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1 대한내과학회지 : 제 87 권제 4 호 ST분절상승심근경색증환자에서증상발생후응급센터도착시간지연에영향을주는요인 1 전남대학교병원심장센터, 2 보건복지부지정심장질환특성화연구센터, 3 전남대학교의과대학예방의학교실, 4 전남대학교간호대학, 5 광주기독간호대학 이재훈 1,2 ㆍ정명호 1,2 ㆍ이정애 3 ㆍ최진수 3 ㆍ박인혜 4 ㆍ채임순 5 ㆍ장수영 1,2 조재영 1,2 ㆍ정해창 1,2 ㆍ이기홍 1,2 ㆍ박근호 1,2 ㆍ심두선 1,2 ㆍ김계훈 1,2 홍영준 1,2 ㆍ박형욱 1,2 ㆍ김주한 1,2 ㆍ안영근 1,2 ㆍ조정관 1,2 ㆍ박종춘 1,2 Factors Influencing Delay in Symptom-to-Door Time in Patients with Acute ST-Segment Elevation Myocardial Infarction Jae Hoon Lee 1,2, Myung Ho Jeong 1,2, Jung Ae Rhee 3, Jin Su Choi 3, In Hyae Park 4, Leem Soon Chai 5, Soo Yong Jang 1,2 Jae Young Cho 1,2, Hae Chang Jeong 1,2, Ki Hong Lee 1,2, Keun-Ho Park 1,2, Doo Sun Sim 1,2, Kye Hun Kim 1,2 Young Joon Hong 1,2, Hyung Wook Park 1,2, Ju Han Kim 1,2, Young keun Ahn 1,2, Jeong Gwan Cho 1,2, and Jong Chun Park 1,2 1 The Heart Center of Chonnam National University Hospital, Chonnam National University Medical School; 2 The Heart Research Center Designated by Korea Ministry of Health and Welfare; Department of 3 Preventive Medicine, Chonnam National University Medical School; 4 Nursing Department of Chonnam National University; 5 Gwangju Christian College of Nursing, Gwangju, Korea Background/Aims: Delay in symptom-to-door time (SDT) in patients with acute ST-segment elevation myocardial infarction (STEMI) is the most important factor in the prediction of short and long-term mortality. The purpose of this study was to investigate the social and clinical factors affecting SDT in patients with STEMI. Methods: We analyzed 784 patients (61.0 ± 13.2 years, 603 male) diagnosed with STEMI from November 2005 to February The patients were divided into four groups according to SDT: Group I (n = 163, 1 h), Group II (n = 183, 1-2 h), Group III (n = 142, 2-3 h) and Group IV (n = 296, > 3 h). Results: Delay in SDT increased with age (Group I, 58.4 ± 12.0; Group II, 59.4 ± 13.3; Group III, 62.0 ± 12.8; Group IV, 63.0 ± 13.8 years, p = 0.001). In 119 patients, transportation was less frequently used as the delay in SDT (41.7% vs. 29.0% vs. 26.1% vs. 9.8%, p < 0.001). By multiple logistic regression analysis, family history [OR, 0.488; CI, ; p = 0.037], previous ischemic heart disease [OR, 0.572; CI, ; p = 0.045], no occupation [OR, 1.600; CI, ; p = 0.020] and method of transportation [OR, 0.353; CI, ; p < 0.001] were independent predictors of delay in SDT. Received: Revised: Accepted: Correspondence to Myung Ho Jeong, M.D., Ph.D., FACC, FAHA, FESC, FSCAI, FAPSIC The Heart Research Center Designafed by Korea Ministry of Health and Welfare, Chonnam National University Hospital, Chonnam National University Medical School, 42 Jebong-ro, Dong-gu, Gwangju , Korea Tel: , Fax: , myungho@chollian.net, mhjeong@chonnam.ac.kr Copyright c 2014 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 - The Korean Journal of Medicine: Vol. 87, No. 4, Conclusions: Our study shows that general education about cardiovascular symptoms and a prompt emergency call could be important to reduce SDT in STEMI. (Korean J Med 2014;87: ) Keywords: Myocardial infarction; Symptom to balloon time; Mortality 서론선진국뿐만아니라한국에서도협심증, 심근경색증등의허혈성심장질환이성인사망률의주요한원인이되고있다. 심근경색증이현재미국에서는사망원인의 1위를차지하고있는질환이고우리나라에서도평균수명의연장및식생활습관의변화등으로그유병률이빠른속도로증가하고있다 [1]. 또한 2012년도국내급성심근경색증의입원 30일내사망률은 7.5% 로써비교적높은편이다. 상호비교를위해성- 연령표준화를거친 OECD 사망률통계에서도한국의입원 30일내사망률은 6.3% 로 OECD 가입국의평균 5.4% 에미치지못하는수준이다 [2]. 급성 ST분절상승심근경색증은대부분관상동맥이완전히폐쇄되어심근에혈액을공급하지못하는질환으로서가장중요한치료는빠른시간내에정상적으로혈액이공급되도록하는것이다. 급성심근경색증증상이발생한시간부터일차적관상동맥중재술을시행받기까지걸린총시간은빠르면빠를수록좋아서 2시간이내가가장좋다. 재관류요법중일차적관상동맥중재술이사망, 재경색증, 뇌졸중을방지하는데혈전용해술보다우수하다. 하지만혈전용해술은용이하고신속하게시설이없는병원에서할수있으나적절한재관류효과를얻지못하는경우가많고관상동맥중재술은적절한재관류를대부분환자에서얻을수있지만시설과전문인력이필요하고시술할때까지시간이지연된다는점이다. 두재관류요법은장단점이있어환자에따라재관류요법의선택이필요하게된다. 가장중요한요소는증상발생후재관류때까지걸리는시간을최소화하고치료를행하는중발생할수있는합병증을최소화하는것이다 [3-7]. 발병부터재관류까지걸리는시간은증상발생후환자가병원을방문하겠다고결심하는시간, 전화후구급차가도착하는시간, 환자후송시간, 병원간후송시간, 병원도착후혈전용해제투여시간, 병원도착후관상동맥중재술때까지시간, 일차적관상동맥중재술과관련된지연시간등으로구분하여설명할수있다. 지연시간을줄이는데는사람들의심근경색 증에대한인식, 조직화된응급의료체계, 병원간상호협조, 의료진의신속한대응등이조화롭게확립되어야가능하다 [8-11]. 심근경색증환자를대상으로가장많은임상연구가이루어지고있는분야가증상발생후에신속하고효과적인치료방법, 특히약물요법및관상동맥중재술이다. 그러나병원도착후시술시간 (door to balloon time) 에관한연구는많이있지만 [12], 증상발생후응급센터에도착할때까지시간 (symptom to door time) 의지연에영향을주는요인에관한연구는비교적적은편이다 [13]. 따라서이연구에서는 ST분절상승심근경색증환자에서증상발생후응급센터에도착할때까지시간에따라분류하여, 증상발생후응급센터에도착할때까지시간지연에관련된요인을알아보고자하였다. 대상및방법연구대상 2005년 11월부터 2012년 2월까지전남대학교병원응급실에내원한 ST분절상승심근경색증환자 2,093예중광주광역시에거주하는 784예 ( 남 603예, 58.3 ± 12.4세, 여 181예, 70.3 ± 11.5세 ) 를대상으로하였다. 증상발생후전남대학교병원응급실에도착할때까지의시간이 1시간이내는 Ⅰ군, 1 시간초과부터 2시간이내는 Ⅱ군, 2시간초과부터 3시간이내는 Ⅲ군, 3시간초과부터는 Ⅳ군으로분류하였다. 급성심근경색증은 30분이상지속되는전형적인흉통, 심근효소치가정상의 2배이상증가한경우, 추적심전도에서심근손상을나타내는 ST-T 절의변화또는새로운 Q파의존재중두가지이상을만족하는경우로정의하였다 [14]. 급성심근경색증의발생이관상동맥의연축에의해발생하였거나응급실에도착했지만일차적관상동맥중재술시행전에사망한환자, 흉통발생시간이애매하여정확한시간이기술되지않은환자, 증상발생후응급실도착시간이 12시간초과인환자는본연구에서제외하였다

3 - Jae Hoon Lee, et al. Delay in ER arrival of STEMI - 연구방법증상발생후응급센터에도착할때까지의총소요시간은응급실당직의가문진하여기록한시간을사용하였다. 나이, 성별, 고혈압및당뇨유무, 흡연, 가족력, 허혈성심장질환과거력, 체질량지수, 체형지수, 종교유무, 동거인, 교육정도, 스트레스관리유무, 직업유무, 거리, 경제적수준, 증상발생시기후, 증상발생시간과요일, 증상발생계절, 내원방법, 주요심장사건에대하여비교분석하였으며, 조사내용은병원의무기록을통해수집하였다. 체형지수는허리둘레에비례하는체질량지수와키의관계식으로허리둘레를체질량지수 2/3자승과키 1/2자승의곱으로나눈값을 0.8 이하와 0.8 초과로구분하였다. 동거인은배우자와함께거주하고있는군과배우자가없거나함께거주하고있지않은군으로구분하였다. 교육정도는초등학교졸업을기준으로 6년이하의학력과 6년초과의학력으로구분하였다. 스트레스관리유무는스트레스발생시참거나없다고하는군과스트레스발생시어떠한행동을하는군으로구분하였다. 증상발생시기후는증상발생한날의평균기온, 최고기온, 최저기온, 일교차, 상대습도, 불쾌지수, 체감온도, 일조량을조사하였고내원방법은전남대학교병원응급센터에도착할당시이용한교통수단을말하며, 119, 전원병원구급차, 자가용등으로구분하였다. 주요심장사건은사망, 재경색증, 표적병변재개통술, 관상동맥우회술등으로정의하였다. 사망은심부전증, 다기관부전증등모든원인에의한사망으로정의하였다. 관상동맥조영술에서혈류의흐름은 Thrombolysis in Myocardial Infarction (TIMI) flow [15] 를이용하였으며원위부가조영되지않을때를 0, 소량이조영되나원위부에완전히조영되지않을때를 I, 원위부가완전히조영되지만혈류가느린경우를 II, 원위부까지신속하게조영되고음영이없어지는경우를 III으로정의하였다. 정량적관상동맥분석은관상동맥중재시술전 Phillips H5000 DCI (Phillips, Eindhoven, Netherlands) 혹은 Allura program (Ver.5.6, Phillips, Eindhoven, Netherlands) 을이용하여측정하였다통계분석방법통계처리는 SPSS-PC 18.0 (Statistical package for the Society Science, SPSS Inc., Chicago, IL, USA) 을이용하였다. 모든연속변수는평균 ± 표준편차로나타냈다. 명목변수의 비교는선형대선형결합교차분석을사용하였고연속형변수의비교는일원배치분산분석을사용하였다. 생존분석은 Kaplan-Meier 방법을이용하였으며증상발생후응급실도착지연에영향을미치는예측인자에대한다변량분석을위해로지스틱회귀분석을사용하였다. 모든자료는 p value 가 0.05 미만일때유의하다고판정하였다. 결과대상자의임상적특성대상환자 784예의임상적특성에서증상발생후응급실도착시간이지연될수록연령이유의하게많았으며 (I군 58.4 ± 12.0 vs. II군 59.4 ± 13.3 vs ± 12.8 vs ± 13.8세, p = 0.001), 여성의비율이유의하게많았다 (16.6 vs vs vs. 30.4%, p < 0.001). 하지만응급실도착시간이지연될수록흡연비율 (64.0 vs vs vs. 49.4%, p = 0.001), 가족력비율은유의하게적어지는경향이보였다 (6.9 vs vs. 2.9 vs. 3.8%, p = 0.011). 그리고증상발생후응급실도착시간이지연될수록체형지수 0.8 초과환자비율이유의하게많아지는경향이보였다 (45.2 vs vs vs. 63.4%, p < 0.001). 그리고허혈성심장질환과거력비율이다른군보다 I군에서유의하게많았다 (19.8 vs. 7.7 vs. 9.2 vs. 8.4%, p = 0.003) (Table 1). 대상자의사회적특성증상발생후응급실도착시간이지연될수록교육정도가 6년이하비율이유의하게많았으며 (14.6 vs vs vs. 36.3%, p < 0.001), 직업이없는비율이유의하게많아지는경향이보였다 (40.1 vs vs vs. 56.9%, p < 0.001). 동거인, 종교유무, 스트레스관리, 거리는유의한차이가없었다 (Table 2). 증상발생시기와내원방법증상이발생한시간, 요일, 계절은각군과유의한차이가없었지만증상발생후응급실도착시간이빠를수록 119를이용한비율이유의하게많았다 (41.7 vs vs vs. 9.8%, p < 0.001) (Table 2)

4 - 대한내과학회지 : 제 87 권제 4 호통권제 650 호 Table 1. Baseline clinical characteristics Variable Group I (n = 163) Group II (n = 183) Group III (n = 142) Group IV (n = 296) p value Age, yr 58.4 ± ± ± ± Gender, female 27 (16.6) 34 (18.6) 30 (21.1) 90 (30.4) < Atypical chest pain 22 (13.5) 27 (14.8) 26 (18.3) 41 (13.9) Diabetes mellitus 33 (20.6) 39 (21.5) 40 (28.4) 77 (26.1) Hypertension 65 (40.1) 80 (44.2) 49 (35.0) 141 (48.0) Dyslipidemia 12 (7.6) 10 (5.6) 4 (3.0) 13 (4.5) Ejection fraction, % 56.4 ± ± ± ± Smoking 87 (64.0) 105 (67.3) 80 (63.0) 121 (49.4) Family history 11 (6.9) 21 (11.7) 4 (2.9) 11 (3.8) BMI, kg/m ± ± ± ± ABSI, > (45.2) 90 (52.6) 62 (51.7) 173 (63.4) < SBP, mmhg ± ± ± ± DBP, mmhg 71.4 ± ± ± ± Previous IHD 32 (19.8) 14 (7.7) 13 (9.2) 25 (8.4) Values are presented as mean ± SD or number (%). ABSI, a body shape index; BMI, body mass index; DBP, diastolic blood pressure; IHD, ischemic heart disease; SBP, systolic blood pressure. Table 2. Sociodemographic characteristics Group I Variable (n = 163) Group II (n = 183) Group III (n = 142) Group IV (n = 296) p value Marital status (single or widowed) 20 (12.3) 22 (12.2) 9 (6.4) 40 (13.6) Religion 73 (48.3) 84 (49.4) 69 (50.7) 140 (51.2) Education < yr 23 (14.6) 34 (19.4) 37 (27.8) 101 (36.3) > 6 yr 134 (85.4) 141 (80.6) 96 (72.2) 177 (63.7) Stress management 57 (46.7) 55 (38.5) 43 (39.4) 91 (36.5) No occupation 65 (40.1) 70 (39.5) 76 (54.3) 168 (56.9) < Distance by car min 106 (65.0) 92 (50.3) 78 (54.9) 168 (56.8) > 20 min 57 (35.0) 91 (49.7) 64 (45.1) 128 (43.2) Symptom onset time 7 a.m. 6 p.m. 78 (47.9) 91 (49.7) 81 (57.0) 160 (54.1) 6 p.m. 7 a.m. 85 (52.1) 92 (50.3) 61 (43.0) 136 (45.9) Day of symptom onset Weekday 105 (64.4) 130 (71.0) 110 (77.5) 215 (72.6) Weekend 58 (35.6) 53 (29.0) 32 (22.5) 81 (27.4) Season Spring 48 (29.4) 38 (20.8) 39 (27.5) 74 (25.0) Summer 29 (17.8) 43 (23.5) 41 (28.9) 70 (23.6) Autumn 39 (23.9) 46 (25.1) 24 (16.9) 72 (24.3) Winter 47 (28.8) 56 (30.6) 38 (26.8) 80 (27.0) Transport vehicle < (41.7) 53 (29.0) 37 (26.1) 29 (9.8) Other hospital ambulance 47 (28.8) 107 (58.5) 83 (58.5) 213 (72.0) Private car 48 (29.4) 23 (12.6) 22 (15.5) 54 (18.2) Values are presented as number (%)

5 - 이재훈외 18 인. 심근경색환자의응급실내원지연 - 기후환경요인증상발생시에기후환경을비교했을때, 평균기온, 최고기온, 최저기온, 일교차, 상대습도, 불쾌지수, 체감온도, 일조량은각군간유의한차이가없었다 (Table 3). 증상발생후일차적관동맥중재술까지의시간관동맥중재술이가능한병원에도착후일차적관동맥중재술까지의시간 (door to balloon time) 은유의한차이가없었지만증상발생후일차적관동맥중재술까지의시간 (symptom to balloon time) 은증상발생후응급실도착시간이늦을수록유의하게지연되었다 (153.0 ± 92.2 vs ± vs ± 67.5 vs ± 131.3, p = 0.001) (Table 4). 관상동맥조영술소견대상환자의관상동맥조영술에서네군모두단일혈관질환이많았으나유의한차이는없었고관상동맥중재술시행전혈류의흐름, 정량적관상동맥분석결과도각군간유의한차이가없었다 (Table 4). Table 3. Comparison of climatic environment Variable Group I (n = 163) Group II (n = 183) Group III (n = 142) Group IV (n = 296) p value Average temperature, C 13.3 ± ± ± ± Maximum temperature, C 18.3 ± ± ± ± Minimum temperature, C 9.2 ± ± ± ± Daily temperature range, C 7.8 ± ± ± ± Relative humidity, % 67.3 ± ± ± ± Discomfort index 56.7 ± ± ± ± Sensible temperature, C 6.0 ± ± ± ± Amount of sunshine, mj/m ± ± ± ± Table 4. Time delay and coronary angiographic findings Variable Group I (n = 163) Group II (n = 183) Group III (n = 142) Group IV (n = 296) p value DBT (median, min) 74.1 ± 19.1 (72) 74.5 ± 22.2 (69) 75.9 ± 19.3 (74) 74.9 ± 21.1 (71.0) SBT (median, min) ± 92.2 (113) ± (165) ± 67.5 (217) ± (394) Vessel number One vessel 103 (63.2) 120 (65.6) 96 (67.6) 167 (56.4) Two vessel 41 (25.2) 44 (24.0) 36 (25.4) 78 (26.4) Three vessel 19 (11.7) 19 (10.4) 10 (7.0) 51 (17.2) Baseline TIMI flow (48.5) 107 (58.5) 69 (48.6) 164 (55.4) I 9 (5.5) 8 (4.4) 7 (4.9) 15 (5.1) II 33 (20.2) 34 (18.6) 35 (24.6) 53 (17.9) III 42 (25.8) 34 (18.6) 31 (21.8) 64 (21.6) QCA analysis RD, mm 3.3 ± ± ± ± MLA, mm 0.2 ± ± ± ± DS, % 93.4 ± ± ± ± Lesion length, mm 23.7 ± ± ± ± Values are presented as mean ± SD or number (%). Unless otherwise indicated. DBT, door to balloon time; DS, diameter stenosis; MLA, minimal luminal diameter; QCA, quantitative angiographic analysis; RD, reference diameter; SBT, symptom to balloon time; TIMI, thrombolysis in myocardial infarction.

6 - The Korean Journal of Medicine: Vol. 87, No. 4, 증상발생후응급실도착시간지연에따른임상경과 6개월주요심혈관계합병증발생률은유의한차이가없었지만증상발생후응급실도착시간이늦을수록 12개월주요심혈관계합병증발생률이유의하게증가하였다 (8.6 vs. 9.8 vs vs. 15.9%, p = 0.013). Kaplan-Meier 생존분석을이용한네군의생존율을추적한결과각군간유의한차이가없었다 (Fig. 1). 다변량회귀분석을이용한예측인자증상발생후응급실도착에영향을주는독립적인인자를살펴보기위해증상발생후응급실도착시간을 2시간이내와 2시간초과로나누어다변량분석을시행하였다. 단변량 분석상 p value < 0.2인연령, 성별, 가족력, 체형지수, 과거허헐성심장질환, 교육정도, 직업유무, 내원방법의인자를이용하여다변량분석을시행한결과연령, 성별, 체형지수, 교육정도는증상발생후응급실도착지연에영향을미치는독립적인인자는아니었다. 가족력 (odds ratio [OR], 0.488; 95% confidence interval [CI], to 0.959; p = 0.037), 허혈성심장질환과거력 (OR, 0.572; 95% CI, to 0.989; p = 0.045), 무직 (OR, 1.600; 95% CI, to 2.380; p = 0.020), 내원방법 (OR, 0.353; 95% CI, to 0.520; p < 0.001) 이증상발생후응급실도착지연에영향을주는유의한예측인자였다 (Table 5). 고찰 Figure 1. Kaplan-Meier analysis demonstrating survival in patients classified according to the survival rate. The cumulative survival rate was not different among the 4 groups (p = 0.202). The log-rank test was used to compare survival curves. Park 등 [13] 의연구에서는증상발생후응급실내원시간지연에영향을미치는요인으로교육정도, 증상발생시간, 전원병원, 내원방법으로보고하고있다. 본연구에서도교육정도, 내원방법이응급실내원시간지연에영향을미치는요인이었으며가족력, 허혈성심장질환과거력, 직업유무가응급실내원시간지연에영향을미치는요인임을볼수있었다. ST분절상승심근경색증환자의치료에서가장중요한것은증상발생후빠른시간내에병원에도착하여재관류요법을받는것인데치료효과를결정하는인자들중가장중요한변수는시간이며 ACC/AHA guideline 에서는 symptom to balloon time 을 120분이내, door to balloon time 을 90분이내로권고하고있다 [16]. 급성심근경색증환자의진단및치료면에서우리나라의 Table 5. Independent predictors for delayed symptom to door time longer than two hours Variable Odds ratio 95% confidence interval p value Age, > 60 yr Gender, female ABSI, > Family history Previous IHD Educational attainment, 6 yr No occupation Method of transportation, < ASBI, a body shape index; IHD, ischemic heart disease

7 - Jae Hoon Lee, et al. Delay in ER arrival of STEMI - 경우에선진국과가장큰차이점은증상발생후내원시간이길다는점이다. 증상발생후내원시간 (symptom to door time) 이 6시간이내에경우가약 70% 정도이고나머지환자들은평균 12시간이경과하여내원하는경우가많다 [17]. 본연구에서도증상발생후응급실도착시간이 1시간이내가 17.9% ( 중앙값 : 40분 ), 1시간초과 2시간이내가 20.1% ( 중앙값 : 83분 ), 2시간초과 3시간이내가 15.6% ( 중앙값 : 138분 ), 3 시간초과가 46.4% ( 중앙값 : 445분 ) 로권고시간내에응급실도착하는경우가많지않다는것을알수있었다. De Luca 등 [18] 의연구에서는 ST분절상승심근경색증환자에서증상발생후일차적관동맥중재술까지의시간 (symptom to balloon time) 이 1년사망률을예측할수있는인자로보고하고있다. 본연구에서는증상발생후일차적관동맥중재술까지의시간은유의한차이가보였지만 1년생존분석결과는유의한차이가보이지않았다. 이는본연구가비교적적은환자군을분석하여서차이가없었을것으로사료되고대단위연구에서는차이가있을것으로판단된다. Barakat 등 [19] 의연구에서나이든사람이젊은사람보다급성심근경색증증상발생후응급의료센터도착시간이지연된다고보고하고있다. 이것은고령환자에서젊은사람보다동반질환들을더가지고있고증상이비전형적으로나타나기때문이라고보고있다 [20]. 본연구에서도증상발생후응급실도착이지연될수록나이가많은것을볼수있었다. 급성심근경색증환자에서여성은남성보다흉통발생률이낮고, 비전형적인흉통을호소하는경우가많다고한다 [21,22]. Bruins 등 [23] 의연구에서는증상발생후응급실도착시간이남성은평균 65분, 여성은평균 76분으로여성이남성보다증상발생후응급실도착이지연되는것을보고했다. Choi 등 [24] 의연구에서도남성은발병후즉시내원한경우 (56.3%) 가많았고, 여성은다른병원을방문하였다가전원한경우 (62.5%) 가많았다. 증상발생후응급의료센터도착까지경과시간은남성은 6시간이하가 63.2% 로가장많았고여성은 12시간이상이 44.6% 로가장많았다. 여성은남성보다흉통등의전형적인증상을적게호소하므로응급의료체계를이용하는시간이지연될수있다고하였다. 본연구도증상발생후응급실도착시간이남성 ( 중앙값 : 138.8분 ) 보다여성 ( 중앙값 : 228.9분 ) 이지연되는것을볼수있었다. 당뇨병, 고혈압, 비만은심혈관계질환의위험인자로여러연구에서보고되고있고, 당뇨병, 혈압이있는환자는급성 심근경색증상의감도가덜하기때문에증상발생후응급실도착이지연된다고보고되고있다 [25-28]. 본연구도고혈압, 당뇨병을가지고있는경우응급실도착이지연되는경향을볼수있었고응급실도착이지연될수록체형지수 0.8 초과인환자비율이많아지는경향을볼수있었다. 이전연구들에서증상발생후응급실도착시간지연을줄이기위해서는증상에대한교육및홍보가절실히필요하다고강조하고있다 [29,30]. Kentsch 등 [31] 의보고된연구에서는협심증과거력이있는환자의경우본인및가족들의높은경각심으로인하여증상발생시에보다적극적으로의료기관이용하기때문에내원시간지연이감소하는결과를보였다. Ridker 등 [32] 의연구에서는학력이높은환자일수록증상발생후응급실도착시간이짧다는결과를보였다. 본연구에서도응급실도착시간이빠를수록가족력이있는환자비율이많은경향을볼수있었고협심증과거력이있는환자비율이다른군보다 I군에서많다는것을볼수있었다. 교육정도에서는증상발생후응급실도착시간이지연될수록 6년이하비율이많아지는경향을보였다. 교육을받은경험이있는경우가그렇지않은경우보다증상발생후응급실도착지연시간이빠르다는연구결과는교육의중요성을지지해준다. 예컨대급성심근경색증의예방과치료과정에대한교육은대상자가건강행위를이행할수있도록필요성을인식시키고, 획일적인교육보다는대상자의요구와지식수준에맞는개별화된단계적인교육이효과적일것으로생각된다. Bhaskaran 등 [33] 의보고된연구에서기온이 1도떨어지면심근경색증위험이발생할위험이 2% 증가한다고보고했다. 또기온저하의영향을받기쉬운경우는관상동맥질환기왕력이있는 75-84세고령환자였으며아스피린복용고령환자에서는영향이적다고보고했다. Lee 등 [34] 의보고된연구에서는계절변화가급성심근경색증발생과관련이있다고보고했다. 1월에급성심근경색증환자가가장많이발생하고, 8월에가장적게발생한다고보고했다. 하지만본연구에서는증상발생후응급실도착당시기후와도착시간지연간의관련성은보이지않았다. 응급의료서비스의빠른사용은급성심근경색증환자에서증상발생후응급실도착시간을단축할수있다고한다 [35]. 2012년건강보험심사평가원통계에서증상발생후응급실도착시간까지걸린시간의중앙값은 148분이지만구급

8 - 대한내과학회지 : 제 87 권제 4 호통권제 650 호 차를이용했을때와그렇지않았을때가각각 130분과 180분으로 50분차이가관찰되었다고보고하였다. 그리고증상발생후재관류요법까지 120분을달성한비율이구급차이용환자에선 47.2% 인반면에이용하지않은환자는 39.2% 로낮아졌다보고하고있다. 본연구에서도응급실도착이빠를수록 119를이용하는비율이많아지는경향이보였다. 본연구의제한점으로는단일기관에서시행한후향적인연구로서도시형태나병원밀도등의차이가있을것으로판단되고전원되는거리가먼타지역환자와흉통발생시간이애매하여정확한시간이기술되지않은환자는제외하였다는점, 타병원에서이송된경우각병원에서의치료적절성이언급되지않았다는점, 병원도착당시의교통상황등다른사회간접자본들에대한고려를하지못한아쉬움이있다. 향후에이러한제한점들을보완하여전국적인다기관연구가필요하리라생각된다. 결론적으로급성심근경색증환자의치료는신속한증상의인지와적절한치료를할수있는의료기관으로신속한이송이중요하며, 증상의신속한인지와효과적인치료를위해서는가족력, 허혈성심장질환과거력과직업이없는일반인을대상으로심근경색증의증상이나징후에대한적극적인홍보와함께 119와같은응급환자이송수단을이용함으로써지연시간을최소화할수있도록교육과계몽이필요할것으로생각된다. 요약목적 : 급성 ST분절상승심근경색증 (ST elevation myocardial infarction, STEMI) 환자에서증상발생후응급실도착지연은단기및장기사망률에영향을미치는중요한요소이다. 본연구는 ST분절상승심근경색증환자에서증상발생후응급실도착 (symptom to door time, SDT) 지연에영향을미치는사회적, 임상적요인을알아보고자한다. 방법 : 2005년 11월부터 2012년 2월까지전남대학교병원에내원한 STEMI 환자 784명 ( 평균연령 61.0 ± 13.2세, 남자 603 명 ) 을분석하였다. SDT 가 1시간이내를 I군, 1시간초과 2시간이내를 II군, 2시간초과 3시간이내를 III군, 3시간초과를 IV군으로나누었다. 결과 : SDT가지연될수록나이가유의하게많아졌고 (58.4 ± 12.0 vs ± 13.3 vs 62.0 ± 12.8 vs 63.0 ± 13.8세, p = 0.001), 여성비율이많았다 (16.6 vs vs vs. 31.0%, p < 0.001). 허혈성심장질환과거력환자에서다른군보다 I군의비율이유의하게많았다 (19.8 vs. 7.7 vs. 9.2 vs. 8.4%, p = 0.003). SDT 가지연될수록체형지수가 0.8초과인비율이유의하게많아지는경향이보였고 (45.2 vs vs vs. 63.4%, p < 0.001), SDT가지연될수록교육정도 6년이하비율이유의하게많았고 (14.6 vs vs vs. 36.3%, p < 0.001), 직업이없는비율이유의하게많았다 (40.1 vs vs vs. 56.9%, p < 0.001). 그리고내원방법에서 SDT가지연될수록 119를이용하는비율이유의하게적었다 (41.7 vs vs vs. 9.8%, p < 0.001). 다변량로지스틱회귀분석에서가족력 [OR, 0.488; CI, ; p = 0.037], 허혈성심장질환과거력 [OR, 0.572; CI, ; p = 0.045], 무직 [OR, 1.600; CI, ; p = 0.020], 내원방법 [OR, 0.353; CI, ; p < 0.001] 이 SDT 지연의독립적인예측인자였다. 결론 : 급성심근경색증증상의인식에대한교육과급성심근경색증증상발생후 119를통한신속한이송이 STEMI 환자에서 SDT을줄일수있는중요한인자임을알수있었다. 중심단어 : 심근경색 ; 일차적관동맥중재술시간 ; 사망률 REFERENCES 1. Lee KH, Jeong MH, Ahn YK, et al. Sex differences of the clinical characteristics and early management in the Korea Acute Myocardial Infarction Registry. Korean Circ J 2007;37: Organisation for Economic Cooperation and Development. OECD Health Data 2009 comparing health statistics across OECD countries [Internet]. Busan: Organisation for Economic Cooperation and Development, 2009 [2009 December 8]. Available from: 3. O Gara PT, Kushner FG, Ascheim DD, et al ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61: e Van de Werf F, Bax J, Betriu A, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of

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