Association Between Preserved Ratio Impaired Spirometry and Clinical Outcomes in US Adults
Authors: Emily S. Wan, Pallavi Balte, Joseph E. Schwartz, Surya P. Bhatt, Patricia A. Cassano, David Couper, Martha L. Daviglus, Mark T. Dransfield, Sina A. Gharib, David R. Jacobs, Ravi Kalhan, Stephanie J. London, Ana Navas-Acien, George T. O’Connor, Jason L. Sanders, Benjamin M. Smith, Wendy White, Sachin Yende, Elizabeth C. Oelsner
Journal: JAMA (2021)

<h3>Importance</h3> Chronic lung diseases are a leading cause of morbidity and mortality. Unlike chronic obstructive pulmonary disease, clinical outcomes associated with proportional reductions in expiratory lung volumes without obstruction, otherwise known as preserved ratio impaired spirometry (PRISm), are poorly understood. <h3>Objective</h3> To examine the prevalence, correlates, and clinical outcomes associated with PRISm in US adults. <h3>Design, Setting, and Participants</h3> The National Heart, Lung, and Blood Institute (NHLBI) Pooled Cohorts Study was a retrospective study with harmonized pooled data from 9 US general population-based cohorts (enrollment, 65 251 participants aged 18 to 102 years of whom 53 701 participants had valid baseline lung function) conducted from 1971-2011 (final follow-up, December 2018). <h3>Exposures</h3> Participants were categorized into mutually exclusive groups by baseline lung function. PRISm was defined as the ratio of forced expiratory volume in the first second to forced vital capacity (FEV<sub>1</sub>:FVC) greater than or equal to 0.70 and FEV<sub>1</sub>less than 80% predicted; obstructive spirometry FEV<sub>1</sub>:FVC ratio of less than 0.70; and normal spirometry FEV<sub>1</sub>:FVC ratio greater than or equal to 0.7 and FEV<sub>1</sub>greater than or equal to 80% predicted. <h3>Main Outcomes and Measures</h3> Main outcomes were all-cause mortality, respiratory-related mortality, coronary heart disease (CHD)–related mortality, respiratory-related events (hospitalizations and mortality), and CHD-related events (hospitalizations and mortality) classified by adjudication or validated administrative criteria. Absolute risks were adjusted for age and smoking status. Poisson and Cox proportional hazards models comparing PRISm vs normal spirometry were adjusted for age, sex, race and ethnicity, education, body mass index, smoking status, cohort, and comorbidities. <h3>Results</h3> Among all participants (mean [SD] age, 53.2 [15.8] years, 56.4% women, 48.5% never-smokers), 4582 (8.5%) had PRISm. The presence of PRISm relative to normal spirometry was significantly associated with obesity (prevalence, 48.3% vs 31.4%; prevalence ratio [PR], 1.68 [95% CI, 1.55-1.82]), underweight (prevalence, 1.4% vs 1.0%; PR, 2.20 [95% CI, 1.72-2.82]), female sex (prevalence, 60.3% vs 59.0%; PR, 1.07 [95% CI, 1.01-1.13]), and current smoking (prevalence, 25.2% vs 17.5%; PR, 1.33 [95% CI, 1.22-1.45]). PRISm, compared with normal spirometry, was significantly associated with greater all-cause mortality (29.6/1000 person-years vs 18.0/1000 person-years; difference, 11.6/1000 person-years [95% CI, 10.0-13.1]; adjusted hazard ratio [HR], 1.50 [95% CI, 1.42-1.59]), respiratory-related mortality (2.1/1000 person-years vs 1.0/1000 person-years; difference, 1.1/1000 person-years [95% CI, 0.7-1.6]; adjusted HR, 1.95 [95% CI, 1.54-2.48]), CHD-related mortality (5.4/1000 person-years vs 2.6/1000 person-years; difference, 2.7/1000 person-years [95% CI, 2.1-3.4]; adjusted HR, 1.55 [95% CI, 1.36-1.77]), respiratory-related events (12.2/1000 person-years vs 6.0/1000 person-years; difference, 6.2/1000 person-years [95% CI, 4.9-7.5]; adjusted HR, 1.90 [95% CI, 1.69-2.14]), and CHD-related events (11.7/1000 person-years vs 7.0/1000 person-years; difference, 4.7/1000 person-years [95% CI, 3.7-5.8]; adjusted HR, 1.30 [95% CI, 1.18-1.42]). <h3>Conclusions and Relevance</h3> In a large, population-based sample of US adults, baseline PRISm, compared with normal spirometry, was associated with a small but statistically significant increased risk for mortality and adverse cardiovascular and respiratory outcomes. Further research is needed to explore whether this association is causal.