Whether they are paid public servants or members of a volunteer force, all firefighters face external risks. Yet the greatest risk might be internal; 44% of firefighters who die on the job die from heart attacks, making it the leading cause of death. What's more, according to a 10-year study of sudden cardiac deaths of American firefighters by the National Fire Protection Association, about half of the firefighters who died of heart attacks had known heart conditions, and about 75% had heart conditions that simple medical testing could have detected.

Firefighters weigh more, smoke more and exercise less than their male counterparts of the same age. Their cholesterol levels are higher and aerobic capacity is lower than middle-aged men, and both measures tend to get worse over their careers. A study of retired Massachusetts firefighters found that the risk of heart attack and other heart problems was the principal reason for leaving the force. It also found that cholesterol, blood pressure, smoking and obesity levels were higher than firefighters currently working.

“Fire departments should consider mandatory annual fitness exams for firefighters,” says Marilyn Ridenour, co-author of the report and an epidemic intelligence officer with the Centers for Disease Control and Prevention's National Institute for Occupational Safety and Health. “That should help reduce these risks.”

The study shows that progress has been made. While heart attacks consistently cause the most deaths among firefighters, the absolute number of deaths have decline by one-third over the past 25 years, through 2006.

“We do have standards, but we need implementation and adherence to the standards,” says Rita Fahy, the study's other co-author who is the with the NFPA.

As with improvements in the detection and treatment of heart disease and related conditions over the past decades, advances in medicines have reduced heart attacks and strokes. It's likely that reducing the risk of heart disease will take the latest insights in cardiovascular medicine and tailor it to the unique work and environmental conditions that firefighters face on a daily basis.

Screening isn't enough to get the job done. A more comprehensive and personalized approach is needed that takes into account the unique needs of firefighters and states the goal of reducing the rate of death from stroke and heart attack. And there should be an obligation to apply the best science to the problem in ways that provide firefighters with a personalized approach to disease prevention and wellness.

First, reducing the risk of stroke and heart attack can't be started soon enough. Take the issue of high blood pressure. An accumulation of data on lifetime risk, which showed that blood-pressure levels previously considered normal or high-normal are associated with substantial risks of cardiovascular complications and that these lifestyle factors are directly linked with high blood pressure: obesity, lack of physical activity, smoking, excessive sodium intake and over-consumption of alcohol. For these reasons, assessing and potentially treating patients with pre-hypertension can reduce the risk of stroke.

Pre-hypertension is systolic pressure of 120 to 139 mmHg or untreated diastolic pressure of 80 to 89 mmHg. Even a relatively young patient with no current evidence of any major target organ damage can eventually reach that category. It's best to protect against advancing vascular disease and changes in the blood pressure early.

As for treatment, too much of what passes for medical practice is influenced by what is read in the media, which boils down to an either/or choice. People get caught up in debates about if a calcium channel blocker is better than a diuretic is better than an angio receptor blocker or an ACE inhibitor. Instead, the prevention and treatment of high blood pressure will vary by many factors including vascular properties, body weight, metabolic features (and community trends in these features) ethnicity, age and renin profile.

For instance, there is a big difference between skinny and obese hypertension. Skinny hypertension is driven by increased activity of the angiotensin renin and sympathetic systems, particularly when patients become physically stressed — an issue of considerable importance to firefighters. Underweight hypertensive patients actually are more challenging to treat then obese hypertensives, because the latter have a tendency to respond well to diuretics and, consequently, often have better outcomes.

Ethnicity imposes different clinical endpoints that required distinct drug strategies. Evidence suggests that combination therapy works equally well across various ethnic subgroups and should be taken into account as fire departments become increasingly diverse. For instance, a recent study found that 52% of black participants required combination therapy to achieve blood pressure control, compared with only 39% of white patients.

Nevertheless, black patients continue to have poorer outcomes and higher mortality rates than white patients. One study showed an overall 15% stroke event rate in those getting the ACE inhibitor compared to a diuretic. However, there is no difference in stroke outcomes for non-black patients. This is explained by a 40% excess stroke rate in black patients, almost certainly a reflection of poorer blood-pressure control because of treatment with inappropriate drugs. This is a dramatic example of where phenotype and drug selection make a very important difference.

Another concern is age. Despite blood-pressure values, most patients over the age of 65 will become hypertensive and have increased coronary risk. There is clear reasoning for clinicians to treat an aging population more aggressively than younger patients.

Phenotypes can help clinicians decide how and when to treat. Most importantly, when it comes to therapy, one size doesn't fit all, and great deal of thinking about optimal strategies is still needed.