MyLinh Duong1, Shofiqul Islam2, Sumathy Rangarajan2, Darryl Leong2, Om Kurmi2, Koon Teo2, Kieran Killian2, Gilles Dagenais3, Scott Lear4, Andreas Wielgosz5, Sanjeev Nair6, Viswanathan Mohan7, Prem Mony8, Rajeev Gupta9, Rajesh Kumar10, Omar Rahman11, Khalid Yusoff12, Johannes Lodewykus du Plessis13, Ehimario U Igumbor14, Jephat Chifamba15, Wei Li16, Yin Lu16, Fumin Zhi16, Ruohua Yan16, Romaina Iqbal17, Noorhassim Ismail18, Katarzyna Zatonska19, Kubilay Karsidag20, Annika Rosengren21, Ahmad Bahonar22, Afazalhussein Yusufali23, Pablo M Lamelas24, Alvaro Avezum25, Patricio Lopez-Jaramillo26, Fernando Lanas27, Paul M O'Byrne2, Salim Yusuf2. 1. Population Health Research Institute, Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; The Research Institute of St Joe's Hamilton, McMaster University, Hamilton, ON, Canada. Electronic address: duongmy@mcmaster.ca. 2. Population Health Research Institute, Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada. 3. Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada. 4. Faculty of Health Sciences and Department of Biomedical Physiology & Kinesiology, Simon Fraser University, Vancouver, BC, Canada. 5. Department of Medicine, University of Ottawa, Ottawa, ON, Canada. 6. Department of Pulmonary Medicine, Medical College, Thiruvananthapuram, Kerala, India; Health Action by People, Thiruvananthapuram, Kerala, India. 7. Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India. 8. Community Health & Epidemiology, St John's Research Institute, Bangalore, Karnataka, India. 9. Eternal Heart Care Centre and Research Institute, Jaipur, Rajasthan, India. 10. Post Graduate Institute of Medical Education and Research (PGIMER), School of Public Health, Chandigarh, India. 11. Department of Community Medicine and School of Public Health, Independent University, Dhaka, Bangladesh. 12. Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia; University College Sedaya International (UCSI), Cheras, Kuala Lumpur, Malaysia. 13. Occupational Hygiene and Health Research Initiative, North-West University, Potchefstroom, North West Province, South Africa. 14. School of Public Health, University of the Western Cape, Cape Town, South Africa. 15. Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe. 16. State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China. 17. Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Sindh, Pakistan. 18. Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia. 19. Department of Social Medicine, Medical University of Wroclaw, Wroclaw, Poland. 20. Division of Endocrinology, Department of Internal Medicine, Medical Faculty of Istanbul University, Istanbul, Turkey. 21. Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital, Östra, Göteborg, Sweden. 22. Hypertension Research Centre, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran. 23. Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates. 24. Estudios Clinicos Latinoamerica (ECLA), Rosario, Santa Fe, Argentina. 25. Dante Pazzanese Institute of Cardiology, São Paulo, São Paulo, Brazil. 26. Fundacion Oftalmologica de Santander (FOSCAL), Floridablanca, Santander, Colombia. 27. University of La Frontera, Temuco, Chile.
Abstract
BACKGROUND: The associations between the extent of forced expiratory volume in 1 s (FEV1) impairment and mortality, incident cardiovascular disease, and respiratory hospitalisations are unclear, and how these associations might vary across populations is unknown. METHODS: In this international, community-based cohort study, we prospectively enrolled adults aged 35-70 years who had no intention of moving residences for 4 years from rural and urban communities across 17 countries. A portable spirometer was used to assess FEV1. FEV1 values were standardised within countries for height, age, and sex, and expressed as a percentage of the country-specific predicted FEV1 value (FEV1%). FEV1% was categorised as no impairment (FEV1% ≥0 SD from country-specific mean), mild impairment (FEV1% <0 SD to -1 SD), moderate impairment (FEV1% <-1 SD to -2 SDs), and severe impairment (FEV1% <-2 SDs [ie, clinically abnormal range]). Follow-up was done every 3 years to collect information on mortality, cardiovascular disease outcomes (including myocardial infarction, stroke, sudden death, or congestive heart failure), and respiratory hospitalisations (from chronic obstructive pulmonary disease, asthma, pneumonia, tuberculosis, or other pulmonary conditions). Fully adjusted hazard ratios (HRs) were calculated by multilevel Cox regression. FINDINGS: Among 126 359 adults with acceptable spirometry data available, during a median 7·8 years (IQR 5·6-9·5) of follow-up, 5488 (4·3%) deaths, 5734 (4·5%) cardiovascular disease events, and 1948 (1·5%) respiratory hospitalisation events occurred. Relative to the no impairment group, mild to severe FEV1% impairments were associated with graded increases in mortality (HR 1·27 [95% CI 1·18-1·36] for mild, 1·74 [1·60-1·90] for moderate, and 2·54 [2·26-2·86] for severe impairment), cardiovascular disease (1·18 [1·10-1·26], 1·39 [1·28-1·51], 2·02 [1·75-2·32]), and respiratory hospitalisation (1·39 [1·24-1·56], 2·02 [1·75-2·32], 2·97 [2·45-3·60]), and this pattern persisted in subgroup analyses considering country income level and various baseline risk factors. Population-attributable risk for mortality (adjusted for age, sex, and country income) from mildly to moderately reduced FEV1% (24·7% [22·2-27·2]) was larger than that from severely reduced FEV1% (3·7% [2·1-5·2]) and from tobacco use (19·7% [17·2-22·3]), previous cardiovascular disease (5·5% [4·5-6·5]), and hypertension (17·1% [14·6-19·6]). Population-attributable risk for cardiovascular disease from mildly to moderately reduced FEV1 was 17·3% (14·8-19·7), second only to the contribution of hypertension (30·1% [27·6-32·5]). INTERPRETATION: FEV1 is an independent and generalisable predictor of mortality, cardiovascular disease, and respiratory hospitalisation, even across the clinically normal range (mild to moderate impairment). FUNDING: Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Ontario Ministry of Health and Long-Term Care, AstraZeneca, Sanofi-Aventis, Boehringer Ingelheim, Servier, and GlaxoSmithKline, Novartis, and King Pharma. Additional funders are listed in the appendix.
BACKGROUND: The associations between the extent of forced expiratory volume in 1 s (FEV1) impairment and mortality, incident cardiovascular disease, and respiratory hospitalisations are unclear, and how these associations might vary across populations is unknown. METHODS: In this international, community-based cohort study, we prospectively enrolled adults aged 35-70 years who had no intention of moving residences for 4 years from rural and urban communities across 17 countries. A portable spirometer was used to assess FEV1. FEV1 values were standardised within countries for height, age, and sex, and expressed as a percentage of the country-specific predicted FEV1 value (FEV1%). FEV1% was categorised as no impairment (FEV1% ≥0 SD from country-specific mean), mild impairment (FEV1% <0 SD to -1 SD), moderate impairment (FEV1% <-1 SD to -2 SDs), and severe impairment (FEV1% <-2 SDs [ie, clinically abnormal range]). Follow-up was done every 3 years to collect information on mortality, cardiovascular disease outcomes (including myocardial infarction, stroke, sudden death, or congestive heart failure), and respiratory hospitalisations (from chronic obstructive pulmonary disease, asthma, pneumonia, tuberculosis, or other pulmonary conditions). Fully adjusted hazard ratios (HRs) were calculated by multilevel Cox regression. FINDINGS: Among 126 359 adults with acceptable spirometry data available, during a median 7·8 years (IQR 5·6-9·5) of follow-up, 5488 (4·3%) deaths, 5734 (4·5%) cardiovascular disease events, and 1948 (1·5%) respiratory hospitalisation events occurred. Relative to the no impairment group, mild to severe FEV1% impairments were associated with graded increases in mortality (HR 1·27 [95% CI 1·18-1·36] for mild, 1·74 [1·60-1·90] for moderate, and 2·54 [2·26-2·86] for severe impairment), cardiovascular disease (1·18 [1·10-1·26], 1·39 [1·28-1·51], 2·02 [1·75-2·32]), and respiratory hospitalisation (1·39 [1·24-1·56], 2·02 [1·75-2·32], 2·97 [2·45-3·60]), and this pattern persisted in subgroup analyses considering country income level and various baseline risk factors. Population-attributable risk for mortality (adjusted for age, sex, and country income) from mildly to moderately reduced FEV1% (24·7% [22·2-27·2]) was larger than that from severely reduced FEV1% (3·7% [2·1-5·2]) and from tobacco use (19·7% [17·2-22·3]), previous cardiovascular disease (5·5% [4·5-6·5]), and hypertension (17·1% [14·6-19·6]). Population-attributable risk for cardiovascular disease from mildly to moderately reduced FEV1 was 17·3% (14·8-19·7), second only to the contribution of hypertension (30·1% [27·6-32·5]). INTERPRETATION: FEV1 is an independent and generalisable predictor of mortality, cardiovascular disease, and respiratory hospitalisation, even across the clinically normal range (mild to moderate impairment). FUNDING: Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Ontario Ministry of Health and Long-Term Care, AstraZeneca, Sanofi-Aventis, Boehringer Ingelheim, Servier, and GlaxoSmithKline, Novartis, and King Pharma. Additional funders are listed in the appendix.
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