To establish a 5-year all-cause mortality risk predicting model for patients with chronic obstructive pulmonary disease (COPD) based on quantitative CT assessment of imaging features across six major thoracic anatomic units, thereby informing precision diagnosis and treatment.

A total of 733 COPD patients who were hospitalized in our department for the first time from December 2012 to September 2023 were selected. Clinical data were collected. Chest CT was used to quantify imaging features across six thoracic anatomic units, and the six-feature model (with a total score of 0~10 points) was established. Discrimination was evaluated using the receiver operating characteristic (ROC) curve. Unsupervised K-Means clustering was used to stratify patients by model scores, and Kaplan-Meier survival analysis assessed 5-year all-cause mortality.

Among 733 COPD patients, 575 were male (78.44%) and 158 were female (21.56%), aged from 41 to 93 years, with a median age of 73 (65, 80) years. With the first admission as the baseline, a total of 278 patients (37.93%) died before the 5-year follow-up point. Comparisons of quantified features of thoracic anatomic units revealed statistically significant differences between non-survivors and survivors (P<0.05): pulmonary artery diameter [30.10 (26.72, 33.36) vs. 28.00 (24.90, 31.77)mm], modified Reiff score [1(0, 3) vs. 0(0, 2)], Weston score [3(0, 7) vs. 0(0, 3)], erector spinae muscle density [30.80(20.07, 37.92) vs. 35.22(28.72, 41.94)HU], visual score of emphysema [(2.91±0.37) vs. (2.56±0.86)], average density of the 4th, 7th, and 10th thoracic vertebrae [121.39(94.65, 150.56) vs. 132.42(105.55, 163.15)HU], patient proportion coexisting thoracic vertebral fracture [57(20.50%) vs. 67(14.73%)], and the six-feature model score [6(5, 7) vs. 5(4, 6)]. The area under the ROC curve (AUC value) of the six-feature model for predicting 5-year all-cause mortality risk in COPD patients was 0.70. K-Means clustering analysis separated patients into four score groups, and Kaplan-Meier curves indicated that the higher score, the higher 5-year all-cause mortality risk of COPD patients. The 5-year all-cause mortality of patients at the high score group (with a score of 8 to 10) reached 65%.

Quantitative CT assessment of imaging features across six major thoracic anatomic units enables effective prediction of 5-year all-cause mortality in COPD. The six-feature model can effectively predict the 5-year all-cause mortality risk of COPD patients, which may facilitate early identification of patients at high risk of death, supporting precision management in COPD.