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Original research
Comparison of five major airflow limitation criteria to identify high-risk individuals with COPD: a contemporary population-based cohort
  1. Yunus Çolak1,2,3,
  2. Børge G Nordestgaard1,2,3,
  3. Jørgen Vestbo4,
  4. Peter Lange2,3,5,6,
  5. Shoaib Afzal1,2,3
  1. 1 Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
  2. 2 The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
  3. 3 Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
  4. 4 Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Manchester Academic Health Science Centre, University of Manchester, and Manchester University NHS Foundation Trust, Manchester, UK
  5. 5 Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark
  6. 6 Department of Internal Medicine, Section of Respiratory Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
  1. Correspondence to Dr Shoaib Afzal, Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark; shoaib.afzal{at}


Background Different airflow limitation criteria are often used to diagnose COPD. We investigated head-to-head whether Global Initiative for Chronic Obstructive Lung Disease (GOLD) (FEV1/FVC <0.70) and four lower limit of normal (LLN) (FEV1/FVC <LLN) criteria to diagnose airflow limitation differ in identifying individuals at risk of COPD exacerbations and mortality.

Methods 108 246 individuals aged 20–100 years randomly selected from the general population were followed from 2003 through 2018 to determine risk of COPD exacerbations, respiratory mortality and all-cause mortality. LLN criteria used equations from Global Lung Initiative (GLI), National Health and Nutrition Examination Survey (NHANES), European Community for Steel and Coal (ECSC) and Copenhagen City Heart Study (CCHS)/Copenhagen General Population Study (CGPS).

Results Prevalence of airflow limitation was 17% for GOLD, 8.6% for GLI, 10% for NHANES, 8.2% for ECSC and 14% for CCHS/CGPS. During 14.4 years follow-up, we observed 2745 COPD exacerbations, 762 respiratory deaths and 10 338 all-cause deaths. Comparing individuals with versus without airflow limitation, HRs for COPD exacerbations were 17 (95% CI 14 to 20) for GOLD, 21 (18 to 24) for GLI, 20 (17 to 23) for NHANES, 21 (18 to 24) for ECSC and 18 (16 to 21) for CCHS/CGPS. Corresponding HRs for respiratory mortality were 3.7 (3.1 to 4.3), 6.4 (5.6 to 7.5), 5.7 (4.9 to 6.6), 6.2 (5.3 to 7.2) and 4.5 (3.9 to 5.2), and for all-cause mortality 1.5 (1.4 to 1.5), 1.9 (1.8 to 2.0), 1.8 (1.7 to 1.9), 1.9 (1.8 to 2.0) and 1.7 (1.6 to 1.7), respectively. Differences in Harrell’s C were minute for these outcomes; nonetheless, Harrell’s C was slightly higher for LLN criteria compared with GOLD for mortality outcomes.

Conclusions The prevalence of airflow limitation ranged from 8% to 17% using GOLD and four different LLN criteria; however, identified individuals with the five different criteria had similar risk of COPD exacerbations and mortality.

  • COPD epidemiology
  • clinical epidemiology
  • COPD exacerbations

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  • Contributors YÇ and SA had full access to all data in the study and had final responsibility for the decision to submit for publication. YÇ, BGN, JV, PL and SA contributed to the study concept and design. YÇ, BGN, JV, PL and SA collected, analysed or interpreted the data. YÇ did the statistical analyses and wrote the draft manuscript. YÇ, BGN, JV, PL and SA revised the manuscript for important intellectual content. BGN obtained funding. BGN provided administrative, technical or material support. BGN and SA supervised the study. All authors have read and approved the final manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding The Lundbeck Foundation. The funder had no role in the design and conduct of the study; collection, management, analysis or interpretation of the data; preparation, review or approval of the manuscript; or decision to submit the manuscript for publication. JV is supported by the NIHR Manchester Biomedical Research Centre.

  • Competing interests YÇ reports personal fees from AstraZeneca, Boehringer Ingelheim and Sanofi Genzyme outside of the submitted work. JV reports personal fees from GlaxoSmithKline, Chiesi Pharmaceuticals, Boehringer Ingelheim, Novartis and AstraZeneca, outside of the submitted work. PL reports grants from AstraZeneca and GlaxoSmithKline and personal fees from Boehringer Ingelheim, AstraZeneca, Novartis and GlaxoSmithKline outside of the submitted work. BGN and SA have nothing to disclose.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by Herlev and Gentofte Hospital and a regional ethics committee (approval number: H-KF-01-144/01) and was conducted according to the Declaration of Helsinki.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Summarised data and scripts for analyses are available according Danish law.