Chronic obstructive pulmonary disease (COPD) has been associated with an increased risk of cardiovascular disease, which has been suggested to relate to both similar risk factors and to similar pathophysiological mechanisms [ 1 Sinden N.J. Stockley R.A. Systemic inflammation and comorbidity in COPD: a result of ‘overspill’ of inflammatory mediators from the lungs? Review of the evidence. Thorax. 2010; 65: 930-936 Crossref PubMed Scopus (248) Google Scholar , 2 Bäck M. Atherosclerosis, COPD and chronic inflammation. Resp Med. 2008; : 60-65 Google Scholar , 3 Fabbri L.M. Rabe K.F. From COPD to chronic systemic inflammatory syndrome?. Lancet. 2007; 370: 797-799 Abstract Full Text Full Text PDF PubMed Scopus (527) Google Scholar , 4 Fabbri L.M. Luppi F. Beghe B. Rabe K.F. Complex chronic comorbidities of COPD. Eur Respir J. 2008; 31: 204-212 Crossref PubMed Scopus (485) Google Scholar ]. The latter notion has also received support from pharmacoepidemiological studies, suggesting reduced cardiovascular risk by respiratory medications [ 5 White W.B. Cooke G.E. Kowey P.R. et al. Cardiovascular safety in patients receiving roflumilast for the treatment of COPD. Chest. 2013; 144: 758-765 Crossref PubMed Scopus (75) Google Scholar , 6 Ingelsson E. Yin L. Bäck M. Nationwide cohort study of the leukotriene receptor antagonist montelukast and incident or recurrent cardiovascular disease. J Allergy Clin Immunol. 2012; 129 ([e2]): 702-707 Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar ]. However, the full impact of COPD on myocardial infarction (MI) and stroke in a population-based cohort remains to be fully investigated. The aim of the present study was to outline the association of COPD with MI and stroke. To this end, we analyzed the prevalence and the association of COPD with incidence and recurrence of these outcomes in a nationwide population-based cohort of approximately 7 million Swedish residents integrating data from the Prescribed Drug, Patient, Cause of Death, Income, Educational and Emigration Registers. The associations between COPD and outcome were examined by Cox proportional hazard models estimating the hazard ratio (HR) of COPD, after either partial adjustment for age, gender and socioeconomic factors (education level and income) or fully adjusted for all factors listed under the respective outcomes in Table 1. The average follow-up time was 3.5 years for incident events, and 2.9 and 2.7 years for recurrent MI and stroke, respectively. Events and event rates are shown in Supplementary Table 1. The cohort and statistical methods have been described in detail in our previous studies [ 6 Ingelsson E. Yin L. Bäck M. Nationwide cohort study of the leukotriene receptor antagonist montelukast and incident or recurrent cardiovascular disease. J Allergy Clin Immunol. 2012; 129 ([e2]): 702-707 Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar , 7 Bäck M. Yin L. Ingelsson E. Cyclooxygenase-2 inhibitors and cardiovascular risk in a nation-wide cohort study after the withdrawal of rofecoxib. Eur Heart J. 2012; 33: 1928-1933 Crossref PubMed Scopus (60) Google Scholar , 8 Bäck M. Yin L. Nagy E. Ingelsson E. The leukotriene receptor antagonist montelukast and aortic stenosis. Br J Clin Pharmacol. 2013; 75: 280-281 Crossref PubMed Scopus (2) Google Scholar ], and an expanded methods section is provided as supplementary material. Table 1Baseline characteristics of the study samples analyzed for incident events (no previous myocardial infarction or ischemic stroke), recurrent myocardial infarction and recurrent ischemic stroke. Confounders included in the fully adjusted model for the respective outcome are listed. Subjects without previous myocardial infarction or ischemic stroke Subjects with previous myocardial infarction Subjects with previous ischemic stroke COPD No COPD COPD No COPD COPD No COPD N 51,348 6,743,342 6442 147,4495 4320 127,971 Mean age (years) 71.05 49.25 69.15 66.55 70.47 69.44 Females (%) 55.67 51.28 41.63 33.61 45.63 48.10 Educational level (%) Low 59.26 18.22 77.62 67.22 80.44 73.38 Mid 32.62 50.42 18.67 24.59 15.60 19.39 High 8.12 31.36 3.71 8.19 3.96 7.23 Income (%) Low 42.51 26.07 50.22 36.14 53.52 44.86 Mid 48.29 48.90 43.96 50.25 41.16 44.51 High 9.20 25.03 5.82 13.61 5.32 10.63 Drug prescriptions (%) ICS a Inhaled corticosteroids. and/or β-agonists 82.77 10.18 79.62 11.96 74.28 10.62 Inhaled anti-cholinergics 41.80 0.68 45.86 2.58 43.98 2.47 Oral steroids 58.88 9.67 58.27 14.83 51.02 13.41 Theophylline 9.35 0.16 10.45 0.66 11.34 1.19 Low-dose ASA b Acetylsalicylic acid. 34.30 10.26 78.33 83.69 66.02 67.34 Dipyridamole 0.99 0.30 N N 10.12 10.31 Oral anticoagulants 10.59 2.40 N N 20.39 18.23 β-Blockers 32.82 14.78 70.29 81.01 N N Calcium antagonists 23.42 7.88 28.70 27.80 N N ACE-inh/ARB c Angiotensin converting enzyme inhibitors and/or angiotensin receptor blockers. 35.05 13.18 62.00 60.61 49.10 45.10 Lipid lowering drugs 22.39 10.60 59.69 70.71 37.31 42.11 N: not included in the model. a Inhaled corticosteroids. b Acetylsalicylic acid. c Angiotensin converting enzyme inhibitors and/or angiotensin receptor blockers. Open table in a new tab N: not included in the model.