A new ACC/AHA Scientific Statement provides the first comprehensive framework for cardiovascular evaluation and management of tactical athletes, including the more than 4 million Americans currently serving as military personnel, firefighters, law enforcement officers, EMS professionals, pilots and astronauts. The statement introduces a novel tactical clinical management (TCM) framework that integrates evidence-based medical care with occupational demands, mission requirements and public safety considerations when evaluating a tactical athlete with cardiovascular disease or increased cardiovascular risk.

Cardiovascular disease is the leading medical cause of duty-related death in many tactical populations. Despite generally high levels of fitness, these individuals can have a high prevalence of cardiovascular risk factors such as hypertension, obesity, prediabetes or diabetes, dyslipidemia and smoking.

"A cardiovascular event for a firefighter, police officer or military service member can have implications far beyond the individual, including the success of the mission and lives of others," said Elizabeth H. Dineen, DO, FACC, chair of the statement's writing group.

To this end, Dineen and colleagues introduce a tactical task classification system based on strength and endurance requirements that acknowledges and incorporates "cardiovascular strain amplifiers" such as heat, altitude, dehydration, sleep deprivation, psychological stress, chronic high-alert status, heavy equipment loads, austere environments and other operational stressors that may substantially increase cardiovascular burden during routine or emergency operations.

Key recommendations and considerations in the statement include:

• Use the new TCM framework to support individualized evaluation and cardiovascular risk assessment within the context of occupational requirements and demands. A stepwise algorithm illustrates this approach.
• Preparticipation screening is critical for all tactical athletes and includes a history and physical examination. An ECG should be performed in tactical athletes under 40 years old exposed to significant cardiovascular strain or in mission-critical roles and is reasonable for other tactical athletes.
• Fitness-for-duty determinations should not only account for individual health risks but also for potential risks to team members, mission success and public safety.
• The cardiovascular implications of conditions such as cardiomyopathies, arrhythmias, congenital heart disease, coronary artery disease, valvular disease, myocarditis and anticoagulation status should be considered. The need for ongoing monitoring is emphasized.
• Operational and environmental factors, including heat, dehydration, altitude, diving and aviation exposures, collision risk and availability of emergency medical care should also be considered.
• Organizations should maintain emergency action plans and rapid AED access because screening alone cannot prevent all sudden cardiac arrests (SCA).

The document provides a detailed review and tables of management considerations for a number of cardiovascular diseases, including genetic cardiomyopathies; myocarditis and other acquired cardiac conditions; congenital heart disease; aortopathy, bicuspid aortic valve and spontaneous coronary artery dissection; syncope, SCA, arrhythmias and devices; cardiac channelopathies; older (>40 years) tactical athletes; and environmental exposures and extremes.

The authors also highlight several priorities for future focus and research, including the development of large prospective registries, evaluation of cardiovascular strain amplifiers, enhanced screening strategies, improved methods for quantifying cardiovascular risk across tactical occupations and career stages, and investigations into the high incidence of SCA and sudden cardiac death among tactical athletes.

"Tactical athletes dedicate their careers to protecting and serving others, often working in physically demanding and life-threatening situations that place unique stresses on the cardiovascular system. Cardiovascular care decisions must balance the health and safety of these individuals with the mission-critical and public safety responsibilities they carry every day," said Dineen.