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1 원저 Korean Circulation J 24;34(8): 좌심실질량을이용한새로운한국인좌심실비대기준에대한연구 고려대학교의과대학내과학교실, 순환기내과 박성미 노영무 안정천 임도선 박창규 김영훈 서홍석 심완주 오동주 An Appraisal of the Electrocardiographic Criteria for Diagnosis of Left Ventricular Hypertrophy in Koreans:Comparison to Echocardiographic Measurement of Left Ventricular Mass Seong Mi Park, MD, Young Moo Ro, MD, Jung Chun Ahn, MD, Do Sun Lim, MD, Chang Gyu Park, MD, Young Hoon Kim, MD, Hong Seog Seo, MD, Wan Joo Shim, MD and Dong Joo Oh, MD Division of Cardiology, Department of Internal Medicine, Korea University, Seoul, Korea ABSTRACT Background and Objectives:Left ventricular hypertrophy (LVH) is associated with an increased risk of cardiovascular morbidity and mortality. Electrocardiography (ECG) is a widely available, simple and cost-effective screening method for the diagnosis of left ventricular hypertrophy. Since all the ECG criteria for LVH used for Koreans are based on ECG data from Caucasians, i.e., people whose body size is generally bigger than Koreans, its test accuracy may be low. The purpose of this study was to investigate by ECG the best cut-off value for LVH in terms of the left ventricular mass, as determined by echocardiogram. Subjects and Methods: We investigated ECG and echocardiograms of 2 consecutive patients who visited the Korean University Anam Hospital. The sensitivity, specificity and diagnostic accuracy of the left ventricular mass for LVH, by the Sokolow-Lyon voltage criteria and Romhilt-Estes point score, were calculated and compared according to the cut-off values of 35, 4 and 45 mm and 3, 4 and 5 points, respectively. Results:The sensitivities of the Sokolow-Lyon voltage criteria at 4 mm were slightly decreased (42.5, 37.5 and 8.8%; 35, 4, 45 mm), but the specificities and diagnostic accuracies were increased (specificities of 84.2, 95. and 99.2%, and diagnostic accuracies of 67.5, 72. and 63%; 35, 4, 45 mm). The sensitivities of a Romhilt-Estes point score of 4 points were slightly decreased (43.8, 37.5 and 13.8%; 3, 4, 5 points), but the specificities and diagnostic accuracies were increased (specificities 85.8, 94.2 and 98/3%, and diagnostic accuracies 69., 71.5 and 64.5%; 3, 4, 5 points). Conclusion:The Sokolow-Lyon voltage criteria at 4 mm or more and a Romhilt-Estes point score 4 points or more are appropriate ECG criteria for LVH in Koreans. (Korean Circulation J 24;34(8): ) KEY WORDS:Hypertrophy, left ventricular;electrocardiogram;left ventricular mass;echocardiogram. 논문접수일 :24 년 3 월 14 일심사완료일 :24 년 4 월 19 일교신저자 : 노영무, 서울성북구안암동 5 가고려대학교의과대학내과학교실, 순환기내과전화 :(2) 전송 :(2) smparkmd@korea.ac.kr 775

2 서론 좌심실비대는비정상적인심부하에대한심근의한반응형태로심장혈관질환의발병및예후와밀접한관계가있다. 1-4) 좌심실비대는고혈압이있는사람에게뿐만아니라평균수명이연장됨에따라노인인구가증가하고생활양식의변화로비만인구가증가함에따라질병이없는사람에서도나타나는경우가많으며좌심실비대그자체만으로도새로운심혈관질환의발생및합병증의위험인자로알려져있다. 5) 현재좌심실비대를진단하는방법으로는단순흉부방사선검사, 심전도검사, 심장초음파검사, 좌심실조영술등이있으며이중심전도검사는가장손쉽고비침습적이며경제적인검사법으로임상에서널리사용되고있으며특히좌심실비대의선별검사 (screening test) 에가장많이쓰이는방법이다. 그러나이방법의진단적정확도는심초음파검사법에미치지못하고있으며또한한국인에서외국인의진단기준을사용하는것에대한검토가없는실정이다. 심전도검사에서좌심실비대기준의척도는주로 QRS voltage 를이용한것으로인종, 체격, 비만, 동반된심폐질환에따라달라질수있으며전흉부유도에서 R- 파와 S- 파의크기는특히흉벽의두께에크게영향을받는것으로알려져있다. 6-9) 따라서우리가통상적으로쓰고있는심전도좌심실비대기준은체격조건이다른서양인의것으로한국인에게그대로적용하였을때진단의정확도가달라질수있다. 즉, 비교적체격이작은, 특히흉벽의두께가상대적으로얇은한국인에게동일한기준으로좌심실비대를진단하였을때예민도는높을수있으나특이도및진단의정확도는떨어질수있다. 이에비해심초음파검사를이용한좌심실비대의진단은그예민도와특이도가각각 93%, 95% 로정확도가매우높다. 1) 따라서이연구의목적은심초음파도를이용하여좌심실후벽및중벽의두께, 내강의크기등을측정하여좌심실질량을측정하고심전도에서의좌심실비대기준과비교하여현재사용하는여러방법의좌심실비대기준이타당한것인지, 또한한국인에게적합한새로운심전도의좌심실비대의진단기준치는어떤것인지를알아보는것이다. 대상및방법 연구대상은고려대학교부속안암병원에내원하여 776 심전도및심초음파검사를받은환자들을대상으로하였다. 이들중심전도에서좌각차단, 부정맥, 심초음파검사에서의국소심벽운동장애, 흉막삼출, 심낭삼출이있는경우, 흉곽형태의이상이있는환자들은제외시켰다. 전체대상은 2 명이었고평균연령은 57.2± 13.1 세였으며남자 116 명, 여자 84명이었다. 이들중기저심폐질환이없으며체중이메트로폴리탄생명표에서권장한이상체중의 8~12% 범위내에들고심초음파검사에서정상을보인 8명 ( 평균연령 56.6± 14.2 세, 남자 45명, 여자 35명 ) 을정상군으로하여좌심실질량의정상값을구하였다. 심전도검사전예에서 12유도심전도를기록하여 Sokolow- Lyon voltage 11) ( 전흉부유도에서 V1 또는 V2 의 S파와 V5 또는 V6의 R파와의합 ) 와 Romhilt-Estes point score 12) 를구하였다. 심초음파검사를이용한좌심실질량측정 Sequoir 256(Acuson, Mountainview, CA, U.S.A) 심초음파기로 5 MHz transducer 를사용하여 M- mode 심초음파도를기록하여좌심실의확장기말내경 (LVID), 심실중격두께 (IVST) 와좌심실후벽두께 (LV- PWT) 를 ASE(American Society Echocardiography) 권유방법 13) 으로측정하였으며, 좌심실질량 (LV mass) 은 cube formula를이용한 corrected ASE method 14) 로계산하였고이를체표면적 (BSA) 으로나누어좌심실질량지수값 (LV mass index) 을구하였다. ASE-cube LV mass(g)= 1.4[(LVID+IVST+LVPWT) 3 -LVID 3 ] LV mass by corrected ASE method(lvm ASE)=.8(ASE-cube LV mass)+.6 LV mass index(lvmi)=lvm ASE/BSA(g/m 2 ) 흉벽두께의측정전흉부유도에서 QRS voltage 를이용한심전도좌심실비대기준과흉벽두께와의관계를알아보기위하여환자들중흉부컴퓨터단층촬영검사 (chest CT) 를시행받은 3명을대상으로하여흉부컴퓨터단층촬영사진에서제 5늑간 ( 심첨부부위 ) 과좌측중액와선이 Korean Circulation J 24;34(8):

3 만나는부위에서흉벽의두께 (chest wall thickness) 를측정하였다 (Fig. 1). 정상군에서좌심실질량과질량지수 8명의정상군을대상으로좌심실질량과좌심실질량지수를구하였다. 심전도의좌심실비대기준과좌심실질량과의진단의정확도비교심초음파검사로측정한좌심실질량지수를기준으로 환자의좌심실비대유무를결정하였고심전도에서 Sokolow-Lyon voltage criteria 의진단기준으로각각 35 mm, 4 mm, 45 mm 일때와 Romhilt-Estes point score 에서각각 3점, 4 점, 5점일때의예민도, 특이도및진단의정확도를비교분석하였다. 통계통계적유의성을검정하기위해 paired t-test, Person s correlation coefficient test 및 Univariate analysis 를이용하였으며 p값이.5 미만일때통계적으로유의함을부여하였다. 결 과 Table 1. The subject characteristics Normal control Entire group Number 8 2 CWT Fig. 1. Measurement of chest wall thickness (CWT)(Distance of a meeting point of mid axillary line and 5th intercostal space). Men:Women (no.) 45:35 116:84* Age (years) 56.6± ±13.1* Height (cm) 159.4± ±9.* Weight (kg) 6.5± ±1.9* BSA (m 2 ) 1.63± ±.18* BMI (kg/m 2 ) 23.8± ±3.5* LVID (mm) 47.9± ±6.1 IVST (mm) 9.98± ±2.75 PWT (mm) 9.96± ±2.43 LVMASE (g) 171.9± ±82.7 LVMI (g/m 2 ) 14.7± ±45.8 Hypertension (no.) 72 *: p=ns, : p<.5. BSA: body surface area, BMI: body mass index, LVID: left ventricular internal dimension, IVST: interventricular septum thickness, PWT: posterior wall thickness, LVMASE: left ventricular mass by correted ASE menthod, LVMI: left ventricular mass index 연구대상의특성정상대조군과전체환자군의특징을비교하여보면나이성별, 체표면적등에는유의한차이가없었다 (Table 1). 고혈압이있는경우에심초음파에의한평균좌심실질량지수값이전체평균값에비해유의하게높았다 (146.3±49.6 g/m 2 vs 128.3±45.8 g/m 2 ). 정상인의좌심실질량지수값및정상상한값정상대조군에서의남녀평균좌심실질량지수값은각각 18.9±18.2 g/m 2, 99.2±15.6 g/m 2 였으며정상상한값은각평균에 2 표준편차를더한값으로남녀각각 g/m 2, 13.4 g/m 2 로정하였고이값이상일때실제좌심실비대가있다고진단하였다. Sokolow-Lyon voltage (mm) Left ventricular mass index (g/m 2 ) Fig. 2. Correlations between Sokolow-Lyon voltage criteria and left ventricular mass index (r=.44, p<.5). 777

4 심초음파와심전도의좌심실비대비교심초음파에의한좌심실질량과심전도의 Sokolow- Lyon voltage criteria 와의상관관계를보면상관계수가.44 로유의한관계를보였으며 (Fig. 2), Romhilt- Estes point score 에서는상관계수가.46 으로역시유의한상관관계를보이고있다 (Fig. 3). 좌심실질량에영향을미치는인자신장, 체중, 체표면적및체질량지수와좌심실질량과의관계를보면각각 r=.22,.37,.31,.27(fig. 4, p<.5) 로높지않은상관관계를가지고있으며그중체중이가장좋은상관관계를가지고있는것을볼수있다. 또한남자인경우좌심실질량이여자에서보다높게나왔으나 (r=.17, p<.5) 체표면적및나이를고려한다음에는의미가없었다 (F=.27, p<.5, Table 2). 나이와의관계를보았을때신장과체중을고려한다음에도좌심실질량과유의한관계가있음을보였다 (F=2.9, p<.5, Table 3). 심전도좌심실비대기준에따른진단의정확도의비교전체환자들중 12 명에서심초음파에서좌심실비 Romhilt-Estes score Left ventricular mass index (g/m 2 ) Fig. 3. Correlations between Romhilt-Estes score and left ventricular mass index (r=.47, p<.5). 3 3 Left ventricular mass (g) 2 1 Left ventricular mass (g) 2 1 r=.22 r= Height (cm) Body weight (kg) 3 Left ventricular mass (g) 2 1 Left ventricular mass (g) 2 1 r=.31 r= Body surface area (m 2 ) Body mass index (kg/m 2 ) Fig. 4. Correlations between left ventricular mass and height, body weight, body surface area, body mass index. 778 Korean Circulation J 24;34(8):

5 Table 2. Univariate analysis showing the relationship between left ventricular mass (LVMASE) and age, body surface area (BSA), and sex Regression df SS F p Total Age <.5 BSA given age <.5 Sex given age and BSA NS Residual df: degree of freedom, SS: sum of squares, F: variance ratio Table 3. Univaraite analysis showing the relationship between left ventricular mass (LVMASE) and height, body weight (BWT), and age Regression df SS F p Total Height <.5 BWT given height <.5 Age given height and BWT <.5 Residual df: degree of freedom, SS: sum of squares, F: variance ratio Table 4. Diagnostic accuracy for Sokolow-Lyon voltage criteria Sensitivity Specificity PP value Accuracy 35 mm 42.5% 84.2% 68.% 67.5% 4 mm 37.5% 95.% 76.9% 72.% 45 mm 8.8% 99.2% 87.5% 63.% PP value: positive predictive value Table 5. Diagnostic accuary for Romhilt-Estes score Sensitivity Specificity PP value Accuracy 3 points 43.8% 85.8% 67.3% 69.% 4 points 37.5% 94.2% 81.1% 71.5% 5 points 13.8% 98.3% 84.6% 64.5% PP value: positive predictive value Table 6. Univariate analysis showing the relationship between precordial voltage (Sokolow-Lyon voltage) and left ventricular mass index (LVMI) and chest wall thickness (CWT) Regression df SS F p Total LVMI <.5 CWT given LVMI <.5 Residual df: degree of freedom, SS: sum of squares, F: variance ratio point score 의좌심실비대기준으로 3점, 4 점, 5 점일때를비교하였을때예민도는각각 43.8%, 37.5%, 13.8% 로역시기준을높일수록떨어지는경향을보였고특이도도각각 85.8%, 94.2%, 98.3% 로 35 mm와 4 mm 사이에특히많이증가하였다 (Table 4, 5). 진단의정확도는 Sokolow-Lyon voltage criteria 에서 4 mm일때 72.%, Romhilt-Estes point score 에서 4점일때 71.5% 로가장높았다. 흉벽두께와 QRS voltage(sokolow-lyon voltage) 와의관계흉부전산화단층촬영을시행한 3명에서좌심실질량지수값을고려한다음흉벽두께와 QRS voltage 와의관계를알아보았을때흉벽두께가상당한영향을미침을알수있었다 (F=4.2, p<.5, Table 6). 실제심초음파검사에서좌심실비대가있으나낮은 voltage 로가음성을보였던환자들중에서 (<35 mm, <4 mm;7 명, 8명 ) 흉벽두께가평균이상으로컸던환자수가각각 3명, 4명 (42.9%, 5.%) 이었으며좌심실비대가없으나높은 voltage 로가양성을보였던환자들중 ( 35 mm, 4 mm;6 명, 2명 ) 흉벽두께가매우얇았던경우가각각 3명, 2명 (5.%, 1.%) 이었다. 고 찰 대를진단받았으며 Sokolow-Lyon voltage criteria 의좌심실비대기준으로 35 mm, 4 mm, 45 mm 일때를비교하였을때예민도는각각 42.5%, 37.5%, 8.8% 로기준을높게할수록떨어졌으나, 35 mm와 4 mm 사이에는차이가적었다. 특이도는각각 84.2%, 95.%, 99.2% 로상승하는소견을보였고 35 mm와 4 mm 사이에특히많이증가하였다. Romhilt-Estes 좌심실비대는비정상적인심부하에대한반응의한형태로서심근산소소모량을증가시키고관상동맥혈류의예비력을감소시키며심근에산소의요구와공급에불균형을초래하여협심증, 심근경색및부정맥, 급사를일으킬수있어좌심실비대의유무는환자의심혈관질환의유병률과예후판정에중요한위험인자이다. 1-4)15) 좌심실비대는심근경색의기왕력, 판막질환, 779

6 고혈압등이있는경우에더잘나타나고, 그외에도성별에따라, 비만도가높을수록, 나이가들수록증가하는것으로알려져있다. 5) 그러나알려진심혈관계질환이없는환자에서도좌심실비대가심혈관질환의이환율과관계가있음을보고하였다. 16) 본연구에서도신장, 체중, 체표면적, 체질량지수가클수록좌심실질량이증가함을보였고이것은기존에보고된바와일치하였다. 17)18) 또한남자인경우, 그리고특히체중이클수록, 신장과체중을보정후에도나이가많을수록좌심실질량이큼을알수있었다. 아마우리나라에서는개별간신장의차이가크지않아체중이크게영향을미친다고볼수있을것이다. Kannel 등 19) 의 Frammgham 연구에의하면 529명을 2년간추적조사한결과질병의유무와관계없이심전도검사에의해진단된좌심실비대가있는경우심혈관관계합병증의이환율이정상대조군의 8배, 고혈압군에비해 3배나증가한다고보고하였고, 좌심실비대가있는남자환자의 35%, 여자환자의 2% 가 5년이내에사망한다고하였다. 좌심실비대의유병률은보고된바에의하면 2) 질병이없는정상인에서 1% 정도에이르며본연구에서도 14/8 명 (17.5%) 로높게나왔다. 좌심실비대의평가방법으로단순흉부방사선검사, 심전도검사, 심초음파검사, 그리고좌심실조영술등이이용되고있다. 이중심전도검사는다른검사법에비해예민도및특이도가낮은제한점이있지만가장손쉽고비침습적이며빨리결과를얻을수있는경제적인방법으로현재까지세계적으로널리사용되어왔다. 심전도검사에서좌심실비대의진단시특이도는 85~ 95% 로크지만예민도는 25~5% 로매우다양하다. 21) 심전도에서좌심실비대의척도로는전흉부유도에서증가된전압과재분극이상을들수있다. 22) Kilty 와 Lepeschkin 23) 은 QRS voltage 에영향을주는인자로체형에대해언급하였다. 흉벽의지방조직이나근육의양이전흉부유도전극과심장사이의거리와전기전도에영향을주기때문에비만하거나체격이상대적으로큰사람에게서는좌심실비대의진단이과소평가될수있다는것이다. Dancy 24) 는피부두께를 skin caliper 로측정하여 QRS voltage 에피부두께가상당한영향을주고있음을보고하였다. 실제로임상에서심전도에서는좌심실비대소견이있으나심초음파도에서는정상을보이는경우가적지않게있고, 그반대의경우또한종 78 종경험하게된다. 따라서저자는심초음파도를이용하여좌심실후벽및중벽의두께, 이완기말좌심실의내강등을이용한좌심실질량및질량지수를측정하여현재통용되고있는서양인을기준으로한심전도좌심실비대기준과비교분석하여봄으로써현재사용하는여러방법의좌심실비대기준이타당한것인지, 또한우리나라사람에적합한진단기준은어떤것인지알아보고자하였다. M-mode 심초음파검사에서좌심실질량을 1986년 Devereux 등의방법인 corrected ASE cube formula 법으로계산한결과정상성인남자의좌심실질량은평균 g, 여자는 g으로나왔으며이는국내에서 M-mode 심초음파검사로산출한여러대학의성적과비교해볼때대상환자의연령별, 성별의차이가많고측정방법이다소달라직접비교하기는어려우나소등 25) 은남자 g, 여자 162. g, 전등 26) 은남자 176. g, 여자 156. g로저자와비슷한값을보고하였다. 또한좌심실질량을체표면적으로나눈값을좌심실질량지수로정하였을때정상성인전체좌심실질량지수평균은 14.7 g/m 2, 남자는 g/m 2, 여자는 99.2 g/m 2 로나타났으며소등 25) 은남자 11.8 g/m 2, 여자 1.5 g/m 2, 전등 26)27) 은남자 13.7 g/m 2, 여자 13.6 g/m 2 로서이결과또한저자들과비슷한값을보고하였다. 본연구에서는좌심실질량지수의정상상한치를정상인의평균에 2 표준편차를더한값으로 g/m 2, 여자 13.4 g/m 2 로하였으며외국의경우 Shub 등 28) 은정상인의좌심실질량지수상한치를남자 144 g/m 2, 여자 132 g/m 2 으로보고한적이있다. 따라서저자들의정상인의좌심실질량및질량지수상한치를심초음파도의좌심실비대기준치로사용하는데무리가없을것으로보인다. 좌심실질량지수와심전도의좌심실비대기준치와의비교에서 Sokolow-Lyon voltage criteria 기준에서유의한상관관계를나타냈으며 (r=.44 p<.5), Romhilt-Estes point score 에서도유의한상관관계를보여주었다 (r=.46, p<.5). Reicheck 등 1) 도 Sokolow-Lyon voltage criteria 기준에서 r=.3, Romhilt-Estes point score에서 r=.64 로본결과와비슷하였다. 흉부전산화단층촬영사진에서흉벽의두께를측정하여좌심실질량지수및심전도에서 QRS voltage 와 Korean Circulation J 24;34(8):

7 비교해본결과흉벽두께가 QRS voltage 에상당한영향을미치며가음성을보였던환자들중에서 (<35 mm, <4 mm;7 명, 8명 ) 흉벽두께가평균이상으로컸던환자수가각각 3명, 4명 (42.9%, 5.%) 이었으며좌심실비대가없으나높은 voltage 로가양성을보였던환자들중 ( 35 mm, 4 mm;6 명, 2명 ) 흉벽두께가매우작았던경우가각각 3명, 2명 (5.%, 1.%) 이었다. 따라서저자들은한국인에게맞는좌심실질량을기준으로좌심실비대를진단할때, 심전도만으로간편하게그리고정확하게진단하기위한방법의일환으로, 실제로심초음파도의좌심실질량지수와심전도의좌심실비대기준으로 Sokolow-Lyon voltage criteria와 Romhilt-Estes point score 와의상관관계를비교분석하여본결과이들모두예민도가낮아특이도를높인기준으로진단의정확도를높여보고자하였다. 좌심실비대기준으로 Sokolow-Lyon voltage criteria 에서기준을 35 mm 와 4 mm 를비교하여보았을때예민도는감소하는경향이있으나 (42.5% vs 37.5%), 특이도및진단의정확도는증가하였다 (84.2% vs 95.%, 67.5% vs 72.%). Romhilt-Estes point score에서도 3점와 4점을비교하여보았을때예민도는감소하였으나 (43.8% vs 37.5%), 특이도및진단의정확도는증가하였다 (85.8% vs 94.2%, 69.% vs 71.5%). 두기준모두에서그기준치를매우높게잡았을때 (Sokolow- Lyon voltage criteria 45 mm, Romhilt-Estes point score 5점 ) 는특이도는 1% 에가까우나예민도가각각 8.8%, 13.8% 로너무낮아진단적가치가없는것으로생각된다. 이번연구의제한점으로볼수있는것은첫째심초음파검사에있어서관찰자의오차가있을수있다는점이다. 이러한오차를줄이기위해서 ASE 검사법을사용함으로서좌심실의중벽과후벽의심내막두께를제거하여측정하던 PENN convention 방법에서의높은오차를다소줄일수있었으리라생각된다. 둘째로대칭성심실비후, 비대칭성심실중격비후, 좌심실확장등에의한좌심실비대의유형을나누어비교하지않았다는점이다. 실제적으로좌심실확장없이경, 중등도의심실벽비후만있었던경우에가음성이많았다. 세번째로병원에내원하여심전도및심초음파검사를시행받은환자들을대상으로하였기때문에비교적평균연령이높 았다는것이다. 마지막으로좌심실질량의증가와심전도의좌심실비대기준을직접비교하는것이과연타당한가하는점이다. 위에서제한점으로지적한바와같이대칭성좌심실비후, 중격비후, 후벽비후등에따른세분화된검사로심전도의좌심실비대의진단기준과비교하여좀더진단적가치가큰것이있는지를검토하여야할것이다. 결론적으로저자들은심초음파도를이용한정상인의평균좌심실질량및좌심실질량지수의상한치를제시하였고이를심전도좌심심비대기준과비교하여객관적인자료를제시하였다는데의의를둘수있겠으며또한한국인에서심전도좌심실비대기준으로 Sokolow- Lyon voltage criteria 는 4 mm 이상, Romhilt-Estes point score 는 4점이상이진단적가치가높을것으로보여이의이용을제기하는바이다. 요약 배경및목적 : 좌심실비대는심혈과질환의존재및예후와밀접한관계가있다. 좌심실비대를진단하는방법들중심전도검사는가장손쉽고경제적인선별검사법으로우리나라에서널리사용되고있다. 그러나심전도를이용한좌심실비대기준은비교적체구가큰서양인을대상으로한것으로한국인에게적용시켰을때진단의정확성이낮을수있다. 따라서이연구의목적은심초음파에의한좌심실질량을측정하여한국인에적합한심전도좌심실비대기준을알아보고자하였다. 방법 : 고려대학교부속안암병원에내원하여심전도및심초음파검사를받은 2 명의환자들을대상으로하였다. 12유도심전도에서 Sokolow-Lyon voltage criteria ( 35 mm, 4 mm, 45 mm) 와 Romhilt-Estes point score( 3 points, 4 points, 5 points) 을좌심실비대기준으로이용하여각각의예민도및특이도, 진단의정확도를비교분석하였다. 결과 : Sokolow-Lyon voltage criteria 에서좌심실비대기준으로 4 mm 이상으로하였을때예민도는약간낮아졌으나 (42.5%, 37.5%, 8.8%; 35 mm, 4 mm, 45 mm) 특이도및진단의정확도는증가하였다 (spe- 781

8 cificity 84.2%, 95.%, 99.2%, diagnostic accuracy 67.5%, 72.%, 63%; 35 mm, 4 mm, 45 mm). Romhilt-Estes point score 에서도좌심실비대기준으로 4점이상으로하였을때예민도는약간낮아졌으나 (43.8%, 37.5%, 13.8%; 3 points, 4 points, 5 points) 특이도및진단의정확도는증가하였다 (specificity 85.8%, 94.2%, 98/3%, diagonostic accuracy 69.%, 71.5%, 64.5%; 3 points, 4 points, 5 points). 결론 : 한국인에서심전도좌심실비대기준으로 Sokolow- Lyon voltage criteria에서 4 mm 이상, Romhilt- Estes point score 에서 4점이상이진단적가치가높을것으로보인다. 중심단어 : 좌심실비대 ; 심전도 ; 좌심실질량 ; 심초음파. 782 REFERENCES 1) Levy D, Garrison RJ, Savage DD, Kannel WB, Castelli WP. Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Study. N Engl J Med 199;322: ) Casale PN, Deverreux RB, Milner M, Zullo G, Harshfield GA, Pickering TG, Laragh JH. Value of echocardiographic measurements of left ventricular mass in predicting cardiovascular morbid events in hypertensive men. Ann Intern Med 1986;15: ) Sullivan JM, Zwaag RV, el-zeky F, Ramanathan KB, Mirvis DM. Left ventricular hypertrophy: effect on survival. J Am Coll Cardiol 1993;22: ) Levy D, Garrison RJ, Savage DD, Kannel WB, Castelli WP. Left ventricular mass and incidence of coronary heart disease in an elderly cohort. Ann Intern Med 1989;11: ) Levy D, Anderson KM, Savage DD, Kannel WB, Christiansen JC, Castelli WP. Echocardiographically detected left ventricular hypertrophy: prevalence and risk factors. Ann Intern Med 1988;18: ) Levy D, Labib SB, Anderson KM, Christiansen JC, Kannel WB, Castelli WP. Determination of sensitivity and specificity of electrocardiographic criteria for ventricular hypertrophy. Circulation 199;81: ) Chou TC. Left Ventricular Hypertrophy: Electrocardiography in Clinical Practice, Adult and Pediatric. 4th ed. Philadelphia: W.B. Saunders; p ) Rudy Y, Wood R, Plonsey R, Lieman J. The effect of high lung conductivity on elecrocardiopotentials. Circulation 1982; 65: ) Horton JD, Sherber HS, Lakatta EG. Distance correlation for precordial electrocardographic voltage in estimating left ventricular mass: an electrocardiographic study. Circulation 1977;55: ) Reichek N, Devereux RB. Left ventricular hypertrophy: relation of anatomic, echocardiographic findings. Circulation 1981;63: ) Sokolow M, Lyon TP. The left ventricular hypertrophy as obtained by unipolar precordial and limb leads. Am Heart J 1949;37: ) Romhilt DW, Estes EH Jr. A point score system for the electrocardiographic diagnosis of left ventricular hypertrophy. Am Heart J 1968;75: ) Sahn DJ, DeMaria A, Kisslo J, Weyman A. Recommandations regarding quantitation in M-mode echocardiography: results of a survey of echocardiographic measurements. Circulation 1978;58: ) Devereux RB, Anlonso DR, Lutas EM, Gottlieb GJ, Campo E, Sachos I, Reichek N. Echocardiographic assessment of left ventricular hypertrophy: comparison to necropsy findings. Am J Cardiol 1986;57: ) Levy D, Garrison RJ, Savage DD, Kannel WB, Castelli WP. Left ventricular mass and incidence of coronary heart disease in an elderly cohort. Ann Intern Med 1989;11: ) Ghali JK, Liao Y, Simmons B, Castaner A, Cao G, Cooper RS. The prognostic role of left ventricular hypertrophy in patients with or without coronary disease. Ann Intern Med 1992;117: ) de Smone G, Daniels SR, Devereux RB, Meyer RA, Roman MJ, de Divitiis O, Alderman MH. Left ventricular mass and body size in normotensive children and adults: assessment of allometric relations and impact of overweight. J Am Coll Cardiol 1992;2: ) Lauer MS, Anderson KM, Larson MG, Levy D. A new method for indexing left ventricular mass for difference in body size. Am J Cardiol 1994;74: ) Kannel WB. Prevalence and natural history of electrocardiographic left ventricular hypertrophy. Am J Med 1983; 75: ) Hammond IW, Alderman MH, Devereux RB, Lutas Em, Spitzer MC, Crowley JS, Laragh JH. The prevalence and correlates of echocardiographic left ventricular hypertrophy among employed patients with uncomplicated hypertension. J Am Coll Cardiol 1986;7: ) Romhilt DW, Bove KE, Norris RJ, Conyers E, Conradi S, Rowlands DT, Scott RC. A critical appraisal of the ECG criteria for the diagnosis of left ventricular hypertrophy. Circulation 1969;4: ) Casale PN, Deverreux RB, Klogfield P, Eisenberg RR, Miller DH, Chaudhary BS, Phillips MC. Electrocardiographic detection of left ventricular hypertrophy: development and prospective validation of improved criteria. J Am Coll Cardiol 1985;6: ) Kilty SE, Lepeschkin E. Effect of body build on the QRS voltage of the electrocardiogram in normal men: its significance in the diagnosis of left ventricular hypertrophy. Circulation 1965;31: ) Dancy M. Factors affecting the relationship between precordial electrocardiographic voltage and left ventricular wall thickness. Eur Heart J 1987;8: ) So JB, Son SS, Kim SH, Jung JW, Park YK, Park OK. Relation of left ventricular mass to body size and left ventricular wall stress in normal adults. Korean Circ J 1996;26: ) Chun HC, Kim YK, Kim KY, Kim JY, Cha SE, Cho SW, Korean Circulation J 24;34(8):

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한국성인에서초기황반변성질환과 연관된위험요인연구

한국성인에서초기황반변성질환과 연관된위험요인연구 한국성인에서초기황반변성질환과 연관된위험요인연구 - - i - - i - - ii - - iii - - iv - χ - v - - vi - - 1 - - 2 - - 3 - - 4 - 그림 1. 연구대상자선정도표 - 5 - - 6 - - 7 - - 8 - 그림 2. 연구의틀 χ - 9 - - 10 - - 11 -