovascular diseases is 45% in firefighters, whereas it is 15% in all occupations combined. There is debate on whether this increase in SCD in firefighters is related to an inherent risk introduced by firefighting as a profession. Research on cardiovascular risk factors in firefighters produces mixed messages. To be able to investigate ‘firefighting’ as a standalone causal effect for the development of CAD a longitudinal cohort study is needed. A control group of people hired for other occupations, also free from CAD risk factors at the starting point, should be enrolled and followed over time. This control group should have workers with similar job demands and psychological stressors (e.g., police, paramedics, military personnel) but no physical stressors unique to firefighting (e.g., smoke, particulate matter, chemical, dust exposures, extreme heat, dehydration, intense physical exertion, carrying heavy fire extinguisher equipment and PPE). At baseline and through the course of the study, common CAD risk factors such as age, hypertension, obesity, high cholesterol and smoking should be measured and controlled for. In this progressive study design factors such as work-related stress, shift work, sleep problems, as well as ‘healthy worker effect’ would be similar across the study and control groups and would be controlled for. This cohort study design is challenging. As a chronic disease CAD develops slowly. Hence, the study design would require a long follow up period. Our literature search at this time did not capture any cohort studies as such. Most of the currently available studies on the topic are cross-sectional and focus on the prevalence of standard CAD risk factors in firefighters or on-duty sudden cardiac deaths. Some highlight lifestyle or underlying background exposures (e.g., preexisting smoking and hypertension) as possible confounders. With these studies, it is not possible to make inferences on a causal association between the firefighting occupation and the development of CAD (during/by ‘firefighting’). Longitudinal, prospective cohort studies, with rigorous methodologic quality are required to be able to infer any causal relationship between firefighting and CAD.

Authors' methods: A comprehensive systematic literature search was undertaken on November 13, 2024. The search was done on commercial medical literature databases using selected keywords for this search. No limitation on the date of publication was implemented during the search. Predetermined inclusion/exclusion criteria were used. Studies were included if published in peer-reviewed journals, written in English, explored the relationship between firefighting and coronary artery disease (CAD), investigated the causal path of CAD in firefighters, compared the firefighter CAD prevalence and incidence rates with the rates in other working populations with similar background occupational risks for CAD, or with firefighter populations from other jurisdictions, or groups of firefighters working different duties (e.g., administration, emergency duty) and/or were systematic reviews/meta-analysis, or cohort, case-control, or comparison studies with sound methodological quality. Studies were excluded if examined occupational groups other than firefighters, studied firefighters with illnesses other than CADs, studied firefighters attending 9/11 World Trade Centre event. (exposure level, intensity, length of exposure were not compatible), were observational studies with no comparison groups, were experimental, simulation, or laboratory studies, were diagnostic and interventional studies, presented low methodological quality, published as conference abstracts/posters, editorials, opinion/position papers, reprints in other journals, narrative reviews, qualitative interviews, study proposals, pilot studies, case studies, case series, and practice guidelines, were written in languages other than English, and not available as full-text articles.

Project Status: Completed

URL for project: https://www.worksafebc.com/en/about-us/research-services/evidence-based-medicine-and-systematic-reviews

Year Published: 2025

URL for published report: https://www.worksafebc.com/en/resources/health-care-providers/guides/firefighting-coronary-artery-disease?lang=en&origin=s&returnurl=https%3A%2F%2Fwww.worksafebc.com%2Fen%2Fforms-resources%23sort%3DDate%26q%3DFirefighting%2520and%2520Coronary%2520Heart%2520Disease%2520(CAD)%26f%3Alanguage-facet%3D%5BEnglish%5D%26tags%3DGuide%7C2d7eb4b30f6a4a319e0d40565c9abbab%2CHealth%2520Care%2520Provider%7C13468b0b3f074f6bade3f57ac3cdfb8e%2CSystematic%2520Review%7Cf78c29d570c14ec3b5a394385905df70&highlight=Firefighting%20and%20Coronary%20Heart%20Disease%20(CAD)

English language abstract: An English language summary is available

Publication Type: Mini HTA

Country: Canada

Organisation Name: WorkSafeBC

Contact Address: 6591 Westminster Highway, Richmond, BC, V7C 1C6 Canada. Tel: 604-231-8417; Fax: 604-279-7698

Contact Name: ebpg@worksafebc.com

Contact Email: ebpg@worksafebc.com

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