On March 17, 2008, a 48-year old career Fire Fighter (FF) responded to a fire in a vacant single family dwelling. Dressed in full turnout gear and wearing his self-contained breathing apparatus (SCBA), the FF helped advance a charged hosed line to provide back-up to the front line fire suppression crew. After providing back-up fire suppression for about 10 minutes, the fire was declared under control and overhaul operations began. While performing overhaul activities with full respiratory protection the FF suddenly collapsed. The on-scene emergency medical service (EMS) unit provided advanced life support (ALS) care within 3 minutes, and this continued during transport to the nearest hospital Emergency Department. Despite arriving at the Emergency Department within 8 minutes of his collapse, efforts to revive the FF were unsuccessful. The death certificate and autopsy, completed by the Deputy Medical Examiner, listed "hypertensive and atherosclerotic cardiovascular disease" as the immediate cause of death. The FF's carboxyhemoglobin level was 3% suggesting that carbon monoxide poisoning was not responsible for his death. NIOSH investigators conclude the FF's sudden cardiac death was probably triggered by the FF responding to the fire alarm, the moderate to severe physical exertion associated with his fireground activities, and his underlying coronary and hypertensive heart disease. It is unlikely the following recommendations could have prevented the FF's death at this time, but NIOSH investigators offer these recommendations to prevent sudden cardiac death in this, and other, Fire Departments across the country. 1. Consider providing symptom limiting and diagnostic imaging exercise stress tests for fire fighters at increased risk for coronary artery disease and sudden cardiac death. 2. Work with the local union to phase-in an annual physical ability test.