UHM 2018, Vol. 45, No.

1 – ChD iN DIVERS

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
1

Department of Preventive Medicine & Community Health, The University of Texas Medical Branch,
2

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

CORRESPONDING AUTHOR: Robert Sanders, MD, FACEP – RWSander@UTMB.edu

_____________________________________________________________________________________________________________________________________________________________________

ABSTRACT
Introduction: In April 2016 the Association of Diving Con-
tractors International (ADCI) consensus guidelines began recom-
mending annual cardiovascular risk stratification of commercial
divers using the Framingham Risk Score (FRS). For those at
elevated risk, further testing is recommended. This approach
has raised concerns about potential operational and financial
impacts. However, the prevalence of elevated cardiovascular
risk and need for additional testing among commercial divers
is not known.
Methods: Clinical data required to calculate the FRS was ab-
stracted for 190 commercial divers in two cohorts. Population
demographics, FRS distribution, contributions of risk factors and
effect of interventions on reducing risk-factor burden were assessed.
Results: Mean FRS score was 1.68 ± 6.35 points, with 13 divers
(6.8%) at intermediate risk and none at high 10-year risk. In
these 13 divers, the mean contributions to the FRS were from age
(6.5 points), cholesterol (3.1 pts.), smoking (1.3 pts.), high-
density lipoprotein (1 pt.), and systolic blood pressure (0.8 pts).
The youngest age group had a significantly higher modifiable risk
score than the oldest age group (5.87 vs 1.2 points, P < 0.001).
All 13 intermediate risk divers could have been reclassified as
low-risk with successful treatment of modifiable risk factors.
Discussion: The prevalence of elevated cardiovascular risk
among commercial divers is low and treatment of modifiable
risk factors could reclassify those at intermediate risk to low
risk. Therefore, FRS implementation coupled with intensive
risk-reduction strategies for at risk-divers may help improve
diver health and prolong the careers of divers while limiting
the need for additional testing and adverse operational impact.
INTRODUCTION:
The Association of Diving Contractors International
(ADCI), a non-profit organization representing more
than 600 diving companies, schools and vendors world-
wide, publishes Medical Consensus Standards for
commercial divers [1]. Among other uses, these stan-
dards are utilized by commercial diving programs to
guide medical evaluation and monitoring of com-
mercial divers. They were recently revised in April
2016 to include recommendations for annual cardio-
vascular risk stratification with the Framingham risk
score (FRS) beginning at the age of 35 [1]. The impetus
for this change was consistent data showing that cardio-
vascular disease is responsible for a significant propor-
tion of fatalities occurring during diving [2].
The FRS is a widely used cardiovascular risk stratifi-
cation tool that estimates risk of “hard” coronary heart
disease, defined as myocardial infarction or sudden
cardiac death, within 10 years [3]. The FRS model in-
cludes age, total cholesterol, high-density lipoprotein
(HDL), hypertension (treated versus untreated), and
smoking status. The FRS classifies individuals as low-,
intermediate- or high-risk based on a 10-year coronary
heart disease risk of less than 10%, 10% to 20%, or
greater than 20%, respectively. For divers with an FRS
that correlates with 10-year risk of cardiovascular
disease of 10% or more, the ADCI recommends addi-
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
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Table 1: Demographics and clinical measurements
NBL OMCSL P-value
male (n,%) 58 (89.2) 124 (99.2) 0.002 β
__________________________________________________________________________
age (n,%) <0.001 β
<35 21 (32.3) 73 (58.4)* 0.022 ±
35-39 3 (4.6) 21 (16.8) 0.908 ±
40-44 13 (20.0)* 18 (14.4) 0.743 ±
45-49 10 (15.4) 6 (4.8) 0.034 ±
50-54 11 (16.9) 4 (3.2) 0.806 ±
55-59 3 (4.6) 2 (1.6) 0.647 ±
>60 4 (6.2) 1 (0.8) --
__________________________________________________________________________
SBP 126 124 0.19 ±
__________________________________________________________________________
treated SBP (n,%) 9 (14) 3 (2.4) 0.003 ±
__________________________________________________________________________
total chol 193 185 0.13 ±
__________________________________________________________________________
HDL 55 53 0.55 ±
__________________________________________________________________________
smoker (n, %) 10 (15.4) 19 (15.2) 1β
__________________________________________________________________________
* Indicates median age group for each cohort.
Median age group for the entire study population was <35.
± Indicates
t-test
β Indicates
Chi Square/Fisher’s Exact Test
Abbreviations: NBL- neutral buoyancy lab; OMCSL - Occupational
Medicine Clinics of South Louisiana; SBP - systolic blood pressure;
total chol - total cholesterol; HDL - high-density lipoprotein
mendations represent an opportunity to improve the
population health of occupational divers, but the
potential for increased stress testing has raised con-
cerns about operational and financial impacts.
METHODS
Institutional review board approval was obtained for
the collection and analysis of data from the National
Aeronautics and Space Administration (NASA) IRB.
Retrospective, de-identified data needed to calculate
the FRS including age category (<35, 35-39, 40-44,
45-49, 50-54, 55-59, >65-69, 70-74, 75-79); gender
category; systolic blood pressure; current smoking
status; total cholesterol; HDL cholesterol; and anti-
hypertensive medication use was obtained from the
electronic medical record (EMR) of the two cohorts
of commercial divers. The first cohort of divers was
employed at the NASA Neutral Buoyancy Lab (NBL)
in Houston, Texas, during the study period, and the
second cohort of divers was seen at the Occupational
Medicine Clinics of South Louisiana (OMCSL), an
76
occupational medicine clinic specializing in dive medi-
cine in New Iberia, Louisiana, during the study period.
The NBL cohort represents a stable and longitudinal
group of commercial divers who are under the routine
care of a dive medicine specialist in between annual
certifying exams. The OMCSL cohort represents a typical
group of commercial divers presenting for annual
medical evaluation to an independent dive medicine
specialist; these divers may or may not undergo interval
medical evaluation or screening between these evalu-
ations.
Data were collected from January 1, 2015, through
October 12, 2016, and preceded the implementation
of the new ADCI standards in our two cohorts. Popu-
lation demographics, FRS distribution, and contribu-
tions of individual modifiable components to overall
risk were assessed. A two-tailed Student’s t-test was
used for the comparison of continuous variables,
and Pearson’s chi-square and Fisher’s exact test were
used for comparison of categorical variables. The R
statistical programming language v3.3.1 was used
for statistical analysis and graphic production.
RESULTS
De-identified data were obtained on 190 divers. Of
these, 125 divers were from the OMCSL cohort and
65 divers were from the NBL cohort. Gender, age dis-
tribution and clinical parameters are summarized in
Table 1. Although the cohort of NBL divers was
significantly older (median age category 40-45 for NBL
and <35 for the OMCSL, respectively, P<0.001), there
was no difference in mean systolic blood pressure,
total cholesterol, HDL, or proportion of smokers
between the two cohorts. The NBL divers were more
likely to be on treatment for hypertension than their
OMCSL counterparts (14% vs. 2.4%, P = 0.005).
Among all divers (N = 190), the overall FRS score
was 1.68 ± 6.35, well below male and female thresh-
olds for stress testing at > 11 and > 19, respectively. The
distributions of FRS scores for the pooled and separate
cohorts are presented in Figure 1. The mean FRS in
the NBL cohort was significantly higher than in the
OMCSL cohort (4.6 vs. 0.2, P < 0.001). However, when
restricting the score to modifiable factors alone, there
was no significant difference (5.06 vs. 5.55, P = 0.36).
Mean modifiable risk score in the combined cohort by
age group is shown in Figure 2 and was significantly
Suresh R, Pavela J, Kus MS, et al.
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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

Suresh R, Pavela J, Kus MS, et al. 77

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

78 Suresh R, Pavela J, Kus MS, et al.

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FIGURe 3. Mean score by category in low-risk and intermediate-risk divers
7.5
5.0
2.5
mean score
0.0
-2.5
-5.0
age SBP
risk category
increased weight the FRS system gives to modifiable
risk factors, such as cholesterol (Figure 4) and smoking
status, in younger individuals. However, this difference
may also reflect a selection among divers as they age,
as only those who remain fit can continue to dive
professionally over several decades. Thus, our data
support the notion that implementation of cardiovas-
cular screening in all divers beginning at age 35
may help promote healthier lifestyles and thereby, over
time, increase the proportion of experienced divers
that can continue diving.
It is important to note that the two cohorts of com-
mercial divers in our study are different with regard to
several factors, of which the most operationally signifi-
cant are age and prevalence of elevated FRS. The NBL
is unique in that it has an in-house dive medicine
specialist who actively monitors divers’ health prior
to each dive and between their annual certifications.
Therefore, the NBL can accommodate older divers.
Suresh R, Pavela J, Kus MS, et al.
group
low risk
intermediate risk
Mean score for each category
of FRS
• age
• SBP = systolic blood pressure
• total cholesterol
• HDL and
• smoking
for divers with low vs.
intermediate 10-year risk.
Error bars represent standard error.
total chol HDL smoking
At the OMCSL, divers are seen primarily during annual
visits and are not necessarily re-evaluated in the interim.
In contrast to the NBL, the OMCSL diving population
is younger and has a significantly lower prevalence of
divers with elevated cardiovascular risk. We believe
this cohort is likely more representative of commercial
diving populations around the United States. Thus,
given that our overall cohort is older and that cardio-
vascular disease prevalence increases with age, the
prevalence of elevated cardiovascular risk in com-
mercial divers reported in this study, although low,
may be higher than is encountered elsewhere.
The low prevalence of elevated cardiovascular risk
in our also study suggests that the operational and finan-
cial impact of cardiovascular screening of at-risk divers
may be limited. These impacts may be further minimized
depending on the leeway given to the diving medical
officer to identify and implement risk mitigation strat-
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

legend

total cholesterol
200 4 FRS points

mean FRS points for TC

mean total cholesterol

150 3 Mean cholesterol

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

80 Suresh R, Pavela J, Kus MS, et al.

 UHM 2018, Vol. 45, No. 1 – ChD iN DIVERS
risk stratification is pursued. Risk factors not included
in the FRS but which could aid in stratification include
the coronary artery calcium score (particularly as a
method to reclassify a diver as low-risk), c-reactive
protein, body mass index, and family medical history.
One recommended approach in those with an inter-
mediate FRS is to proceed with non-invasive function-
al or anatomic evaluation of the coronary arteries by
stress-testing (such as mentioned by the ADCI guide-
lines) or coronary artery calcium score, respectively.
Indeed, exercise stress testing and coronary artery
calcium score in asymptomatic individuals at inter-
mediate risk can reclassify them into low- or high-
risk categories [9]. It should be noted that the United
States Preventive Services Task Force has concluded
there is insufficient evidence to recommend exercise
ECG for the prediction of coronary events in interme-
diate-risk asymptomatic individuals due to the unclear
risk-benefit trade-off, as false-positives have the po-
tential for serious harm due to unnecessary invasive
follow-up [10]. We believe this consideration supports
our recommendation regarding the use of early risk
modification rather than immediate additional testing.
Once individuals undergo non-invasive testing, those
reclassified as low-risk can return to diving duties while
continuing necessary risk factor modification. Those
reclassified as high-risk will likely remain disqualified,
but based on our findings and approach, we believe the
number of divers affected will be small. This approach
to coronary risk stratification in divers is intended to
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.
Suresh R, Pavela J, Kus MS, et al.
LIMITATIONS
This study is a cross-sectional survey of divers’ cardio-
vascular risk burden. A follow-up longitudinal study
will be performed to assess long-term trends in cardio-
vascular risk reduction with implementation of cardio-
vascular screening. We also did not have data on the
use of lipid-modifying agents in all divers; therefore,
we could not comment on prevalence of use of these
medications or their impact on total cholesterol or
HDL levels.
CONCLUSIONS
Approximately 7% of commercial divers we tested had
an FRS correlating with an intermediate 10-year risk
for cardiovascular disease, and no diver had a high
10-year risk. Age was the largest mean contributor
to risk, but treatment of modifiable risk factors could
have reclassified all divers to low-risk. A risk reduction
strategy for three to six months for intermediate-risk
divers prior to additional testing may improve diver
health, extend the careers of experienced divers, and
minimize operational impact of the new standards.
n
Acknowledgments
The authors would like to acknowledge the contributions
of Jessica Shafer of the Lifetime Surveillance of Astronaut
Health program at NASA for her assistance in abstracting
and compiling the NBL diver database.
The authors declare that no conflicts of interest exist
with this submission.
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