Impaired Spirometry and COPD Increase the Risk of Cardiovascular Disease: A Canadian Cohort Study

Obstructive Airway Disease is Associated with Increased Cardiovascular Disease Risk Independent of Phenotype: Evidence from Two Nationwide Population-Based Studies

Background

Cardiovascular disease (CVD), as the most common comorbidity of chronic obstructive pulmonary disease (COPD), has received much attention. However, robust evidence of the relationship between other obstructive airway disease (OAD) phenotypes, such as asthma, asthma-COPD overlap (ACO), and CVD risk is limited. We aimed to compare the magnitude of CVD risk across different OAD phenotypes using two nationwide population-based studies.

Methods

We analyzed cross-sectional data from the National Health and Nutrition Examination Survey 1999-2018 (N=44,972, representing 183,508,900 adults). Survey-weighted descriptive analysis and logistic regression were used to investigate the prevalence of CVD (including heart failure, coronary heart disease, angina pectoris, and myocardial infarction) across OAD phenotypes and calculate odds ratios (ORs) with 95% confidence intervals (CIs). Additionally, longitudinal data from the China Health and Retirement Longitudinal Study (CHARLS) (N=13,533) were analyzed to validate these findings and calculate hazard ratios (HRs) with 95% CIs for new-onset CVD using Cox proportional hazards models.

Results

The weighted prevalence of at least one CVD in asthma, COPD, and ACO was 6.21%, 16.82%, and 20.75%, respectively. Individuals with asthma, COPD, and ACO had a significantly higher prevalence of CVD than those without OAD, with ORs of 1.55 (95% CI: 1.34-1.78), 1.76 (95% CI: 1.50-2.07), and 2.99 (95% CI: 2.47-3.61), respectively. During the 9-year follow-up, 2,444 (18.1%) individuals developed CVD in CHARLS. The incidence of CVD was significantly higher in individuals with asthma (HR=1.67, 95% CI: 1.26-2.21), COPD (HR=1.71, 95% CI: 1.48-1.97), and ACO (HR=2.67, 95% CI: 2.21-3.24) than those without OAD.

Conclusion

Individuals with OAD have a higher prevalence of comorbid CVD and an increased risk of developing CVD independent of phenotype, especially in those with ACO. These findings emphasize the need for awareness and appropriate cardiovascular screening in OAD.

The association between cardiovascular diseases and their subcategories with the severity of chronic obstructive pulmonary disease: a large cross-sectional study based on a Chinese hospital population cohort

Background

Current evidence suggests that cardiovascular disease (CVD) plays a role in the progression of chronic obstructive pulmonary disease (COPD). However, the relationship between CVD and the severity of COPD remains inadequately understood. Therefore, this study aims to elucidate the association between CVD and the severity of COPD.

Methods

In this cross-sectional study involving 7,152 individuals with COPD., Logistic regression, subgroup and sensitivity analyses were employed to evaluate the association between CVD, its subcategories, and the severity of COPD.

Results

Multivariable logistic regression analysis showed that CVD and hypertension remained independently associated with COPD severity (P < 0.001). Patients with CVD had a 1.701 times higher risk of developing severe or very severe COPD compared to those without CVD, while patients with hypertension had a 1.686 times higher risk of developing severe or very severe COPD compared to those without hypertension (P < 0.05). Subgroup analyses showed that the association between CVD and COPD severity remained stable among men, patients ≤ 70 years of age, patients > 70 years of age, BMI < 24 or ≥24 kg/m2, and never smokers, whereas coronary artery disease was significantly associated with COPD severity only among patients ≤ 70 years of age and never smokers (P < 0.05). In addition, hypertension was also stably associated with COPD severity among men, patients ≤ 70 years of age, patients > 70 years of age, BMI < 24 or ≥24 kg/m2, and never smokers. Sensitivity analyses reconfirmed the robustness of the associations of CVD and hypertension with COPD severity among patients who excluded bronchiectasis, tuberculosis, lung cancer, pulmonary hypertension, pulmonary heart disease, and diabetes (P < 0.05).

Conclusion

The strong association between CVD and its subcategories (mainly hypertension) and the severity of COPD suggests that the potential risk of exacerbation of CVD should also be addressed in the clinical management of patients with COPD. However, limitations of the cross-sectional design may limit the extrapolation of the results, and more large prospective clinical cohort studies are needed in the future to further validate the association.

Preserved Ratio Impaired Spirometry in US Primary Care Patients Diagnosed with Chronic Obstructive Pulmonary Disease

Background

Preserved ratio impaired spirometry (PRISm) represents a population with spirometry results that do not meet standardized COPD obstruction criteria, yet present with high respiratory symptom burden and might benefit from respiratory management and treatment. We aimed to determine prevalence of PRISm in US primary care patients diagnosed with COPD, describe their demographic, clinical, and CT scan characteristics.

Methods

An observational registry study utilizing the US APEX COPD registry, composed of patients diagnosed with COPD aged 35+ years. Demographic and clinical data were collected from EHRs and complemented by questionnaires. Multivariable logistic regression was performed to assess whether PRISm predicts lung function decline.

Results

Prevalence of PRISm within a primary care population clinically diagnosed with COPD was 23.6% (678/2866, 95% CI 22.0-25.1). Those with PRISm were more likely female (55.9% vs 46.9%), younger (66.3±11.1 vs 69.2±10.3 years), with a greater mean BMI (33.5±9.2 vs 27.8±7.2 kg/m2), more often African American or Hispanic (37.2% vs 26.3%), and with fewer current smokers (33.1% vs 36.8%) when compared to those meeting COPD spirometry criteria (all p<0.05). Compared to COPD GOLD 0 patients, individuals with PRISm had greater BMI (33.5±9.2 vs 30.6±7.8), and were more likely current smokers (33.1% vs 23.4%), both p<0.05. Patients with PRISm had similar respiratory symptoms (chronic bronchitis, CAT, and mMRC) to overall COPD patients, but more frequently than GOLD 0 COPD patients (p<0.01). Emphysema was more commonly reported in CT scans from patients with PRISm 70.3% (260/369, 95% CI 65.8-75.3) than those with GOLD 0 COPD 64.1% (218/340, 95% CI 58.8-69.2) (p<0.05). PRISm status was not predictive of lung function decline.

Interpretation

One in four primary care patients with clinically diagnosed COPD in a large US registry fulfil the spirometric definition of PRISm rather than COPD, but suffers from emphysema in CT and significant respiratory symptoms.

The association between preserved ratio impaired spirometry (PRISm) and cognitive function among American older adults: the mediating role of systolic blood pressure

BACKGROUND

Recent studies have drawn attention to the association between preserved ratio impaired spirometry (PRISm) and cognitive function decline. High systolic blood pressure (SBP) is a known risk factor for both PRISm and dementia. This study aimed to investigate whether elevated SBP may mediate the relationship between PRISm and cognitive function in older adults.

METHODS

This study analyzed 732 participants aged ≥ 60 years who had completed spirometry and cognitive function tests in the National Health and Nutrition Examination Survey (NHANES) 2011-2012. Multivariable linear regression was employed to assess the relationship between PRISm and cognitive function, as measured through the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) Word Learning sub-test, the Animal Fluency test (AFT), the Digit Symbol Substitution test (DSST), and global cognition tests. All cognitive tests were modeled as z-scores, and global cognition was calculated as the sum of the z-scores of the CERAD, AFT, and DSST. Mediation analyses were conducted to test the mediating effect of SBP on the association between PRISm and cognitive function.

RESULTS

Participants with PRISm had lower AFT (β = -0.300; 95% confidence interval [CI] = -0.479 to -0.122; p = 0.001), DSST (β = -0.157; 95% CI = -0.309 to -0.004; p = 0.044), and global cognition scores (β = -0.211; 95% CI = -0.369 to -0.053; p = 0.009) than those with normal spirometry, after adjusting for all potential confounders. SBP was considerably associated with AFT (β = -0.084; 95% CI = -0.162 to -0.005; p = 0.038) and DSST (β = -0.132; 95% CI = -0.207 to -0.057; p < 0.001), mediating 7.9% and 18.0% of the association of PRISm with cognitive function, respectively. Furthermore, SBP mediated 17.1% of the association of PRISm with global cognition.

CONCLUSIONS

The findings suggested the potential role of SBP as a mediator of associations between PRISm and cognitive decline in older adults.

The association between preserved ratio impaired spirometry and adverse outcomes of depression and anxiety: evidence from the UK Biobank

BACKGROUND

Preserved ratio impaired spirometry (PRISm) is a new lung function impairment phenotype and has been recognized as a risk factor for various adverse outcomes. We aimed to examine the associations of this new lung function impairment phenotype with depression and anxiety in longitudinal studies.

METHODS

We included 369 597 participants from the UK Biobank cohort, and divided them into population 1 without depression or anxiety and population 2 with depression or anxiety at baseline. Cox proportional hazard models were performed to evaluate the associations of lung function impairment phenotype with adverse outcomes of depression and anxiety, as well as their subtypes.

RESULTS

At baseline, 38 879 (10.5%) participants were diagnosed with PRISm. In population 1, the adjusted hazard ratios (HRs) for PRISm (v. normal spirometry) were 1.12 (95% CI 1.07-1.18) for incident depression, and 1.11 (95% CI 1.06-1.15) for incident anxiety, respectively. In population 2, PRISm was a risk factor for mortality in participants with depression (HR: 1.46; 95% CI 1.31-1.62) and anxiety (HR: 1.70; 95% CI 1.44-2.02), compared with normal spirometry. The magnitudes of these associations were similar in the phenotypes of lung function impairment and the subtypes of mental disorders. Trajectory analysis showed that the transition from normal spirometry to PRISm was associated with a higher risk of mortality in participants with depression and anxiety.

CONCLUSIONS

PRISm and airflow obstruction have similar risks of depression and anxiety. PRISm recognition may contribute to the prevention of depression and anxiety.

A Multi-Specialty Delphi Consensus on Assessing and Managing Cardiopulmonary Risk in Patients with COPD

Background

In Canada, COPD represents a significant burden to the patient and health system, as it is often under or misdiagnosed and sub-optimally treated. Cardiovascular disease (CVD) is a common co-morbidity in COPD and there is significant interplay between these two chronic conditions. Across all stages of COPD disease severity, deaths can be attributed not only to respiratory causes but also to cardiovascular-related factors. The established links between COPD and CVD suggest the need for a greater degree of collaboration between respirologists and cardiologists. This modified Delphi consensus was initiated to consider how optimal COPD care can be delivered within Canada, with specific consideration of reducing cardiopulmonary risk and outcomes in COPD patients.

Methods

A steering group with interest in the management of COPD and CVD from primary care, cardiology, and respirology identified 40 statements formed from four key themes. A 4-point Likert scale questionnaire was sent to healthcare professionals working in COPD across Canada by an independent third party to assess agreement (consensus) with these statements. Consensus was defined as high if ≥75% and very high if ≥90% of respondents agreed with a statement.

Results

A total of 100 responses were received from respirologists (n=30), cardiologists (n=30), and primary care physicians (n=40). Consensus was very strong (≥90%) in 28 (70%) statements, strong (≥75 and <90%) in 7 (17.5%) statements and was not achieved (<75%) in 5 (12.5%) of statements.

Conclusion

Based on the consensus scores, 9 key recommendations were proposed by the steering group. These focus on the need to comprehensively risk stratify and manage COPD patients to help prevent exacerbations. Consensus within this study provides a call to action for the expeditious implementation of the latest COPD guidelines from the Canadian Thoracic Society.

An Italian Delphi Consensus on the Triple inhalation Therapy in Chronic Obstructive Pulmonary Disease

BACKGROUND

The management of chronic obstructive pulmonary disease (COPD) lacks standardization due to the diverse clinical presentation, comorbidities, and limited acceptance of recommended approaches by physicians. To address this, a multicenter study was conducted among Italian respiratory physicians to assess consensus on COPD management and pharmacological treatment.

METHODS

The study employed the Delphi process using the Estimate-Talk-Estimate method, involving a scientific board and expert panel. During a 6-month period, the scientific board conducted the first Delphi round and identified 11 broad areas of COPD management to be evaluated while the second Delphi round translated all 11 items into statements. The statements were subsequently presented to the expert panel for independent rating on a nine-point scale. Consensus was considered achieved if the median score was 7 or higher. Consistently high levels of consensus were observed in the first rating, allowing the scientific board to finalize the statements without requiring further rounds.

RESULTS

Topics generating substantial discussion included the pre-COPD phase, patient-reported outcomes, direct escalation from a single bronchodilator to triple therapy, and the role of adverse events, particularly pneumonia, in guiding triple therapy prescriptions. Notably, these topics exhibited higher standard deviations, indicating greater variation in expert opinions.

CONCLUSIONS

The study emphasized the significance that Italian pulmonologists attribute to managing mortality, tailoring treatments, and addressing cardiovascular comorbidities in COPD patients. While unanimous consensus was not achieved for all statements, the results provide valuable insights to inform clinical decision-making among physicians and contribute to a better understanding of COPD management practices in Italy.

Trend of prevalence and characteristics of preserved ratio impaired spirometry (PRISm): Nationwide population-based survey between 2010 and 2019

PURPOSE

This study aimed to evaluate the prevalence, trends, and factors of preserved ratio with impaired spirometry (PRISm) by using a nationally representative sample.

PATIENTS AND METHODS

The datasets of the Korea National Health and Nutrition Examination Survey 2010-2019 were used: of total 32,949 participants aged ≥40 and no missing data on spirometry, 24,523 with normal, 4,623 with obstructive, and 3,803 with PRISm were identified. PRISm was defined as FEV1/FVC ≥70% and FEV1% of the predicted value (%pred) <80. PRISm-lower limit of normal (LLN) was defined when FEV1/FVC ≥LLN and FEV1

RESULTS

Estimated average prevalence of PRISm was 10.4% (PRISm-LLN 11.1%). Joinpoint regression analyses found a relatively stable trend of PRISm for both fixed ratio and LLN. The multivariable-adjusted logistic regression model showed female sex, BMI ≥25 kg/m2, metabolic syndrome, hypertriglyceridemia, abdominal obesity, low HDL-choleterol, hypertension, and diabetes were associated with the increased probability of PRISm.

CONCLUSION

Whenever a PRISm pattern is identified in a clinical context, it may be necessary to measure absolute lung volumes to investigate underlying physiological abnormalities and to identify factors that is modifiable.

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Key Words Collapse

MESH Headings

• Humans
• Spirometry
• Female
• Male
• Middle Aged
• Prevalence
• Republic of Korea/epidemiology
• Adult
• Aged
• Nutrition Surveys
• Forced Expiratory Volume
• Pulmonary Disease, Chronic Obstructive/epidemiology
• Pulmonary Disease, Chronic Obstructive/physiopathology
• Pulmonary Disease, Chronic Obstructive/diagnosis

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Grants

• Ministry of Health and Welfare
• Korean Health Industry Development Institute

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Affiliation(s)

Hyunji Choi Department of Laboratory Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Republic of Korea
Chul-Ho Oak Division of Pulmonology, Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Republic of Korea
Mann-Hong Jung Division of Pulmonology, Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Republic of Korea
Tae-Won Jang Division of Pulmonology, Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Republic of Korea
Sung-Jin Nam Division of Pulmonology, Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Republic of Korea
Taemin Yoon Center for Future Medicine, Kosin University Gospel Hospital, Busan, Republic of Korea

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Collaborators Collapse

Association of preserved ratio impaired spirometry with mortality and cardiovascular diseases: a systematic review and meta-analysis

BACKGROUND

Preserved ratio impaired spirometry (PRISm) is a type of abnormal lung function. PRISm and mortality have been explored in several studies, but a comprehensive evaluation of the associations is limited. The current study aims to conduct a systematic review and meta-analysis in order to investigate the mortality and cardiovascular diseases in patients with PRISm.

METHODS

PubMed, Embase, and Web of Science databases, as well as gray literature sources, were searched for relevant studies published up to 7 September 2023 without language restrictions. This review included all published observational cohort studies that investigated the association of PRISm with mortality in the general population, as well as subgroup analyses in smokers and pre-bronchodilation spirometry studies. The outcomes of interest were all-cause mortality, cardiovascular mortality, and respiratory-related mortality. The Newcastle-Ottawa scale assessed study quality. Sensitivity and subgroup analyses explored heterogeneity and robustness. Publication bias was assessed with Egger's and Begg's tests.

RESULTS

Overall, eight studies were included in this meta-analysis. The pooled HR was 1.60 (95% CI, 1.48-1.74) for all-cause mortality, 1.68 (95% CI, 1.46-1.94) for CVD mortality, and 3.09 (95% CI, 1.42-6.71) for respiratory-related mortality in PRISm group compared to normal group. In the subgroup analysis, participants with PRISm had a higher effect (HR, 2.11; 95% CI, 1.74-2.54) on all-cause mortality among smokers relative to participants with normal spirometry. Furthermore, the association between PRISm and mortality risk was consistent across several sensitivity analyses.

CONCLUSIONS

People with PRISm were associated with an increased risk of all-cause mortality, CVD mortality, and respiratory-related mortality as compared to those with normal lung function in the general population.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023426872.

Implications of Cardiopulmonary Risk for the Management of COPD: A Narrative Review

Chronic obstructive pulmonary disease (COPD) constitutes a major global health burden and is the third leading cause of death worldwide. A high proportion of patients with COPD have cardiovascular disease, but there is also evidence that COPD is a risk factor for adverse outcomes in cardiovascular disease. Patients with COPD frequently die of respiratory and cardiovascular causes, yet the identification and management of cardiopulmonary risk remain suboptimal owing to limited awareness and clinical intervention. Acute exacerbations punctuate the progression of COPD in many patients, reducing lung function and increasing the risk of subsequent exacerbations and cardiovascular events that may lead to early death. This narrative review defines and summarises the principles of COPD-associated cardiopulmonary risk, and examines respiratory interventions currently available to modify this risk, as well as providing expert opinion on future approaches to addressing cardiopulmonary risk.

Physiological Characterization of Preserved Ratio Impaired Spirometry in the CanCOLD Study: Implications for Exertional Dyspnea and Exercise Intolerance

Rationale: It is increasingly recognized that adults with preserved ratio impaired spirometry (PRISm) are prone to increased morbidity. However, the underlying pathophysiological mechanisms are unknown. Objectives: Evaluate the mechanisms of increased dyspnea and reduced exercise capacity in PRISm. Methods: We completed a cross-sectional analysis of the CanCOLD (Canadian Cohort Obstructive Lung Disease) population-based study. We compared physiological responses in 59 participants meeting PRISm spirometric criteria (post-bronchodilator FEV1 < 80% predicted and FEV1/FVC ⩾ 0.7), 264 control participants, and 170 ever-smokers with chronic obstructive pulmonary disease (COPD), at rest and during cardiopulmonary exercise testing. Measurements and Main Results: Individuals with PRISm had lower total lung, vital, and inspiratory capacities than healthy controls (all P < 0.05) and minimal small airway, pulmonary gas exchange, and radiographic parenchymal lung abnormalities. Compared with healthy controls, individuals with PRISm had higher dyspnea/[Formula: see text]o2 ratio at peak exercise (4.0 ± 2.2 vs. 2.9 ± 1.9 Borg units/L/min; P < 0.001) and lower [Formula: see text]o2peak (74 ± 22% predicted vs. 96 ± 25% predicted; P < 0.001). At standardized submaximal work rates, individuals with PRISm had greater Vt/inspiratory capacity (Vt%IC; P < 0.001), reflecting inspiratory mechanical constraint. In contrast to participants with PRISm, those with COPD had characteristic small airways dysfunction, dynamic hyperinflation, and pulmonary gas exchange abnormalities. Despite these physiological differences among the three groups, the relationship between increasing dyspnea and Vt%IC during cardiopulmonary exercise testing was similar. Resting IC significantly correlated with [Formula: see text]o2peak (r = 0.65; P < 0.001) in the entire sample, even after adjusting for airflow limitation, gas trapping, and diffusing capacity. Conclusions: In individuals with PRISm, lower exercise capacity and higher exertional dyspnea than healthy controls were mainly explained by lower resting lung volumes and earlier onset of dynamic inspiratory mechanical constraints at relatively low work rates. Clinical trial registered with www.clinicaltrials.gov (NCT00920348).

Budesonide/Glycopyrrolate/Formoterol for the Management of COPD in a UK Primary Care Population: Real-World Use and Early Medication Success

Purpose

Real-life research is needed to evaluate the effectiveness of budesonide/glycopyrrolate/formoterol (BGF) in routine COPD primary care management. We assessed the frequency of medication success among patients with COPD who initiated BGF using real-world data.

Patients and Methods

Patients with a recorded diagnostic COPD code who started BGF with ≥2 prescriptions within 90-days were identified in the UK Optimum Patient Care Research Database and followed from first prescription until censoring at the end of follow-up (180-days), death, leaving database or end of data at 24/10/2022. The primary outcome was medication success at 90-days post-BGF initiation, defined as no major cardiac or respiratory event (ie no complicated COPD exacerbation, hospitalization for any respiratory event, myocardial infarction, new/hospitalized heart failure, and death) and no incidence of pneumonia. Medication success was also assessed at 180-days post-BGF initiation. Overall real-life medication success was claimed if the lower 95% confidence interval (CI) for the proportion of patients meeting the primary outcome was ≥70% (defined a priori).

Results

Two hundred eighty-five patients were included. Prior to BGF initiation, these patients often had severe airflow obstruction (mean ppFEV1: 54.5%), were highly symptomatic (mMRC ≥2: 77.9% (n = 205/263); mean CAT score: 21.7 (SD 7.8)), with evidence of short-acting β2-agonist (SABA) over-use (≥3 inhalers/year: 62.1%, n=179/285), repeat OCS prescriptions (≥2 courses/year: 33.0%, n = 95/285) and multiple primary care consultations (≥2 visits/year: 61.1%, n = 174/285). Overall, 39.6% of patients (n = 113/285) switched from previous triple therapies. Real-life medication success was achieved by 96.5% of patients (n = 275/285 [95% CI: 93.6, 98.3]) during 90-days treatment with BGF and by 91.8% (n = 169/184 [95% CI: 86.9, 95.4]) of patients at 180-days. The prescribed daily dose of SABA remained stable over the study period.

Conclusion

The majority of patients initiating BGF experienced real-life medication success reflecting the absence of severe cardiopulmonary events. These benefits were apparent after 90-days of treatment and sustained over 180-days.

Differences in cardiovascular risk and health-related quality of life in COPD patients according to clinical phenotype

Chronic obstructive pulmonary disease (COPD) has a high prevalence and a major impact on health-related quality of life (HRQL). COPD exacerbations are an important cause of morbidity and mortality, affecting cardiovascular risk, and are associated with poorer health status. The aim of this study was to assess the association between cardiovascular risk (CVR) and HRQL, according to exacerbator or non-exacerbator phenotype. We undertook a cross-sectional, observational, descriptive study of 107 patients with COPD. Patients with two or more moderate exacerbations or one severe exacerbation in the previous year were considered as exacerbators. The CVR was calculated with the Framingham scale and SCORE (Systematic Coronary Risk Evaluation) and the HRQL was assessed with the generic questionnaire Short Form-36 Health Survey (SF-36), the St George Respiratory Questionnaire (SGRQ) and the COPD Assessment Test (CAT). Statistical analysis was done with SPSS version 26.0 for Windows. The SF-36 and the SGRQ showed lower values for the exacerbator phenotype, indicating a poorer quality of life. The CAT questionnaire showed values above 10 for the exacerbator phenotype, and lower values in the non-exacerbator group. After categorizing the sample according to their median age (65 years), we found a greater deterioration in HRQL in patients under 65 years of age according to the SF-36, the SGRQ and the CAT. We also detected differences in HRQL between non-exacerbator patients with a high CVR according to the Framingham (≥ 20%) and SCORE (≥ 5%) scales compared to those without this risk. A tendency towards worse HRQL was observed in non-exacerbator patients with a high CVR, which was statistically significant for the SGRQ impact domain on the SCORE scale. The CAT also showed a worse quality of life in non-exacerbator patients with a high CVR, which was significant in the Framingham model (Framingham high risk 8.41 vs non-high risk 6.05, p < 0.01). These differences were not observed in exacerbator patients. Our findings confirm that a high CVR influences HRQL in patients with COPD, especially in non-exacerbator patients with a high CVR, measured according to the SGRQ and the CAT.

Impact of preserved ratio impaired spirometry on coronary artery calcium score progression: a longitudinal cohort study

Background

Preserved ratio impaired spirometry (PRISm) is associated with increased cardiovascular disease (CVD) risk and mortality. However, a causal relationship between PRISm and CVD remains unclear. We investigated the progression of coronary artery calcium (CAC) scores based on the presence of PRISm and reduced forced vital capacity (FVC).

Methods

This retrospective cohort study included 11 420 participants aged ≥40 years with forced expiratory volume in 1 s (FEV1)/FVC ≥0.7 who underwent at least two health screening examinations with coronary computed tomography scan between 2003 and 2020, and were without a history of CVD or interstitial lung disease. Participants with PRISm, defined as FEV1/FVC ≥0.7 and FEV1 <80% predicted, were further divided by low FVC (FVC <80% predicted). We estimated the 5-year progression rates of CAC by comparing participants with and without PRISm at baseline using mixed linear models.

Results

Of the 11 420 participants, 8536 (75%), 811 (7%) and 2073 (18%) had normal spirometry, PRISm with normal FVC and PRISm with low FVC, respectively. During the mean (range) follow-up of 6.0 (0.5-17.2) years, the multivariable adjusted ratio of 5-year CAC progression rates comparing participants with PRISm to those with normal spirometry was 1.08 (95% CI 1.04-1.13). This rate was higher in participants with PRISm with low FVC (1.21 (95% CI 1.12-1.30)) than in those with normal FVC.

Conclusion

In this longitudinal cohort study of subjects without a history of CVD, PRISm was significantly associated with CAC progression, which was more evident in the group with PRISm and low FVC.

Association of preserved ratio impaired spirometry with mortality: a systematic review and meta-analysis

BACKGROUND

Preserved ratio impaired spirometry (PRISm) is prevalent within the general population. Increased mortality has been reported among subjects with PRISm, but the evidence has never been summarised. This systematic review aims to synthesise evidence on the association between PRISm and the risk of all-cause, cardiovascular and respiratory-related mortality.

METHODS

We systematically searched MEDLINE, Embase and Web of Science for population-based cohort studies from inception to April 2023 using the terms related to impaired spirometry and mortality. Titles and abstracts were screened to identify eligible studies that reported mortality estimates for individuals with PRISm. We excluded studies that adopted other definitions of impaired spirometry, had a specific study setting (e.g. HIV patients), had an insufficient follow-up period (<1 year) or reported duplicated data. Random-effects meta-analysis was used to produce pooled hazard ratio (HR) with 95% confidence intervals. Between-study heterogeneity was assessed with I2.

RESULTS

Eight studies met the inclusion criteria involving 40 699 individuals with PRISm. All included studies reported increased risk of all-cause mortality among adults with PRISm. Meta-analysis showed that PRISm was associated with an increased risk of all-cause mortality (pooled HR 1.71, 95% CI 1.51-1.93; I2=64%), cardiovascular mortality (pooled HR 1.57, 95% CI 1.44-1.72; I2=35%) and respiratory-related mortality (pooled HR 1.97, 95% CI 1.55-2.49; I2=0%).

CONCLUSIONS

Individuals with PRISm have a significantly increased risk of mortality compared with those with normal spirometry.