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UHM 2018, Vol. 45, No.


Research Article
Do not fear the Framingham: Practical application to properly evaluate
and modify cardiovascular risk in commercial divers
Rahul Suresh, MD, MS 1,2*; James Pavela, MD 1,2*; Marcin S. Kus, MD 3;
Tony Alleman, MD 4; Robert Sanders, MD 2,5
* Co-first authors
Department of Internal Medicine, The University of Texas Medical Branch, Galveston, Texas

Department of Preventive Medicine & Community Health, The University of Texas Medical Branch,

Galveston, Texas
3 Department of Occupational and Environmental Medicine, Duke University, Durham, North Carolina

4 Occupational Medicine Clinics of South Louisiana, New Iberia, Louisiana

5 Neutral Buoyancy Lab, Sonny Carter Training Facility, National Aeronautics and Space Administration,

Houston, Texas



The Association of Diving Contractors International
Introduction: In April 2016 the Association of Diving Con-
(ADCI), a non-profit organization representing more
tractors International (ADCI) consensus guidelines began recom-
mending annual cardiovascular risk stratification of commercial than 600 diving companies, schools and vendors world-
divers using the Framingham Risk Score (FRS). For those at wide, publishes Medical Consensus Standards for
elevated risk, further testing is recommended. This approach commercial divers [1]. Among other uses, these stan-
has raised concerns about potential operational and financial dards are utilized by commercial diving programs to
impacts. However, the prevalence of elevated cardiovascular guide medical evaluation and monitoring of com-
risk and need for additional testing among commercial divers mercial divers. They were recently revised in April
is not known. 2016 to include recommendations for annual cardio-
Methods: Clinical data required to calculate the FRS was ab- vascular risk stratification with the Framingham risk
stracted for 190 commercial divers in two cohorts. Population
score (FRS) beginning at the age of 35 [1]. The impetus
demographics, FRS distribution, contributions of risk factors and
for this change was consistent data showing that cardio-
effect of interventions on reducing risk-factor burden were assessed.
Results: Mean FRS score was 1.68 ± 6.35 points, with 13 divers vascular disease is responsible for a significant propor-
(6.8%) at intermediate risk and none at high 10-year risk. In tion of fatalities occurring during diving [2].
these 13 divers, the mean contributions to the FRS were from age The FRS is a widely used cardiovascular risk stratifi-
(6.5 points), cholesterol (3.1 pts.), smoking (1.3 pts.), high- cation tool that estimates risk of “hard” coronary heart
density lipoprotein (1 pt.), and systolic blood pressure (0.8 pts). disease, defined as myocardial infarction or sudden
The youngest age group had a significantly higher modifiable risk cardiac death, within 10 years [3]. The FRS model in-
score than the oldest age group (5.87 vs 1.2 points, P < 0.001). cludes age, total cholesterol, high-density lipoprotein
All 13 intermediate risk divers could have been reclassified as (HDL), hypertension (treated versus untreated), and
low-risk with successful treatment of modifiable risk factors.
smoking status. The FRS classifies individuals as low-,
Discussion: The prevalence of elevated cardiovascular risk
intermediate- or high-risk based on a 10-year coronary
among commercial divers is low and treatment of modifiable
risk factors could reclassify those at intermediate risk to low heart disease risk of less than 10%, 10% to 20%, or
risk. Therefore, FRS implementation coupled with intensive greater than 20%, respectively. For divers with an FRS
risk-reduction strategies for at risk-divers may help improve that correlates with 10-year risk of cardiovascular
diver health and prolong the careers of divers while limiting disease of 10% or more, the ADCI recommends addi-
the need for additional testing and adverse operational impact. tional non-invasive stress testing [1]. These recom-


KEYWORDS: commercial diver; Framingham risk score; cardiovascular risk factors; smoking and diving; diving medical clearance

Copyright © 2017 Undersea & Hyperbaric Medical Society, Inc. 75

UHM 2018, Vol. 45, No. 1 – ChD iN DIVERS

occupational medicine clinic specializing in dive medi-
Table 1: Demographics and clinical measurements
cine in New Iberia, Louisiana, during the study period.
The NBL cohort represents a stable and longitudinal
male (n,%) 58 (89.2) 124 (99.2) 0.002 β
__________________________________________________________________________ group of commercial divers who are under the routine
age (n,%) <0.001 β care of a dive medicine specialist in between annual
<35 21 (32.3) 73 (58.4)* 0.022 ±
certifying exams. The OMCSL cohort represents a typical
35-39 3 (4.6) 21 (16.8) 0.908 ±
group of commercial divers presenting for annual
40-44 13 (20.0)* 18 (14.4) 0.743 ±
45-49 10 (15.4) 6 (4.8) 0.034 ± medical evaluation to an independent dive medicine
50-54 11 (16.9) 4 (3.2) 0.806 ± specialist; these divers may or may not undergo interval
55-59 3 (4.6) 2 (1.6) 0.647 ± medical evaluation or screening between these evalu-
>60 4 (6.2) 1 (0.8) -- ations.

SBP 126 124 0.19 ± Data were collected from January 1, 2015, through
October 12, 2016, and preceded the implementation
treated SBP (n,%) 9 (14) 3 (2.4) 0.003 ±
__________________________________________________________________________ of the new ADCI standards in our two cohorts. Popu-
total chol 193 185 0.13 ± lation demographics, FRS distribution, and contribu-

HDL 55 53 0.55 ± tions of individual modifiable components to overall

risk were assessed. A two-tailed Student’s t-test was
smoker (n, %) 10 (15.4) 19 (15.2) 1β
__________________________________________________________________________ used for the comparison of continuous variables,
* Indicates median age group for each cohort. and Pearson’s chi-square and Fisher’s exact test were
Median age group for the entire study population was <35.
used for comparison of categorical variables. The R
± Indicates
β Indicates
statistical programming language v3.3.1 was used
Chi Square/Fisher’s Exact Test
Abbreviations: NBL- neutral buoyancy lab; OMCSL - Occupational
for statistical analysis and graphic production.
Medicine Clinics of South Louisiana; SBP - systolic blood pressure;
total chol - total cholesterol; HDL - high-density lipoprotein RESULTS
De-identified data were obtained on 190 divers. Of
these, 125 divers were from the OMCSL cohort and
mendations represent an opportunity to improve the 65 divers were from the NBL cohort. Gender, age dis-
population health of occupational divers, but the tribution and clinical parameters are summarized in
potential for increased stress testing has raised con- Table 1. Although the cohort of NBL divers was
cerns about operational and financial impacts. significantly older (median age category 40-45 for NBL
and <35 for the OMCSL, respectively, P<0.001), there
METHODS was no difference in mean systolic blood pressure,
Institutional review board approval was obtained for total cholesterol, HDL, or proportion of smokers
the collection and analysis of data from the National between the two cohorts. The NBL divers were more
Aeronautics and Space Administration (NASA) IRB. likely to be on treatment for hypertension than their
Retrospective, de-identified data needed to calculate OMCSL counterparts (14% vs. 2.4%, P = 0.005).
the FRS including age category (<35, 35-39, 40-44, Among all divers (N = 190), the overall FRS score
45-49, 50-54, 55-59, >65-69, 70-74, 75-79); gender was 1.68 ± 6.35, well below male and female thresh-
category; systolic blood pressure; current smoking olds for stress testing at > 11 and > 19, respectively. The
status; total cholesterol; HDL cholesterol; and anti- distributions of FRS scores for the pooled and separate
hypertensive medication use was obtained from the cohorts are presented in Figure 1. The mean FRS in
electronic medical record (EMR) of the two cohorts the NBL cohort was significantly higher than in the
of commercial divers. The first cohort of divers was OMCSL cohort (4.6 vs. 0.2, P < 0.001). However, when
employed at the NASA Neutral Buoyancy Lab (NBL) restricting the score to modifiable factors alone, there
in Houston, Texas, during the study period, and the was no significant difference (5.06 vs. 5.55, P = 0.36).
second cohort of divers was seen at the Occupational Mean modifiable risk score in the combined cohort by
Medicine Clinics of South Louisiana (OMCSL), an age group is shown in Figure 2 and was significantly

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UHM 2018, Vol. 45, No. 1 – CHD iN DiVERS


FIGURe 1. Pooled and individual cohort frequency of FRS

# of divers

total FRS
Histogram of number of divers by FRS score (x-axis) and age group (color-coded) in the overall cohort (A),
in the NBL cohort (B), and in the OMCSL cohort (C), respectively. The dashed line indicates the threshold for
intermediate risk among males (red) and females (blue). * indicates that the age group 55-59 and 60-64 are
combined into a single group (using the 60-64 group color pink) in the B and C inserts.


FIGURe 2. Mean modifiable risk by age group

mean modifiable risk score

Mean modifiable risk score

• systolic blood pressure
• total cholesterol
• HDL and
• smoking
by age group (x-axis).
Error bars represent standard error.

age group

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Table 2: Comparison of youngest and oldest divers by score and clinical parameters
____ Framingham risk score ____ ___ mean clinical parameter*____
risk factor youngest oldest P-value youngest oldest P-
divers divers divers divers value

total modifiable score 5.87 1.2 <0.001 – – –

SBP 0.23 0.4 0.5 122 mm Hg 125 mm Hg 0.5
total cholesterol 3.5 0.4 <0.001 177 mg/dL 179 mg/dL 0.9
HDL 0.24 0.2 0.9 54.7 mg/dL 55 mg/dL 0.9
smoking status 1.89 0.2 <0.001 23.40% 20% 0.9

* Clinical parameter refers to actual measurements whereas the Framingham risk score refers to the points
assigned to those measurements

higher in the youngest age bracket than it was in the studied had an intermediate 10-year risk for cardio-
oldest (5.87 vs. 1.2, P < 0.001). This was driven vascular disease, and none had a high 10-year risk.
primarily by risk points attributed to smoking status This compares favorably with the general population.
(1.89 vs. 0.2, P < 0.001) and total cholesterol (3.5 vs. 0.4, A 2004 study found the prevalence of intermediate-risk
P < 0.001) (Table 2). However, when mean systolic individuals [4] be age in the general population to be:
blood pressure, mean total cholesterol, mean HDL, and • 0.2% of males aged 20-29;
smoking status were compared, there was no signifi- • 7.4% of males aged 30-39;
cant difference between the two groups despite the • 16.2% of males aged 40-49;
difference in age (Table 2). • 52.0% of males aged 50-59; and
In the pooled group, there were 13 divers (6.8%) • 80.8% of males aged 60-69.
whose FRS corresponded with an intermediate 10-year Although age was the largest contributing category
risk; eight of these divers were in the NBL cohort to the 13 divers who were found to have an intermediate-
(12.3% of the cohort) and five were in the OMCSL level risk score, all 13 divers had sufficiently high modi-
cohort (4% of the cohort). In these 13 divers, the fiable risk scores such that clinically feasible interven-
highest mean contribution to the overall FRS came tions could recategorize them into the low-risk group.
from age (6.5 points), cholesterol (3.1 points), smoking For example, in those divers at intermediate risk who
(1.3 points), HDL (1 point), and systolic blood pressure smoked, smoking cessation alone would reclassify them
(0.8 points). All but three divers were over the age of as low-risk. Likewise, intensive statin therapy aimed
50. In low-risk divers, the highest mean contribution at 30%-40% reduction in total cholesterol would have
to the overall FRS came from cholesterol, followed by reclassified five of the seven non-smoking divers as
smoking (Figure 3). low-risk. In the remaining two divers, a combination
of anti-hypertensive and cholesterol-lowering therapy
DISCUSSION would be required. Not only would these clinically fea-
Recent recommendations by the ADCI to perform sible interventions reclassify the divers as low-risk
annual FRS assessment for systematic occupational and avoid additional testing, they would be in keeping
surveillance of cardiovascular risk in commercial divers with standard United States Preventive Services Task
provides an opportunity to improve diver health but Force (USPSTF) and joint American College of Cardi-
has also raised concerns regarding its financial and ology (ACC)/American Heart Association (AHA) recom-
operational impact. We performed a retrospective ana- mendations on smoking cessation and cardiovascular
lysis of two commercial diving populations to quantify disease prevention, respectively [5–7].
the number of individuals that would be considered We also found that there was a significantly high-
intermediate- or high-risk cardiovascular based on the er mean modifiable risk score in the youngest div-
FRS. Our analysis revealed that only 6.8% of all divers ers as compared to the oldest divers. This is due to the

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FIGURe 3. Mean score by category in low-risk and intermediate-risk divers


low risk
intermediate risk

mean score

Mean score for each category
of FRS
• age
• SBP = systolic blood pressure
-2.5 • total cholesterol
• HDL and
• smoking
for divers with low vs.
intermediate 10-year risk.
Error bars represent standard error.
age SBP total chol HDL smoking

risk category

increased weight the FRS system gives to modifiable At the OMCSL, divers are seen primarily during annual
risk factors, such as cholesterol (Figure 4) and smoking visits and are not necessarily re-evaluated in the interim.
status, in younger individuals. However, this difference In contrast to the NBL, the OMCSL diving population
may also reflect a selection among divers as they age, is younger and has a significantly lower prevalence of
as only those who remain fit can continue to dive divers with elevated cardiovascular risk. We believe
professionally over several decades. Thus, our data this cohort is likely more representative of commercial
support the notion that implementation of cardiovas- diving populations around the United States. Thus,
cular screening in all divers beginning at age 35 given that our overall cohort is older and that cardio-
may help promote healthier lifestyles and thereby, over vascular disease prevalence increases with age, the
time, increase the proportion of experienced divers prevalence of elevated cardiovascular risk in com-
that can continue diving. mercial divers reported in this study, although low,
It is important to note that the two cohorts of com- may be higher than is encountered elsewhere.
mercial divers in our study are different with regard to The low prevalence of elevated cardiovascular risk
several factors, of which the most operationally signifi- in our also study suggests that the operational and finan-
cant are age and prevalence of elevated FRS. The NBL cial impact of cardiovascular screening of at-risk divers
is unique in that it has an in-house dive medicine may be limited. These impacts may be further minimized
specialist who actively monitors divers’ health prior depending on the leeway given to the diving medical
to each dive and between their annual certifications. officer to identify and implement risk mitigation strat-
Therefore, the NBL can accommodate older divers. egies, such as diver education and individual score

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FIGURe 4. Mean total cholesterol and corresponding points by age group

250 5


total cholesterol
200 4 FRS points

mean FRS points for TC

mean total cholesterol

150 3 Mean cholesterol

(left y-axis, light gray)
Mean point contribution
for total cholesterol
100 2 (right y-axis, dark gray)
per age group.

50 1

0 0

<35 35-49 40-44 45-49 50-54 55-59 60-64

age group

optimization. Given that risk factor modification can dietitian, regular aerobic exercise, and/or weight loss
reduce FRS below the threshold for further testing, prior to, or in conjunction with, pharmaceutical therapies
one approach to minimize financial impact would be to reduce blood pressure and cholesterol. The treating
to pursue aggressive risk factor modification for three provider should ensure appropriate follow-up within
to six months in lieu of proceeding directly to non- four weeks [8] and within four to 12 weeks [7] of
invasive testing in asymptomatic, intermediate-risk initiation of blood pressure and cholesterol medications,
divers. In developing a treatment strategy, the certify- respectively. During this initial period of risk modifi-
ing physician should consider the number and severity cation, divers could retain their diving privileges. This
of risk factor(s), degree of risk reduction needed, the approach, if successful, would negate the need for further
available interventions, potential barriers to compliance non-invasive cardiovascular testing while allowing divers
with recommendations, and the potential time required to keep diving.
to achieve the necessary risk reduction. An individual- However, if risk remains elevated above the ADCI-
ized approach, after accounting for these factors, can in- recommended threshold despite intervention or due to
clude lifestyle modifications such as smoking cessation, non-compliance, diving privileges could be reconsid-
the “DASH diet,” dietary counseling by a registered ered, even in the absence of symptoms, while further

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UHM 2018, Vol. 45, No. 1 – ChD iN DIVERS

risk stratification is pursued. Risk factors not included LIMITATIONS

in the FRS but which could aid in stratification include This study is a cross-sectional survey of divers’ cardio-
the coronary artery calcium score (particularly as a vascular risk burden. A follow-up longitudinal study
method to reclassify a diver as low-risk), c-reactive will be performed to assess long-term trends in cardio-
protein, body mass index, and family medical history. vascular risk reduction with implementation of cardio-
One recommended approach in those with an inter- vascular screening. We also did not have data on the
mediate FRS is to proceed with non-invasive function- use of lipid-modifying agents in all divers; therefore,
al or anatomic evaluation of the coronary arteries by we could not comment on prevalence of use of these
stress-testing (such as mentioned by the ADCI guide- medications or their impact on total cholesterol or
lines) or coronary artery calcium score, respectively. HDL levels.
Indeed, exercise stress testing and coronary artery
calcium score in asymptomatic individuals at inter- CONCLUSIONS
mediate risk can reclassify them into low- or high- Approximately 7% of commercial divers we tested had
risk categories [9]. It should be noted that the United an FRS correlating with an intermediate 10-year risk
States Preventive Services Task Force has concluded for cardiovascular disease, and no diver had a high
there is insufficient evidence to recommend exercise 10-year risk. Age was the largest mean contributor
ECG for the prediction of coronary events in interme- to risk, but treatment of modifiable risk factors could
diate-risk asymptomatic individuals due to the unclear have reclassified all divers to low-risk. A risk reduction
risk-benefit trade-off, as false-positives have the po- strategy for three to six months for intermediate-risk
tential for serious harm due to unnecessary invasive divers prior to additional testing may improve diver
follow-up [10]. We believe this consideration supports health, extend the careers of experienced divers, and
our recommendation regarding the use of early risk minimize operational impact of the new standards.
modification rather than immediate additional testing. n
Once individuals undergo non-invasive testing, those Acknowledgments
reclassified as low-risk can return to diving duties while The authors would like to acknowledge the contributions
continuing necessary risk factor modification. Those of Jessica Shafer of the Lifetime Surveillance of Astronaut
reclassified as high-risk will likely remain disqualified, Health program at NASA for her assistance in abstracting
but based on our findings and approach, we believe the and compiling the NBL diver database.
number of divers affected will be small. This approach The authors declare that no conflicts of interest exist
to coronary risk stratification in divers is intended to with this submission.
minimize the need for non-invasive testing and enable
divers to keep diving while they modify their cardio-
vascular risk. This incentivizes divers and employers
to prioritize health maintenance, prevention and risk
mitigation while minimizing operational impact.

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