Background: The long-term prognosis of individuals with chronic obstructive pulmonary disease (COPD) and preserved ratio impaired spirometry (PRISm) in the general population remains insufficiently characterized. We aimed to evaluate 10-year all-cause and cause-specific mortality risks across distinct spirometric phenotypes.

Methods: Data were derived from the Shanghai sub-cohort of the Chinese Pulmonary Health (CPH) study, a nationally representative cross-sectional survey conducted between June 2012 and February 2014. A total of 5,281 participants with interpretable spirometry at baseline were included and classified into five spirometric phenotypes: Normal, COPD, PRISm, small airway dysfunction (SAD), andrestrictive dysfunction. Vital status was ascertainedfromlocal Centers for Disease Control and Prevention (CDC) death registry over a follow-up period of up to 120 months. Cause of death was coded according to the International Classification of Diseases, 10th Revision (ICD-10). Cox proportional hazards models were used to estimate adjusted hazard ratios (HRs) for all-cause mortality, and Fine-Gray subdistribution hazard models were applied for cause-specific mortality (respiratory, cardiovascular, and cancer), treating deaths from other causes as competing events. Multivariable models were adjusted for age, sex, education, body mass index, smoking status, and comorbidities

Results:During a median follow-up of 10 years, 342 deaths occurred (overall mortality 6.5%). Mortality was higher in COPD (117/592, 19.8%) than in non-COPD participants (225/4,689, 4.8%). Compared with normal spirometry, COPD was independently associated with a higher risk of all-cause mortality (HR 1.66, 95% CI 1.26–2.18) after adjustment. Among COPD patients, older age, male sex, and more advanced GOLD stage were independently associated with mortality. In the non-COPD population, mortality was significantly higher in those with PRISm than in those with normal spirometry (27/210, 12.9% vs 124/3,190, 3.9%), and this difference remained significant after adjustment (HR 2.67, 95% CI 1.76–4.05). Furthermore, cause-specific analysis revealed that COPD was driven by respiratory and cancer mortality, whereas PRISm was significantly associated with elevated risks of cardiovascular and cancer mortality.

Conclusion: In this population-based cohort with long-term follow-up, both COPD and PRISm were associated with substantially elevated all-cause mortality, with distinct cause-specific patterns. These findings underscore the prognostic value of comprehensive spirometric phenotyping in long-term risk stratification.