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Correspondence |

COPD and GOLD Stage IAbout COPD and GOLD Stage I FREE TO VIEW

Philip H. Quanjer; Tim J. Cole, ScD
Author and Funding Information

From the Department of Pulmonary Diseases and Department of Paediatrics (Dr Quanjer), Erasmus Medical Centre, Erasmus University; and MRC Centre of Epidemiology for Child Health (Dr Cole), UCL Institute of Child Health.

Correspondence to: Philip H. Quanjer, MD, PhD, Kervel 19, 7443 GT, Nijverdal, The Netherlands; e-mail: pquanjer@xs4all.nl


Financial/nonfinancial disclosure: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2012 American College of Chest Physicians


Chest. 2012;141(4):1122. doi:10.1378/chest.11-2840
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Published online

To the Editor:

An abnormally low FEV1/FVC ratio is universally accepted as indicative of obstructive lung disease. Clearly, the choice of cutoff to define abnormality is important. The GOLD (Global Initiative for Chronic Obstructive Lung Disease) group set the lower limit of normal (LLN) at 0.7 irrespective of age, defining GOLD COPD stage I as FEV1/FVC below 0.7 and FEV1 above 80% predicted.1 In a recent issue of CHEST (January 2012), Mannino and Diaz-Guzman2 argue that patients in GOLD stage I are at increased risk of premature death from respiratory causes.

As shown in many publications, the 0.7 cutoff is too simplistic. After age 45, the LLN based on the fifth centile of the FEV1/FVC ratio falls progressively below 0.7, meaning that the 0.7 cutoff identifies many older patients above the LLN as false positives. Several studies have tried to validate GOLD stage I for identifying obstructive lung disease:

  • In asymptomatic subjects, it was neither associated with premature death3,4 nor with an abnormal decline in FEV1, respiratory care use, or quality of life compared with a reference group.5

  • It was not associated with premature death or respiratory symptoms.6

  • The adjusted hazard ratio for premature death was not significant.7

  • Now, Mannino and Diaz-Guzman2 state that subjects in GOLD stage I who are above the LLN are at increased risk of premature death from respiratory causes. They fail to present adjusted hazard ratios for respiratory death. Hence, their conclusion lacks evidence; it also contradicts a previous study where the same analysis was done on the same data.6

Thus, there is no evidence to support the use of GOLD stage I. Conversely, there is considerable evidence in favor of the LLN:

  • Only GOLD stage I with FEV1/FVC below the LLN was associated with increased risk of death.6,7

  • The use of the LLN for both FEV1/FVC and FEV1, rather than a fixed ratio and 80% predicted, identified persons with an increased risk of death and prevalence of respiratory symptoms.8

  • “After correction for potential confounders, only severe COPD as defined by the BTS [British Thoracic Society] criteria was still associated with mortality.”9

We conclude that GOLD stage I is not associated with respiratory disease or death from respiratory causes unless FEV1/FVC is below the LLN. Incorrectly labeling subjects as having COPD by the GOLD criteria has detrimental consequences for the individual and family: It incurs high costs for society, and it hampers research into the causes of COPD and its treatment. The mystery is why the GOLD group continues to encourage its use.

Global Initiative for Chronic Obstructive Lung DiseaseGlobal Initiative for Chronic Obstructive Lung Disease Global strategy for the diagnosis, management and prevention of chronic obstructive lung disease. GOLD Web site.http://www.goldcopd.com. Accessed November 2, 2010.
 
Mannino DM, Diaz-Guzman E. Interpreting lung function data using 80% predicted and fixed thresholds identifies patients at increased risk of mortality. Chest. 2012;1411:73-80 [CrossRef] [PubMed]
 
Mannino DM, Doherty DE, Sonia Buist A. Global Initiative on Obstructive Lung Disease (GOLD) classification of lung disease and mortality: findings from the Atherosclerosis Risk in Communities (ARIC) study. Respir Med. 2006;1001:115-122 [CrossRef] [PubMed]
 
Ekberg-Aronsson M, Pehrsson K, Nilsson JA, Nilsson PM, Löfdahl CG. Mortality in GOLD stages of COPD and its dependence on symptoms of chronic bronchitis. Respir Res. 2005;6:98 [CrossRef] [PubMed]
 
Bridevaux P-O, Gerbase MW, Probst-Hensch NM, Schindler C, Gaspoz JM, Rochat T. Long-term decline in lung function, utilisation of care and quality of life in modified GOLD stage 1 COPD. Thorax. 2008;639:768-774 [CrossRef] [PubMed]
 
Vaz Fragoso CA, Concato J, McAvay G, et al. Chronic obstructive pulmonary disease in older persons: a comparison of two spirometric definitions. Respir Med. 2010;1048:1189-1196 [CrossRef] [PubMed]
 
Mannino DM, Sonia Buist A, Vollmer WM. Chronic obstructive pulmonary disease in the older adult: what defines abnormal lung function? Thorax. 2007;623:237-241 [CrossRef] [PubMed]
 
Vaz Fragoso CA, Concato J, McAvay G, et al. The ratio of FEV1to FVC as a basis for establishing chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2010;1815:446-451 [CrossRef] [PubMed]
 
Pedone C, Scarlata S, Sorino C, Forastiere F, Bellia V, Antonelli Incalzi R. Does mild COPD affect prognosis in the elderly? BMC Pulm Med. 2010;10:35 [CrossRef] [PubMed]
 

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References

Global Initiative for Chronic Obstructive Lung DiseaseGlobal Initiative for Chronic Obstructive Lung Disease Global strategy for the diagnosis, management and prevention of chronic obstructive lung disease. GOLD Web site.http://www.goldcopd.com. Accessed November 2, 2010.
 
Mannino DM, Diaz-Guzman E. Interpreting lung function data using 80% predicted and fixed thresholds identifies patients at increased risk of mortality. Chest. 2012;1411:73-80 [CrossRef] [PubMed]
 
Mannino DM, Doherty DE, Sonia Buist A. Global Initiative on Obstructive Lung Disease (GOLD) classification of lung disease and mortality: findings from the Atherosclerosis Risk in Communities (ARIC) study. Respir Med. 2006;1001:115-122 [CrossRef] [PubMed]
 
Ekberg-Aronsson M, Pehrsson K, Nilsson JA, Nilsson PM, Löfdahl CG. Mortality in GOLD stages of COPD and its dependence on symptoms of chronic bronchitis. Respir Res. 2005;6:98 [CrossRef] [PubMed]
 
Bridevaux P-O, Gerbase MW, Probst-Hensch NM, Schindler C, Gaspoz JM, Rochat T. Long-term decline in lung function, utilisation of care and quality of life in modified GOLD stage 1 COPD. Thorax. 2008;639:768-774 [CrossRef] [PubMed]
 
Vaz Fragoso CA, Concato J, McAvay G, et al. Chronic obstructive pulmonary disease in older persons: a comparison of two spirometric definitions. Respir Med. 2010;1048:1189-1196 [CrossRef] [PubMed]
 
Mannino DM, Sonia Buist A, Vollmer WM. Chronic obstructive pulmonary disease in the older adult: what defines abnormal lung function? Thorax. 2007;623:237-241 [CrossRef] [PubMed]
 
Vaz Fragoso CA, Concato J, McAvay G, et al. The ratio of FEV1to FVC as a basis for establishing chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2010;1815:446-451 [CrossRef] [PubMed]
 
Pedone C, Scarlata S, Sorino C, Forastiere F, Bellia V, Antonelli Incalzi R. Does mild COPD affect prognosis in the elderly? BMC Pulm Med. 2010;10:35 [CrossRef] [PubMed]
 
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