Risk Factors, Morbidity, and Mortality in Association With Preserved Ratio Impaired Spirometry and Restrictive Spirometric Pattern: Clinical Relevance of Preserved Ratio Impaired Spirometry and Restrictive Spirometric Pattern.

Background: Preserved ratio impaired spirometry (PRISm) and restrictive spirometric pattern (RSP) are often considered interchangeable in identifying restrictive impairment in spirometry.
Research Question: Do PRISm and RSP have different individual associations with risk factors, morbidity, and mortality?
Study Design and Methods: In a cross-sectional and longitudinal study, including 26,091 Norwegian general population men (30 to 46 years of age), we explored the association of PRISm and RSP with smoking habits, BMI, education, respiratory symptoms, self-reported cardiopulmonary disease, and mortality after 26 years of follow-up. PRISm was defined as FEV ₁ /FVC ≥ lower limit of normal (LLN) and FEV ₁  < LLN, and RSP was defined as FEV ₁ /FVC ≥ LLN and FVC < LLN. We compared the associations of PRISm and RSP to airflow obstruction and normal spirometry, both as mutually (PRISm alone, RSP alone) and nonmutually exclusive (PRISm, RSP) categories, adjusting for age, BMI, smoking, and education. We also conducted sensitivity analyses using Global Initiative for Chronic Obstructive Lung Disease criteria to define spirometric abnormalities.
Results: The prevalence of the mutually exclusive spirometric patterns was as follows: normal 82.4%, obstruction 11.0%, PRISm alone 1.4%, RSP alone 1.7%, and PRISm + RSP 3.5%. PRISm alone patients were frequently obese (11.2%), had active or previous tobacco use, commonly reporting cough, phlegm, wheeze, asthma, and bronchitis. RSP alone patients were both obese (14.6%) and underweight (2.9%), with increased breathlessness, but similar smoking habits to patients with normal spirometry. The prevalence of heart disease was 4.6% in PRISm alone, 2.7% in RSP alone, and 1.6% in obstruction. With normal spirometry as a reference, RSP alone had increased all-cause (hazard ratio [HR], 1.57; 95% CI, 1.21-2.04), cardiovascular (HR, 1.48; 95% CI, 0.88-2.48), diabetes (HR, 6.43; 95% CI, 1.88-21.97), and cancer (excluding lung) mortality (HR, 1.51; 95% CI, 0.95-2.42). PRISm alone had increased respiratory disease mortality (HR, 4.00; 95% CI, 1.22-13.16). Patients with PRISm + RSP had intermediate characteristics and the worst prognosis. Findings were overall confirmed with nonmutually exclusive categories and Global Initiative for Chronic Obstructive Lung Disease criteria.
Interpretation: PRISm and RSP are spirometric patterns with distinct risk factors, morbidity, and mortality, which should be differentiated in future studies.
Competing Interests: Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: L. C. and R. N. report funding from AstraZeneca, outside the submitted work. K. S. reports fees from UCB Pharma and MSD, outside the submitted work. None declared (A. J., A. G.).
(Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)