Case Report J Korean Geriatr Soc 2014;18(4): Print ISSN On-line ISSN 기저질환이없는노인

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1 Case Report J Korean Geriatr Soc 2014;18(4): Print ISSN On-line ISSN 기저질환이없는노인에서급성심근경색과폐색전증이동시에발현한 1 예 좋은강안병원내과 이승환 김현석 이동석 박홍민 이태근 이용규 Simultaneous Development of ST-Segment Elevation Myocardial Infarction and Pulmonary Embolism in an Healthy Elderly Woman Seung Hwan Lee, MD, Hyun Seok Kim, MD, Dong Seok Lee, MD, Hong Min Park, MD, Tae Keun Lee, MD, Yong Kyu Lee, MD Department of Internal Medicine, Good Gang-an Hospital, Busan, Korea A 73-year-old woman who presented with chest discomfort visited the emergency room. The 12-lead electrocardiography showed ST-segment elevation in II, III, and lead augmented vector foot. Emergent coronary angiography revealed a thrombus in the distal right coronary artery. Percutaneous coronary angioplasty with a stent was performed. After the procedure, persistent dyspnea occurred. Her chest computed tomography (CT) showed occlusion of the bilateral pulmonary artery. We could not find a source for the embolization or a hypercoagulable state. We started a course of dual antiplatelets with oral anticoagulants. Pulmonary embolism was resolved at follow-up chest CT scan. Aspirin, clopidogrel and warfarin were given for 6 months. The patient is doing well now 1 year after the episode. Key Words: Myocardial infarction, Pulmonary embolism, Antithrombotic agents, Percutaneous coronary intervention 서 폐색전증은체내다른부위에서발생한혈전, 종양, 공기혹은지방등으로폐동맥의폐색을일으키는질환이다. 드물게심근병증, 부정맥, 우좌단락이나혈액응고장애등으로인하여폐색전증과급성심근병증이동시에발생한경우도보고된바있다 1-6). 기저질환이나위험요인을가지고있지않은 론 Received: July 23, 2014 Revised: September 18, 2014 Accepted: October 22, 2014 Address for correspondence: Tae Keun Lee, MD Department of Internal Medicine, Good Gang-an Hospital, 493 Suyeong-ro, Suyeong-gu, Busan , Korea Tel: , Fax: goodganganim@gmail.com 고령의여성이가슴통증을주소로내원하여심전도와심초음파를통해 ST분절상승심근경색으로진단하고혈전흡입술과경피적관상동맥성형술을시행하였다. 이후호흡곤란이지속되어흉부단층촬영을시행하여폐색전증을진단하였다. 항혈소판제제와경구항응고제를 6개월동안투여하여폐색전증은호전되었다. 위험인자가없는고령의환자에서발생한급성심근경색과폐색전증을진단하고 triple oral antithrombotic therapy 로치료한예로임상에서흔히볼수없어보고하는바이다. 증례 73세여자가수일전부터가슴이답답한증상이간헐적으로있었으나치료받지않고지내다가, 갑작스런가슴통증을 Copyright 2014 Korean Geriatric Society This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (

2 Seung Hwan Lee, et al: Treatment of Pulmonary Embolism With Acute Myocardial Infarction 호소하며응급실을방문하였다. 40년전폐결핵을진단받고완치되었으며, 다른질환으로진료받거나치료받은적은없었고, 음주와흡연은하지않았다. 응급실을방문하였을때의활력징후는혈압이 160/100 mmhg, 맥박수 77 beats/min, 체온 36.5, 호흡수 22 breaths/min 였으며, 의식은명료하였다. 다리의부종, 압통이나열감은없었다. 응급실에서시행한말초혈액검사는백혈구 5,550/mm 3, 혈색소 7.7 g/dl, 혈소판 225,000/mm 3 였고, C-reactive protein 0.42 mg/dl, aspartate aminotransferase 18 IU/L, alanine aminotransferase 11 IU/L, 총빌리루빈 0.4 mg/dl, 총단백 6.4 mg/dl, 알부민 3.9 mg/ dl, 혈액요소질소 16.0 mg/dl, 크레아티닌 1.1 mg/dl, 총콜레스테롤 134 mg/dl, 중성지방 79 mg/dl, high-density lipoprotein- 콜레스테롤 39 mg/dl, low-density lipoprotein-콜 레스테롤 77 mg/dl 였다. creatine kinase-myoglobin 3.14 ng/ml, troponin-i ng/ml, brain natriuretic peptide 841 pg/ml였다. 혈액응고검사에서 prothrombin time (PT) 11.4 초, activated partial thromboplastin time 24.2 초이었으며, 소변검사에서는특이소견없었다. 심전도검사에서맥박수 77 beats/min 이며, 하벽의허혈성심질환을나타내는소견이었다 (Fig. 1A). 흉부 X-선촬영은심비대를보였으며, 양폐야에서음영이증가되어있었다 (Fig. 2). 심초음파검사에서심박출률은 53% 로정상이었으나, 첨부를포함한우심실의운동불능증, 우심실의확장, 하대정맥의울혈, 삼첨판역류, 폐동맥고혈압소견을보였다 (Fig. 3). ST분절상승심근경색으로진단하고응급관상동맥조영술을시행하여우측관상동맥원위부가막힌것을확인하였다 Fig. 1. (A) Electrocardiography: showed ST-segment elevation in lead II, III, and lead augumented vector foot. (B) After percutaneous coronary intervention, Q wave was observed and ST elevation was changed into T-wave inversion. 252 J Korean Geriatr Soc 18(4) December 2014

이승환외 : 급성심근경색과폐색전증의치료 (Fig. 4A). 우측관상동맥의협착부위에서풍선확장술을시행하였으나혈류가회복되지않았다. 흡인카테터를이용한혈전흡입술과스텐트삽입술후원위부혈전은남아있으나, thrombolysis in myocardial infarction grade 2의혈류를확인하여 (Fig.

시술후에흉부 X선촬영은변화없었으나환자가호흡곤란을지속적으로호소하여흉부단층촬영 을시행하여양측폐동맥에서색전이있는것을확인하였다 (Fig. 5A, B). 폐색전증을진단하고두가지의항혈소판제와경구항응고제를투여하였다. 하대정맥초음파와복부단층촬영을시행하였으나하지정맥의혈전과악성종양은발견되지않았다.

3 이승환외 : 급성심근경색과폐색전증의치료 (Fig. 4A). 우측관상동맥의협착부위에서풍선확장술을시행하였으나혈류가회복되지않았다. 흡인카테터를이용한혈전흡입술과스텐트삽입술후원위부혈전은남아있으나, thrombolysis in myocardial infarction grade 2의혈류를확인하여 (Fig. 4B) aciximab 을볼루스 (bolus) 투여하고시술을종료하였다. 심전도에서보였던 II, III, lead augumented vector foot 의 ST분절상승은 T파의역전으로바뀌었고, Q파가관찰되었다 (Fig. 1B). 시술후에흉부 X선촬영은변화없었으나환자가호흡곤란을지속적으로호소하여흉부단층촬영 을시행하여양측폐동맥에서색전이있는것을확인하였다 (Fig. 5A, B). 폐색전증을진단하고두가지의항혈소판제와경구항응고제를투여하였다. 하대정맥초음파와복부단층촬영을시행하였으나하지정맥의혈전과악성종양은발견되지않았다. 항트롬빈 III 78%, 항카디오리핀항체음성, C단백활동 73%, S단백 68%, 루프스 anticoagulant 0.9 screen/confirm, Fibrinogen 421 mg/dl, Factor X 79%, 호모시스테인 μmol/l 로응고장애는동반되지않았다. 호흡곤란은항응고요법을시작한 1일후부터호전되기시작하여 3일째되던날없어졌다. 에녹사파린 (enoxaparin) 은항응고요법 5일째까지투여하였다. 3개월후추적흉부단층촬영에서이전에관찰되던폐동맥의색전은사라졌다 (Fig. 5C, D) 이후외래진료에서 6개월간와파린치료후종결하였다. 현재아스피린과클로피도그렐유지중이며, 호흡곤란증상없이지내고있다. 고 찰 Fig. 2. Chest antero-posterior X-ray showed cardiomegaly and haziness in both lung fields at admission. 폐색전증은비교적흔하지만때때로치명적일수있는질환이다 7). 대부분의폐색전증환자는비특이적증상을나타내거나때때로무증상인경우가많아진단이힘든경우도있다. 체내다른부위에서발생한혈전, 종양, 공기혹은지방등으로폐동맥의폐색을일으키는질환으로대부분심부정색혈전에의해발생하게되지만, 골반, 신장, 상지, 우심방이나우심실의혈전이원인이되기도한다 8). 혈관협착및경화반파열 Fig. 3. (A) Apical 4 chamber view of echocardiography with Doppler showed regurgitation of tricuspid valve. (B) Continuous wave mode of Tricupid valve. Peak gradient pressure between atrium and ventricle was 43.3 mmhg. J Korean Geriatr Soc 18(4) December

right coronary artery; and (B) after thrombus aspiration, balloon dilation, and stent insertion, thrombus (arrow) remained but thrombolysis in myocardial infarction grade 2 flow was observed.

4 Seung Hwan Lee, et al: Treatment of Pulmonary Embolism With Acute Myocardial Infarction Fig. 4. Coronary angiogram with selective catheterization of the right coronary artery: (A) acute phase of ST-segment elevation myocardial infarction, showing stenosis (arrow) and total occlusion of distal right coronary artery; and (B) after thrombus aspiration, balloon dilation, and stent insertion, thrombus (arrow) remained but thrombolysis in myocardial infarction grade 2 flow was observed. 에의한혈전생성이흔한원인인급성심근경색과는병태생리기전이다른지만, 드물게부정맥, 우좌단락이나혈액응고장애등으로인하여폐색전증과급성심근병증이동시에발생한경우도보고된바있다 1-6). 또, 우심실의심근경색의매우드문합병증으로도폐색전증이발생할수있으며, 고령의환자에서는악성종양으로인한혈전색전증이원인이되기도한다. 본증례의환자는심초음파, 하지정맥도플러 (Doppler) 초음파, 복부단층촬영에서혈전이나악성종양을발견하지못하였으며심초음파도플러영상에서해부학적결함이발견되지않았으나, 폐색전증이발생한경우에는혈전의유무가치료방침의결정에영향을미치지않기때문에바로항응고요법을시작하였다. 부동자세, 최근의수술, 뇌졸중, 마비, 중심정맥장치, 악성종양, 만성심장질환, 자가면역질환과정맥혈전색전증의병력이폐색전증의위험인자로알려져있으나 7), 본증례의환자는이러한위험인자나심혈관질환의위험인자로생각되는요인이없었다. 우심실심근경색과폐색전증은임상증상과진단적검사에서비슷한양상으로나타날수있어초기평가에심초음파는비침습적이고빠른검사로감별진단에도움이된다 9). 급성우심실심근경색은대부분우관상동맥근위부의폐색으로일어나기때문에대개는하벽의심근경색을유발한다. M-mode 를이용한심초음파검사에서우심실심근경색은우심실확장소견과우심실대좌심실의이완기말면적비율의증가소견을나타낼수있다 10). 반면, 폐색전증의심초음파소견으로는 Fig. 5. Chest computed tomography scan using contrast: Panels A and B showed a filling defect at pulmonary artery. (C, D) Filling defect was resolved after 3 months. 우심실확장소견, 심첨부는보존되고특히 free wall motion 의운동저하증을나타내는 McConnell Sign, D-shape의좌심실, 삼첨판역류, 폐동맥고혈압소견, 호흡과관계없이하대정맥의확장소견이있다 11). 본증례의환자는심초음파에서우심방과우심실의확장소견과더불어운동저하증을보여우심실심근경색의소견을나타내었다. 또한하대정맥의울혈소견및우심실과우심방의최대압력차가 43 mmhg 로우심실수축기압은 mmhg 로측정되어폐동맥고혈압소견이동반되어있었다 (Fig. 3). 급성관상동맥증후군의치료는항혈전치료가필수적으로적절한항혈전치료에대한많은연구가이루어지고있다. Bhatt 등 12) 의연구에따르면, 경피적관상동맥중재술을시행받은군에대한아스피린단독요법과클로피도그렐을포함하는 dual antiplatelet therapy (DAPT) 에대한연구에서 DAPT 군에서사망, 심근경색, 재시술의빈도가적고, 출혈의빈도는비슷하였다. 심방세동, 이전의정맥혈전색전증, 인공심장판막등으로장기간항응고요법이필요한경우에는두가지종류의항혈소판제제와경구항응고제를포함하는 triple oral antithrombotic therapy (TOAT) 를고려할수있는데, DAPT 와 TOAT 를비교한연구에서 TOAT 가출혈의위험은증가하였지만색전증의위험은감소시켰다 13). 하지만이연구들에서 254 J Korean Geriatr Soc 18(4) December 2014

5 이승환외 : 급성심근경색과폐색전증의치료 대부분심방세동으로경구항응고제를복용하였기때문에폐색전증을동반한급성관상동맥증후군의항혈전치료에대해서는아직확립된바없다. Oake 등 14) 은메타분석을통해와파린을복용한후 PT inernational normalized ratio (INR) 3 이상에서출혈의빈도가증가하였고, 2 미만에서색전증의빈도가유의하게증가한다고하였다. 저자들은이를바탕으로와파린을 PT INR 을치료목표로처방하였다. Walter 등 15) 에의하면급성폐색전증환자의경험적항응고요법으로혈역동학적으로안정적인환자에서는저분자량헤파린이미분획헤파린에비해사망률이낮고혈전색전증의재발률과출혈의발생이낮았다. 이를종합하여본증례의환자는에녹사파린을투여하고, 아스피린 300 mg과클로피도그렐 800 mg 을부하 (loading) 하고경피적관상동맥중재술을시행하고와파린을처방하였다. 아스피린 100 mg, 클로피도그렐 75 mg, 와파린병합치료를 6개월간유지하였고추적단층촬영에서폐색전의호전을보여, 현재아스피린, 클로피도그렐만처방중이다. 폐색전증은흔하지만때때로치명적인질환으로빠른진단과치료로치사율을낮출수있는질환이다. 특히고령의환자는폐색전증의위험요인에노출되기쉬운반면, 증상이다양하고비특이적이며, 뚜렷한위험인자나선행요인이없는경우진단의어려움을겪을수있다. 가슴통증으로내원한환자에서호흡곤란이동반되며, 심초음파검사소견이심근경색을시사하는소견이외에폐동맥고혈압소견이동반될때에는폐색전증도염두에두고접근해야한다. 급성관상동맥증후군을동반한폐색전증의치료는아직확립되어있지않지만, 본증례의환자는경피적관상동맥성형술을시행후혈전용해를시행하지않고아스피린, 클로피도그렐과와파린의항혈전치료로폐색전증이호전되었다. 이해관계명시 (Conflict of Interest Disclosures) : 저자 ( 들 ) 은본논문과관련하여이해관계의충돌이없음을천명합니다. REFERENCES 1. Cakir O, Ayyildiz O, Oruc A, Eren N. A young adult with coronary artery and jugular vein thrombosis: a case report of combined protein S and protein C deficiency. Heart Vessels 2002;17: Melhem A, Desai A, Hofmann MA. Acute myocardial infarction and pulmonary embolism in a young man with pernicious anemia-induced severe hyperhomocysteinemia. Thromb J 2009;7:5. 3. Haghi D, Sueselbeck T, Papavassiliu T, Haase KK, Borggrefe M. Paradoxical coronary embolism causing non-st segment elevation myocardial infarction in a case of pulmonary embolism. Z Kardiol 2004;93: Kim ES, Kim SH, Hur JW, Yook DS, Kim SM, Cha TJ, et al. A case of impending paradoxical embolus in a patient with acute pulmonary embolism. J Korean Soc Echocardiogr 2002;10: Lee MY, Yoon DH, Lee CW, Park KT, Ryu MS, Choi HH, et al. Concurrent coronary thromboembolism and pulmonary thromboembolism without right-to-left shunt. Korean J Med 2011;81: Kim SK, Kim SH, Cheon JH, Kim JU, Ko SH, Lee SW. Recurrent acute pulmonary embolism associated with protein s deficiency. J Korean Geriatr Soc 2013;17: Rwegerera GM, King MB. Pulmonary artery thrombosis in a patient with right-sided heart failure. Niger J Clin Pract 2014;17: Weinmann EE, Salzman EW. Deep-vein thrombosis. N Engl J Med 1994;331: Ginghina C, Caloianu GA, Serban M, Dragomir D. Right ventricular myocardial infarction and pulmonary embolism differential diagnosis: a challenge for the clinician. J Med Life 2010;3: Rallidis LS, Makavos G, Nihoyannopoulos P. Right ventricular involvement in coronary artery disease: role of echocardiography for diagnosis and prognosis. J Am Soc Echocardiogr 2014;27: McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol 1996;78: Bhatt DL, Hulot JS, Moliterno DJ, Harrington RA. Antiplatelet and anticoagulation therapy for acute coronary syndromes. Circ Res 2014;114: Dewilde WJ, Oirbans T, Verheugt FW, Kelder JC, De Smet BJ, Herrman JP, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet 2013;381: Oake N, Jennings A, Forster AJ, Fergusson D, Doucette S, van Walraven C. Anticoagulation intensity and outcomes among patients prescribed oral anticoagulant therapy: a systematic review and meta-analysis. CMAJ 2008;179: Walter RJ, Moores LK, Jimenez D. Pulmonary embolism: current and new treatment options. Curr Med Res Opin 2014;30: J Korean Geriatr Soc 18(4) December

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<4D F736F F F696E74202D20BFA1C4DA5FC0D3BBF3C3CAC0BDC6C42E BC8A3C8AF20B8F0B5E55D> 심장 (Heart) 심초음파 서울대병원내과 김용진 심장은평생몇번이나뛸까요? 1) 3 백만번 2) 3 천만번 3) 3 억번 4) 30 억번 30 억박동, 2 억리터의혈액 Cause 심장질환 6.2 12.4 11.1 16.2 뇌졸중 4.3 8.5 7.7 11.3 기타심혈관질환 2.6 5.1 6.0 8.8 심혈관질환 13.1 26.0 24.8 36.3 총사망 50.4