Focused Issue - 당뇨병과수술 당뇨병환자의수술전심혈관계위험도평가 동국대학교의과대학내과학교실김경아 Preoperative Assessment of Cardiac Risk in the Patient with Diabetes Kyoung Ah Kim Departm

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1 동국대학교의과대학내과학교실김경아 Preoperative Assessment of Cardiac Risk in the Patient with Diabetes Kyoung Ah Kim Department of Medicine, Dongguk University IIsan Hospital, Dongguk University School of Medicine, Goyang, Korea Abstract 142 Approximately 50% of people with diabetes will at some point undergo related to their disease. Since patients with diabetes mellitus are four times more likely to have silent ischemia and coronary artery disease compared to the risk of non-diabetic patients, they are at a higher risk for perioperative complications. Preoperative evaluation can identify many patients at increased risk of an adverse cardiac event, and appropriate perioperative management can reduce that risk. Although there is great potential to reduce perioperative cardiovascular risk, it is also impractical to perform cardiovascular testing prior to non-cardiac in all patients. Therefore, it is important to determine perioperative risk and the appropriateness of cardiac testing and to provide prophylactic treatment to reduce risk. Perioperative cardiac risk stratification is determined by comorbidity, other cardiovascular risk factors, functional status, and type of. By categorizing the cardiac risk, physicians can perform in low risk patients without the need for cardiac testing. When preoperative risk assessment identifies intermediate- and high-risk patients, further cardiac testing might be warranted. This article reviews the perioperative evaluation of patients with diabetes with a clinical focus on cardiovascular risk. (J Korean Diabetes 2011;12: ) Keywords: Diabetes mellitus, Surgery, Perioperative care, Risk management, Coronary artery disease 서론 수술과전신마취에따른심혈관계사망률은 0.3% 이고, 비치명적심근경색이 1% 에서발생한다. 수술기주위 (perioperative) 사망의 40% 는심장사 (cardiac death) 에의한다. 당뇨병은관상동맥질환과무증상허혈증을동반하는경우가많으므로 [1] 수술기주위심혈관질환의이환율과사망률은일반인에비해 2~3 배증가한다 [2,3]. 특히인슐린치료를받는당뇨병환자는비심장수술을시행받는환자에서의심장위험도를예측하기위한 revised cardiac risk index (RCRI) 위험인자중하나이다 [4]. 따라서당뇨병환자는수술전심혈관질환에대한충분한평가가필요하다. 그러나주요한수술을받는모든환자에게수술전비침습적심장검사를시행할근거는없다. 따라서수술기주위위험도평가를하여심장검사를시행할지여부를결정하고예방적약물치료를시작하는것이중요하다 [4]. 본리뷰에서는당뇨병환자에서비심장질환수술시수술기주위심혈관질환위험도평가를고찰하겠다. 임상적평가 : 병력청취 / 이학적검진 각개인의수술전위험도는환자의병력, 동반질환, 받고자하는수술유형, functional capacity, 이학적검진, 심전도검사로유추할수있다. 주의깊은병력 교신저자 : 김경아, 경기도고양시일산구식사동 814 번지동국대학교병원내분비대사내과, kyoung-ah.kim@dumc.or.kr

2 청취는수술위험도가높은심혈관질환이나동반질환을발견하는데있어중요하다. 특히당뇨병에서는관상동맥질환위험이높고무증상허헐증을동반하는가능성이많다. 환자의병력상 active cardiac conditions 을가지는경우는수술을연기하고평가를해야된다 (Table 1)[4]. 이는다음과같다. 1 불안정관상동맥증후군 불안정또는심한협심증 최근의심근경색 2 비대상성심부전 3 주요한부정맥 4 심한판막질환또한환자의 functional capacity 를평가하여수술의위험도를예측해야한다. 수술 - 특이적인위험 수술방법에따른수술위험도가달라지므로수술전심혈관질환평가를하는데중요한요소가된다. 그이유로는첫째, 일부질환들은심혈관질환의위험인자를같이공유하는경우가많다. 예를들어 vascular 를받는환자는관상동맥질환을동반할가능성이높다. 둘째, 수술자체로급격한심장스트레스를유발할수있다. 예를들어응급수술은수술기주위심장위험이 2~5 배로증가한다. 수술방법에따른위험도는 Table 1 과같이분류한다. 수술기주위심혈관계사건위험도의임상적예측인자 긴급하지않은주된비심장수술을받게되는안정된환자에있어서수술기주위심혈관계사건의위험도를예측하기위한여러가지 risk index 가소개되고있다. 이중 1999 년 Lee 등이제시한 revised cardiac risk index 가많이쓰이고있다 [5]. 이는다음과같은 6 개의위험인자로구성되있다. 12 고위험수술 (intraperitoneal, intrathoracic, suprainguinal vascular) 22 허혈성심질환 ( 심근경색병력또는활동성협심증, 설하니트로글리세린사용자, 최근스트레스테스트상이상소견, 심전도상 Q waves, 관상동맥재개통술의병력과진행중인흉통 ) 32 울혈성심부전 42 뇌혈관질환 ( 뇌졸증, 일과성허혈발작 ) 52 수술전인슐린치료를하는당뇨병 62 수술전크레아티닌 > 2mg/dL 위험인자가많을수록수술의위험도는높아지며 RCRI 가 0, 1, 2 또는 3 개이상시주요심장사건이발생할확률은각각 0.4%, 0.9%, 7%, 11% 이다. 나이를보정하고고혈압을포함한 modified Lee index 도소개되고있다 [6,7]. 비심장수술에서심혈관계평가알고리즘 143 American College of Cardiology (ACC)/American Table 1. Cardiac risk stratification for noncardiac surgical procedures Risk stratification (reported cardiac risk a > 5%) Intermediate risk (reported cardiac risk from 1% to 5%) Low risk b (reportedcardiac risk < 1%) Example procedures Aortic or other major vascular Peripheral vascular Intraperitoneal and intrathoracic Carotid endarterectomy Head and neck Orthopedic Prostate Endoscopic procedures Superficial biopsy Cataract Breast Ambulatory Adapted from Fleisher et al. Circulation 2009;120:e [4]. a Combined incidence of cardiac death and non-fatal myocardial infarction. b These procedures do not generally require further preoperative cardiac testing.

3 144 Heart Association (AHA) 에서수술기주위심혈관계위험도에관한평가및조치에관해다음과같은가이드라인을제시했다. 당뇨병환자에서도이가이드라인에따른검사진행여부를결정한다 (Fig 1). 1) Step 1; 일단수술이응급상황인지판단하는것이중요하다. 환자상태또는수술적응증에따라심혈관계질환에대한평가나치료없이수술을진행해야되는경우가있다. 응급비심장수술이필요한환자는수술을진행하고수술후에수술기주위감시와함께위험도계층화와위험인자관리가필요하다. 응급수술이아니라면 step 2 로진행한다. 2) Step 2; Active cardiac condition 이있는지평가하고만약이에해당되면수술을연기하고 ACC/AHA 가이드라인에따른평가와치료를한후수술을결정한다. 많은경우추후치료방침을정하기위한심혈관조영술을시행하게된다. 만약이런상태가아니라면 step 3 로진행한다. (1) (2) Emergent noncardiac No (elective) Active cardiac conditions No Evaluate & treat per ACC/AHA guidelines 3) Step 3; 수술의위험도를판단한다., intermediate, low risk 로분류하며, low-risk 를하는환자들은대부분추가적인평가없이예정대로수술을진행한다. 이런환자들에있어서는심혈관계검사를하더라도대개는환자관리의방침이바뀌지않기때문에추가적검사나조치없이예정된수술을진행한다. 4) Step 4; functional capacity 를평가한다. Metabolic equivalents (METs) 가 4 이상이고증상이없는경우예정대로수술을진행한다. 5) Step 5; functional capacity 가불량하거나 (4 METs 미만 ) 거동이불편하여 functional capacity 를평가할수없는경우에해당된다. 4 METs 미만은 1~2 블록을걷지못하거나, 가벼운집안일을못하는경우, 계단이나언덕을오르지못하는경우등에해당된다. 이때는다음의 clinical risk factor 가있는지확인한다. 12 허혈성심질환 22 대상성또는기존의심부전 Surgery Consider Surgery Preoperative surveillance & postoperative risk stratification & risk factor management (3) Low-risk No (4) Functional capacity 4 METs without symtoms No or unknown (5) Clinical risk factors 0 1~2 3 Intermediaterisk with HR control or consider noninvasive testing if it will change management Consider testing if it will change management Fig. 1. Cardiac evaluation and care algorithm for noncardiac. HR, heart rate; MET, metabolic equivalents. a Consider perioperative beta-blockade for populations in which this has been shown to reduce cardiac morbidity/ mortality.

4 32 당뇨병 42 신부전 52 뇌혈관질환 Clinical risk factor 의개수와수술방법의위험도에따라추가적인평가및조치여부를결정하게된다. Clinical risk factor 가없는경우는수술방법의위험도에상관없이추가적인검사없이예정대로수술을진행하는것이적절하다. 그러나당뇨병환자는다음카테고리로생각한다 개이상의 clinical risk factor 를갖고 vascular 를예정하면치료방침의변경이예상될경우비침습적검사를시행한다 개이상의 clinical risk factor 를갖고 intermediate, 또는 1~2 개의 clinical risk factor 를갖고 vascular/intermediate 가예정되있으면심박수조절을하면서계획대로수술을진행한다. 또는비침습적검사를통하여치료방침의변경이예상된다면추가적으로비침습적검사를시행할수있다. 수술기주위약물치료 관상동맥질환을가진환자에서베타차단제의사용은비심장수술전후의심근허혈의감소, 심근경색및사망의위험성을감소시키는것으로보고되고있다. 베타차단제는수술이전부터협심증, 증상이있는부정맥, 고혈압또는현재의가이드라인적응증에따라써온환자에서는금기증이없다면지속한다. 그러나, 기존에베타차단제를써오지않았다면고용량의베타차단제를용량 titration 없이관례적으로사용하는것은유용성이없고때로는해로울수있다. 가능하면수술전수일내지수주전에시작하는것이좋고지속성제재가속효성제재보다좋을것으로보고되었다. 수술이전부터스타틴을복용하던환자는계속복용하는것이좋다. 또한 vascular 에서도스타틴의사용이권고된다. 결론 주요한비심장수술을받는대부분의환자들은수술기주위심혈관사건이발생할위험이크다. 적절한수술전평가는추가적인심장검사가필요한고위험군환자를식별해내고적절한치료를시작함으로써수술기주위, 그리고장기적인결과의호전을가져온다. 수술기주위검사는환자의관리에명백히영향을 미칠수있는경우에제한적으로시행하여야하며일반적으로, 추가적인심장검사와재개통술의적응증은수술이아닌일반적인상황에서와유사하다. 단, 수술의긴급성, 환자의위험인자, 수술자체의위험등여러요소를고려하여판단한다. 당뇨병환자는무증상관상동맥질환의유병률이높으므로적응증이되면추가적인비침습적스트레스검사를고려한다. 허혈성심질환을발견하기위해가장흔히쓰이는비침습적심장스트레스테스트로는 treadmill 또는 bicycle ergometry 이있다. 그러나, 비심장수술을받는환자의상당수가동반질환으로운동능력이제한돼있으므로이때는약물부하테스트 (d o b u t a m i n e echocardiography, dipyridamole myocardial perfusion scintigraphy) 를시행한다. 수술기주위심장위험을최소화하기위해약물치료로관상동맥질환이의심되는환자들은베타차단제, 스타틴을투여한다. 수술기주위심장위험도를줄이기위해예방적관상동맥재개통술실시하는것은효용성이없음이시사되었다. 비심장수술전평가는많은환자들에의단기적, 장기적심장위험도에대한종합적인평가를제공해주어수술기주위위험을줄일뿐아니라, 적절한근거에기인한치료로장기간결과를호전시킬수있다. 참고문헌 01. S Airaksinen KE. Silent coronary artery disease in diabetes--a feature of autonomic neuropathy or accelerated atherosclerosis? Diabetologia 2001;44: S Gu W, Pagel PS, Warltier DC, Kersten JR. Modifying cardiovascular risk in diabetes mellitus. Anesthesiology 2003;98: S Rabbitts JA, Nuttall GA, Brown MJ, Hanson AC, Oliver WC, Holmes DR, Rihal CS. Cardiac risk of noncardiac after percutaneous coronary intervention with drug-eluting stents. Anesthesiology 2008;109: S Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF ACCF/ AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac : a report of the American college of cardiology foundation/american heart association task force on practice guidelines. Circulation 2009;120:e S Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. 145

5 Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac. Circulation 1999;100: S Boersma E, Kertai MD, Schouten O, Bax JJ, Noordzij P, Steyerberg EW, Schinkel AF, van Santen M, Simoons ML, Thomson IR, Klein J, van Urk H, Poldermans D. Perioperative cardiovascular mortality in noncardiac : validation of the Lee cardiac risk index. Am J Med 2005;118: S Welten GM, Schouten O, van Domburg RT, Feringa HH, Hoeks SE, Dunkelgrün M, van Gestel YR, Goei D, Bax JJ, Poldermans D. The influence of aging on the prognostic value of the revised cardiac risk index for postoperative cardiac complications in vascular patients. Eur J Vasc Endovasc Surg 2007;34:

Pharmacotherapeutics Application of New Pathogenesis on the Drug Treatment of Diabetes Young Seol Kim, M.D. Department of Endocrinology Kyung Hee Univ

Pharmacotherapeutics Application of New Pathogenesis on the Drug Treatment of Diabetes Young Seol Kim, M.D. Department of Endocrinology Kyung Hee Univ Application of New Pathogenesis on the Drug Treatment of Diabetes Young Seol Kim, M.D. Department of Endocrinology Kyung Hee University College of Medicine & Hospital E mail : ycell2@yahoo.co.kr Abstract