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1 원저 Korean Circulation J 2003;33(4): 급성전벽심근경색증후심근회복을예측할수있는관상동맥혈류의형태 가톨릭대학교의과대학내과학교실 윤호중 박철수 조은주 정해억 전희경 정욱성김종진 승기배 채장성 김재형 최규보 홍순조 Coronary Artery Flow Velocity Pattern Predicting Myocardial Recovery after Acute Anterior Myocardial Infarction Ho-Joong Youn, MD, Chul-Soo Park, MD, Eun-Ju Cho, MD, Hae-Ok Jung, MD, Hui-Kyung Jeon, MD, Wook-Sung Chung, MD, Jong-Jin Kim, MD, Ki-Bae Seong, MD, Jang-Seong Chae, MD, Jae-Hyung Kim, MD, Kyu-Bo Choi, MD and Soon-Jo Hong, MD Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea ABSTRACT Background and Objectives:The relationship between the coronary artery flow velocity pattern on the distal left anterior descending coronary artery (LAD), using transthoracic Doppler echocardiography (TTE) and myocardial recovery, following an acute myocardial infarction (MI), has not been studied. Subjects and Methods:The coronary flow velocity at the distal LAD was recorded with TTE, immediately, on the 7th day, and at an average, on the 10th month, in 36 patients following an acute anterior MI. The peak diastolic coronary flow velocity (PDV), the initial velocity pattern and alteration in the velocity pattern, during the follow-up period, were analyzed by the changes in the left ventricular systolic function and the anterior apical wall motion. The subjects were divided into two groups: the recovery (R) group: n=24, M:F=14:10, mean age=60±9 yrs; and the non-recovery (NR) group: n=12, M:F=11:1, mean age=61±11 yrs, according to their myocardial recovery status. Results: The early flow velocity at the distal LAD, using TTE after MI, was divided into 4 patterns; a normal biphasic flow pattern, with a larger diastolic and a smaller systolic component; a pattern, with slow flow and deceleration slope; a pattern, with a retrograde flow; and a pattern, with a rapid diastolic deceleration slope and an early systolic reversal flow. A normal biphasic flow pattern was observed in 16 (66%) of the R-group (n=24), and 1 (8%) of the NR-group (n=12) (p=0.001) patients. A rapid diastolic deceleration slope and an early systolic reversal flow pattern was only observed in 4 of the NR-group (n=12) (p=0.003) patients. Conclusion:The patterns, with a rapid diastolic deceleration slope and a systolic retrograde flow, early after MI, and a persistent slow flow velocity during follow up, are related to poor myocardial recovery following an acute anterior MI. (Korean Circulation J 2003;33 (4): ) KEY WORDS:Coronary disease;blood flom velocity;myocardial infarction;echocardiography. 논문접수일 :2002 년 11 월 19 일수정논문접수일 :2002 년 12 월 30 일심사완료일 :2003 년 11 월 14 일교신저자 : 윤호중, 서울영등포구여의도동 62 가톨릭대학교의과대학성모병원내과학교실전화 :(02) 전송 :(02) younhj@catholic.ac.kr 259

2 서론 급성심근경색증환자에서경피적관동맥풍선성형술이혈전용해제치료에비하여혈관재개통률및임상적결과에있어서우수하다는것이이미알려져있지만 1-3) 시술후에도지속되는느린혈류속도는좌심실기능의회복지연또는불량한기능회복과밀접한관련이있으며이는심근경색후미세혈관장애로인한것이라는보고들이있어왔다. 4-6) 관상동맥혈류속도의저하는조영술상조영제의느린진행속도를통해서관찰할수있으며대부분의경우에병적인상태-즉심근경색후심한잔류협착및심근내미세혈관의손상등-을시사해주며관상동맥풍선확장술및스텐트삽입술후혈류속도가개선된다. 7-10) 객관성있는관상동맥의혈류속도의측정을위하여관상동맥조영술상의 TIMI flow grade 11)12) 또는 TIMI frame count 13)14) 나 Doppler guide wire 15)16) 와같은관혈적인검사방법을이용하게되었다. TIMI flow grade나 TIMI frame count(tfc) 는관상동맥조영술을이용하여비교적손쉽게측정할수있고, Doppler guide wire는관상동맥혈관에서의절대혈류속도를측정할수있는방법으로서임상적으로유용한정보를제공해왔다. 한편관상동맥의좌전하행지원위부는심실간구 (interventricular groove) 를거쳐주행하며흉벽과는불과 1~4 cm 정도밖에떨어져있지않기때문에최근개발된 6-MHz 이상의고주파탐촉자를이용하여경흉부적으로좌전하행지원위부에서의관상동맥혈류의관찰이가능해지게되었다 ) 그러나급성심근경색증환자에서경흉부심초음파를이용하여측정된좌전하행지원위부의혈류속도및혈류의형태가갖는임상적의미와그중요성에대해서는아직까지평가된적이없었다. 저자들은급성전벽심근경색증환자에서기저상태에서의좌전하행지원위부의혈류를장기간추적관찰함으로써심근경색증에서관상동맥의혈류속도및혈류형태와좌심실기능회복과의관련성을알아보고자본연구를시행하였다. 대상및방법 대상가톨릭의대성모병원에흉통을주소로내원한환자중내원당시설하나트로글리세린에반응하지않는흉 260 통이 30분이상지속되었고, 심전도상전흉부 ST 분절이 2 mm 이상상승되거나 CPK 효소치가정상범위보다 2배이상증가를보였던전벽심근경색증환자 36명 ( 남 : 여 =25:11, 평균연령 =61±10 세 ) 을대상으로하였으며과거력상심근경색증의병력, 중등도이상의판막질환, 일차성심근증, 심전도상좌각차단및심인성 shock 이있었던경우는본연구에서제외하였다. 대상환자중 6명은내원후혈전용해제치료만받았으며, 12명에서는혈전용해제치료후일주일이내에관동맥중재술을, 2명의환자에서는혈전용해제치료없이직접관동맥중재술 (Direct percutaneous coronary intervention), 6명에서는혈전용해제치료후일주일이후에지연관동맥중재술 (Delayed percutaneous coronary intervention) 를받았고나머지 10명의환자에서는당시의여러가지상황-환자의치료거부, 흉통후내원시간의지연등-으로어떤치료도받지못하였다. 경흉부심초음파를이용한벽운동장애및관상동맥좌전하행지원위부혈류의측정 36명의환자를대상으로급성전벽심근경색증으로진단받은당일, 1주일째, 그리고평균 10 개월 ( 범위 7~ 13개월 ) 이후에전향적이고연속적으로심초음파검사를시행하였으며 (Fig. 1) 16분절벽운동분류기준에따라서벽운동장애를관찰하였으며, 그중에서좌전하행지의분포부위인전벽심첨부의한분절 (anteroapical segment) 의벽운동장애를점수화 ( 정상벽운동 =1, 운동저하 =2, 무운동 =3, 운동실조 =4) 하여평가하였다. 회복군과비회복군의정의는시기별로벽운동점수, 좌심실의용적, 및좌심실구혈률 (left ventricular ejection fraction) 을측정하여평균 10개월후심근경색증으로진단받은당일에비하여 1) 전벽심첨부분절의벽운동점수가한단계이상호전된경우, 2) 좌심실수축기용적 AMI Immediate LAD Flow using TTE WMS LV volume & EF CAG 1 week PCI LAD Flow using TTE WMS LV volume & EF 10th month LAD Flow using TTE WMS LV volume & EF Fig. 1. Study protocol. AMI:acute anterior myocardial infarction, LAD:left anterior descending coronary artery, WMS:wall motion score, EF:ejection fraction, CAG: coronary angiogram, PCI:percutaneous coronary intervention. Korean Circulation J 2003;33(4):

3 이감소된경우및 3) 좌심실구혈률이 10% 이상개선된경우를회복군 (Recovery group, R-group) 으로, 1) 전벽심첨부분절의벽운동점수가개선이되지않거나오히려악화된경우 2) 좌심실수축기용적이증가된경우및 3) 좌심실구혈률이감소된경우를비회복군 (Nonrecovery group, NR-group) 으로나누어분류하였다. 좌전하행지원위부에서의혈류측정은 5~12 MHz 의주파수범위를갖는탐촉자 (Ultraband transducer, H- P Sonos 5500) 를좌측쇄골중앙선상의 4번째와 5번째늑간사이에위치시킨후심첨 2방도를변형시켜서심첨부를보이게한후기계에내장되어있는낮은속도범위 (low velocity range) 를갖는색도플러를작동시켜서, 심첨부근처에붉은색의관상의전향적혈류가관찰되면, 가능한 sample volume 을혈류방향에수평이되도록각도를조절한후간헐파형도플러상이완기가주를이루는혈류가확인되면이를기록하였다 (Fig. 1). 간헐파형도플러상최대이완기혈류속도 (peak diastolic velocity, PDV, cm/sec) 는생리학적범위의심박수 (60~100 회 / 분 ) 내에서 3회이상의심주기에서측정하여평균을구하였으며각시기별로관상동맥혈류의형태변화를관찰하였다. 대상환자에서관상동맥혈류를측정하는동안심인성 shock 이나고혈압범위의혈압을보이는경우는없었다. 혈류형태에따른분류상느린혈류속도는이완기혈류속도가 13 cm/s 이하로정의하였으며, 20) 이완기초기혈류속도의감속속도가 600 ms 미만이면서수축기초기에역류성혈류를보일때급속경사를보이는형태로정의하였다. 21) 이완기혈류속도가 13 cm/s 이상이면서, 이완기초기혈류속도의감속속도가 600 msec 이상일때정상혈류형태로정의하였고, 이완기혈류속도의방향이반대로기록될때역류성혈류로정의하였다. 관상동맥조영술모든환자에서내원 1주일이내에기존의방법을이용하여관상동맥조영술이시행되었고, Quantitative Coronary Analysis(QCA) system 을이용하여 % 내경협착 (percent diameter stenosis), 병변의길이 (mm) 를측정하였으며, 좌전하행지의병변형태는 ACC/AHA guideline 22) 에따라서 A 및 B1 병변은단순병변 (simple lesion) 으로, B2 및 C 병변은복합병변 (complex lesion) 으로분류하였고의미있는협착은 70% 이상으로정의하였다. 관상동맥조영술중좌전하행지의 TIMI flow 는심초음파검사결과를모르는상태에서두명의심장내과전문의에의하여분석되었다. 20명의환자에서스텐트삽입술이시행되었는데, 시술전모든환자에게 aspirin 과 clopidogrel 또는 ticlopidine 을투여하였고, 유도초삽입후 10,000 단위의헤파린을투여하였으며시술중간헐적으로헤파린을투여하여활성응고시간을 300초이상으로유지하였다. 일차적스텐트시술은 6F 또는 7F 유도도관을이용하여일반적인방법으로시행하였으며대부분환자에서병변부위를풍선도자로먼저확장한후스텐트를삽입하였다. 성공적인스텐트시술은시술후잔여협착이 30% 미만이면서 TIMI flow 가 2도이상으로유지되는경우로정의하였다. 통계분석모든자료는평균 ± 표준편차로표시하였으며통계분석에는윈도우용 SPSS 8.0(Statistical Package for Social Science) 프로그램을이용하였고두군간의비교는 Student s t-test 와 Chi Square 분석으로구하였으며, 시기별세군간의비교는 repeated measured Table 1. Clinical characteristics R-group NR-group Number Age (yrs) 60±09 61±11 Sex 14:10 11:1 HTN (%) 12 (50) *2 (17)* NIDDM (%) 07 (29) 2 (17) TC (mg/dl) 191± ±51 TG (mg/dl) 114± ±82 HDL (mg/dl) 044±150 44±9 CPK 2204± ±3273* Q MI (%) 16 (67) **0 (100)* Initial EF (%) 49.1±13.8 *43.5±7.5 F/U EF (%) 063.7± *40.9±9.6* Initial WMS 03.08± ±0.76 F/U WMS 03.25± ±0.87* Value are mean±sd. R-group:recovery group, NR-group:nonrecovery group, HTN:hypertension, NIDDM: noninsulin dependent diabetes, TC:total cholesterol, TG:triglyceride, HDL:high density lipoprotein cholesterol, CPK:creatine phosphokinase, Q-MI:Q wave myocardial infarction, F/U:follow up, WMA:wall motion score, *:p<0.05 versus R-group 261

ANOVA 를이용하여, p 값이 0.05 미만인경우에통계적유의성을두었다. 결과 임상적인특징 (Table 1) 장기추적관찰에서좌심실의회복군 (R-group) 에서는심근경색초기좌심실이완기용적이 69.3±23.5 ml 에서 68.6±26.6 ml로유의한차이를보이지는않았으나, 좌심실수축기용적은 36.7±18.7 ml에서 25.9± 14.

4 ANOVA 를이용하여, p 값이 0.05 미만인경우에통계적유의성을두었다. 결과 임상적인특징 (Table 1) 장기추적관찰에서좌심실의회복군 (R-group) 에서는심근경색초기좌심실이완기용적이 69.3±23.5 ml 에서 68.6±26.6 ml로유의한차이를보이지는않았으나, 좌심실수축기용적은 36.7±18.7 ml에서 25.9± 14.6 ml로유의하게감소하였고 (p<0.05), 비회복군 (NR-group) 에서는심근경색초기좌심실이완기용 적이 85.5±24.9 ml에서 99.9±35.7 ml 로유의하게증가하였고 (p<0.05), 좌심실수축기용적또한 48.7± 17.0 ml에서 59.7±25.4 ml로유의하게증가하였다 (p<0.05). 좌심실의회복군 (R-group) 에서는심근경색초기좌심실구혈률이 49.1±13.8% 에서 63.7±8.7% 로유의하게향상되었으나 (p<0.05), 비회복군 (NRgroup) 에서는 43.5±7.5% 에서 40.9±9.6% 로감소하였으며, 장기추적후두군간에는유의한차이를보였다 (p<0.05). 전벽심첨부의벽운동점수는회복군에서 3.08±0.51에서 3.25±0.62 로향상되었고, 비회복군에서는 2.83±0.76에서 1.83±0.87 로유의하게감소하였으며장기추적후두군간에는유의한차이를보였다 A B C D Fig. 2. Flow patterns of distal LAD immediate after AMI and their schematic representation. A:normal pattern showing biphasic flow with lager diastole and smaller systole, B:pattern showing slow flow less than 13 cm/sec and slow deceleration slope, C:pattern showing rapid diastolic deceleration slope less than 600 ms and early systolic flow reversal, D:pattern showing retrograde flow. 262 Korean Circulation J 2003;33(4):

(p<0.05). 임상적으로좌심실의비회복군에서회복군에비하여 CPK 효소치와 Q파심근경색의빈도가유의하게높았다 ( 각각 p<0.05). 관상동맥조영술상의비교 (Table 2) 관상동맥조영술상비회복군이회복군에비하여좌전하행지의협착정도가유의하게심하였고 (p<0.05), ACC/ AHA guideline 에따른병변분류상복합병변이유의하게많았다 (p<0.05). 급성심근경색증초기에관찰되는좌전하행지원위부의혈류형태 (Fig.

5 (p<0.05). 임상적으로좌심실의비회복군에서회복군에비하여 CPK 효소치와 Q파심근경색의빈도가유의하게높았다 ( 각각 p<0.05). 관상동맥조영술상의비교 (Table 2) 관상동맥조영술상비회복군이회복군에비하여좌전하행지의협착정도가유의하게심하였고 (p<0.05), ACC/ AHA guideline 에따른병변분류상복합병변이유의하게많았다 (p<0.05). 급성심근경색증초기에관찰되는좌전하행지원위부의혈류형태 (Fig. 2) 급성심근경색증으로내원한직후경흉부도플러심초음파로측정된좌전하행지원위부의혈류는 4가지의혈류형태로구분할수있었는데, 전체환자중 17명 (47%) 에서는이완기가수축기보다큰정상적인혈류형태를 (Fig. 2A), 11명 (31%) 에서는이완기혈류속도가 13 cm/s 미만으로매우느리면서감속경사 (deceleration slope) 가느린형태를 (Fig. 2B), 4명 (11%) 에 Table 3. Coronary artery flow pattern in both groups 서는이완기감속경사가 600 ms 미만으로매우급하면서수축기초기에역류성혈류를보이는형태를 (Fig. 2C), 4명 (11%) 에서는이완기와수축기가모두역류되어있는형태 (Fig. 2D) 를보였다. 두군간혈류형태의비교 (Table 3) 심근경색직후, 정상적인관상동맥혈류형태는회복군에서는 24명중 16명 (66%), 비회복군에서는 12명중 1명 (8%) 으로서비회복군에서그빈도가유의하게낮았으며 (p=0.001), 이완기감속경사가매우급하면서수축기초기에역류성혈류를보이는형태는오직비 Table 2. Angiographic characteristics R-group NR-group Max diameter stenosis (%) 79±25 95±6* Lesion length (mm) 14.5± ±5.5 B2 & C on ACC/AHA (%) 14 (58) 12 (100)* TIMI III (%) 14 (58) 07 (58) Multivessel Disease (%) 11 (46) 06 (50) Value are mean±sd. R-group:recovery group, NR-group:nonrecovery group, *:p<0.05 versus R-group R-group (n=24) NR-group (n=12) p 16 (66%) 1 (08%)* (25%) 5 (42%)* NS 00 (00%) 4 (33%)* (08%) 2 (17%)* NS R-group:recovery group, NR-group:nonrecovery group, *:p<0.05 versus r-group. 263

6 cm/s P=NS 17.6± ± ±13.3 Immediate 1 week 10th month R-group cm/s P=NS 15.8± ± ±12.6 Immediate 1 week 10th month NR-group Fig. 3. Serial follow up of flow velocity of distal LAD, R-group:recovery group, NR-group:nonrecovery group, NS:not significant. 회복군의 4명에서만관찰되었다 (p=0.003). 이완기혈류속도가매우느리면서감속경사가느린혈류형태와역류성혈류형태는비회복군에서더많이관찰되었지만통계적인유의성은없었다. 두군간혈류속도및형태의추적관찰 (Fig. 3) 회복군에서의혈류속도는심근경색초기에 17.6± 22.7 cm/s 에서장기추적시 23.9±13.3 cm/s 로통계학적으로유의하지는않았지만점차적인상승을관찰할수있었으며특히역류성혈류는재관류시술후정상적인전향적혈류형태로의변화를보였다. 비회복군에서의혈류속도는초기에 15.8±28.1 cm/s 에서장기추적에서 13.6±12.6 cm/s 로초기혈류속도가회복되지않거나오히려저하되는경향을보였다. 특징적으로, 비회복군에서이완기감속경사가매우빠르면서수축기초기에역류성혈류를보이는형태를보였던 4명중 2 명에서는같은형태의혈류가장기간지속되었으며, 나머지두명에서는느린혈류속도로변화하는것을관찰할수있었다. 고찰 심근경색증후 TIMI flow 는잔류협착의정도를시 사하며, 재관류치료후지속적으로 TIMI flow 가낮을경우미세혈관기능의장애및좌심실기능회복의지연등과관련이있다는보고가있었으며 4)12) TIMI 2 flow 가 TIMI 3 flow 에비하여현저히나쁜예후를보여주었기때문에재관류치료의일차적인목표는 TIMI 3 flow 가되어야된다는여러증거들이강조되어왔다. 23) Doppler guide wire가개발되면서관상동맥혈류속도를정확하게측정할수있게되었고관상동맥의혈류역학적평가에많은도움을주었지만관혈적인검사방법이기때문에임상에서연속적으로추적관찰하기는어려운실정이다. 15)16) 이러한면에서최근개발된고주파경흉부심초음파탐촉자와낮은속도범위를갖는특별한프로그램을이용하게되면좌전하행지원위부의혈류속도를손쉽게측정할수있으며 Doppler guide wire 와의비교연구에서그상관도가매우높은것으로입증되어왔다 ) 본연구를통하여급성심근경색증으로내원후경흉부도플러심초음파로측정된좌전하행지원위부의혈류는 4가지혈류형태 (Fig. 2), 즉이완기가수축기보다큰정상적인이면성의혈류형태, 이완기혈류속도가매우느리면서감속경사가느린형태, 이완기감속경사가매우급하면서수축기초기에역류성혈류를보이는형태, 이완기와수축기가모두역류되어있는형 264 Korean Circulation J 2003;33(4):

7 태로구분할수있었다. 장기추적에서좌심실의기능회복을보인환자군의 66% 에서는급성심근경색증초기에정상적인혈류의형태를보였는데이는비교적성공적인재관류가이루어졌음을시사해준다. 이완기와수축기가모두역류되어있는역류성혈류형태는전체환자중 11% 에서관찰되었는데모두좌전하행지의완전폐색으로측부혈관에의해원위부에서역류성혈류가관찰되는경우로서비교적측부혈류가잘발달된상태를나타낸다. 경흉부심초음파상좌전하행지원위부에서관찰되는역류성혈류는좌전하행지의완전폐색을진단하는데있어서그예민도와특이도가매우높은것으로보고되어있다. 24) 역류성혈류는장기추적에서정상적인전향적혈류의형태로회복되었는데이는좌전하행지의혈류가관동맥중재술후재개통되었거나다른측부혈류를통해서혈류가전향적으로이루어진경우로추정할수있다. 심근경색후좌전하행지원위부에서관찰되는느린감속경사와함께느린혈류속도를보이는형태는전체환자중 31% 에서관찰되었다. 저자들은앞서시행한연구들 20)25) 에서느린혈류속도는좌전하행지의협착정도뿐아니라협착병변의형태-단순또는복잡병변- 를시사함을관찰하였으며, 13 cm/s 미만의이완기혈류속도는복잡병변을시사하는데각각 73.4% 의예민도와 85.6% 의특이도를나타냄을보고한바있다. 심근경색후 TIMI flow 의정도는잔류협착의정도를시사하며, 본연구에서심근경색증초기에관찰되는느린혈류속도를보이는형태는좌심실기능이회복되지않은군에서회복된군에비하여많이관찰되었지만통계학적인유의성은없었으며좌심실기능이회복된군에서는장기추적에서혈류속도가아울러향상되는것을관찰할수있었다. 최근 Kawamoto 등 21) 과 Akasaka 등 26) 은급성심근경색증의재관료치료후 Doppler Guide wire 를이용한연구에서 TIMI Ⅱ flow 를두가지형태로나누어느린혈류속도와느린감속속도를보이는형태를 type 1 TIMI Ⅱ로, 빠른이완기감속경사와수축기초기에역류성혈류를보이는형태를 type 2 TIMI Ⅱ로분류하였으며, 전자의형태는스텐트삽입술후혈류가개선되었으나, 후자의형태는혈류의개선이이루어지지않았을뿐아니라심근회복도전자에비하여불량하였음을보고하였다. Iwakura 등 27) 은급성심 근경색증환자의재관료치료후 Doppler Guide wire 와심근조영심초음파를이용한연구에서이러한형태의혈류가 no reflow 와관련이있음을보고하였다. 저자들역시경흉부심초음파를이용하여빠른이완기감속경사와수축기초기에역류성혈류를보이는형태의혈류를관찰하였는데이러한형태는모두장기추적관찰에서심기능이회복되지않은환자에서만관찰되었다. 이러한관상동맥혈류형태를보이게되는기전은정확히밝혀져있지는않지만, 심근경색증후심근내미세혈관계의심각한손상이오게되면, 미세혈관저항의증가가일어나게되어서수축기초기에역류성혈류를나타내게되고, 또한미세혈관내혈액의용적감소로이완기혈류의감속속도가빨라지게되는것으로설명하고있다. 27) 본연구에서경흉부심초음파를이용하여 Doppler guide wire를이용한연구와유사한혈류형태를관찰할수있었으며, 모두좌심실의비회복군에서만관찰되었음은이러한혈류형태가심근경색후심각한미세혈관손상및그것으로인한좌심실의기능회복지연또는저하와관련이있음을시사해준다. 본연구의중요한제한점으로는추적관상동맥조영술이중재시술을시행받은환자를포함하여, 전체대상환자에서시행되지않았고, Doppler Guide wire 와의비교검사가시행되지않았으며대상환자에서치료방법이매우이질적이었다는점이다. 이미좌전하행지원위부에서경흉부심초음파를이용한관상동맥혈류의측정은 Doppler Guide wire와의비교연구에서그상관성이높음이입증되어있으므로 17) 별도의관혈적인검사방법은필요하지않을것으로사료된다. 또한대상환자별치료형태가다양하고각각의치료군에포함된환자수가많은차이를보여서서로비교하기어려웠기때문에본연구의결과에서는제외하였으나, 치료방법에따른혈류속도의변화는심근경색후직접관동맥중재술을시행했던 2명의환자에서만이평균 16.7 cm/s 에서 23.2 cm/s 로유의한증가를보였다. 향후더많은대상을포함시켜서치료방법에따른혈류속도의변화에대한연구가필요하다. 본연구는급성심근경색증의초기관상동맥의혈류형태와장기추적에서관찰되는좌심실기능회복과의관련성을보고자한것으로, 여기에는이미알려진여러관련인자들-특히심근경색초기의성공적재관류여 265

8 부, 잔여협착의정도, 초기경색심근의범위및좌심실기능저하의정도- 이포함될것이며이러한여러인자들외에비관혈적으로측정가능한관상동맥의혈류속도및형태가심근경색증의초기에좌심실기능의회복여부를예측할수있는하나의인자가될수있는지를알아보고자한것이다. 좌전하행지원위부에서관찰되는낮은혈류속도는좌심실기능회복군에서혈류속도가향상되는것으로보아, 미세혈관의손상보다는심외막관상동맥의잔여협착정도와관련이있고이것은관동맥중재술을통하여좌심실기능이개선될여지를보여준다. 그러나비회복군에서만관찰되었던이완기감속경사가급하면서수축기초기에역류성혈류를보이는형태는, 심근내미세혈관의심각한손상으로좌심실기능이회복되기어려운상태를예측하게한다. 그러므로경흉부심초음파를이용한관상동맥혈류의평가는심외막관상동맥뿐만이아니라심근내미세혈관의상태에대한평가까지도가능할수있다. 심외막관상동맥혈류속도및혈류형태에대한관찰과함께최근이루어지고있는경흉부심초음파를이용하여심근내미세혈관의손상여부를직접관찰하고자하는시도들은 28)29) 아직까지좌전하행지가분포되는심근에국한되어있기는하지만심근경색후좌심실기능회복을예측하는데많은도움을줄수있을것으로기대된다. 요약 배경및목적 : 급성전벽심근경색증환자에서좌전하행지원위부의혈류를장기간추적관찰함으로써심근경색증에서좌심실기능회복에관련되는관상동맥의혈류속도및혈류형태를알아보고자하였다. 방법 : 급성전벽심근경색증환자 36명을대상으로경흉부심초음파를이용하여전벽심첨부의벽운동장애정도와, 좌심실의이완기및수축기용적, 좌심실구혈률을진단당일, 1주일째, 그리고평균 10 개월째에전향적이고연속적으로측정하여벽운동, 좌심실용적및좌심실구혈률의개선을보였던 24 명을회복군 ( 남 : 여 =14: 10, 평균연령 =60±9 세 ) 으로, 개선을보이지않거나오히려악화된 12명을비회복군 ( 남 : 여 =11:1, 평균연 266 령 =61±11 세 ) 으로분류하였다. 좌전하행지원위부에서의혈류측정은 5~12 MHz 의주파수범위를갖는탐촉자를이용하여간헐파형도플러상최대이완기혈류속도 (cm/sec) 를측정하였으며각시기별로관상동맥혈류의형태변화를관찰하였다. 결과 : 급성심근경색증으로내원한직후경흉부도플러심초음파로측정된좌전하행지원위부의혈류는전체환자중 17명 (47%) 에서이완기가수축기보다큰정상적인혈류형태를, 11명 (31%) 에서는이완기혈류속도가매우느리면서감속경사가느린형태를, 4명 (11%) 에서는이완기감속경사가매우급하면서수축기초기에역류성혈류를보이는형태를, 4명 (11%) 에서는이완기와수축기가모두역류되어있는 4가지형태로구분되었다. 정상적인관상동맥혈류형태는회복군에서는 24 명중 16명 (66%), 비회복군에서는 12명중 1명 (8%) 으로서회복군에서그빈도가유의하게높았으며,(p=0.001) 이완기감속경사가매우급하면서수축기초기에역류성혈류를보이는형태는오직비회복군의 4명에서만관찰되었다 (p=0.003). 장기추적관찰에서회복군에서는혈류속도의점차적인상승을관찰할수있었으나비회복군에서는장기추적관찰에서초기혈류속도가회복되지않거나오히려저하되는경향을보였다. 결론 : 심근경색증환자에서경흉부심초음파상관찰되는좌전하행지의혈류속도및형태를통하여좌심실의기능회복을예측할수있다. 특히이완기감속경사가매우급하면서수축기초기에역류성혈류를보이는형태는심근경색증후좌심실의기능회복불량을예측할수있는특징적인혈류형태이다. 중심단어 : 관동맥질환 ; 혈류속도 ; 심근경색증 ; 심초음파. REFERENCES 1) Grines CL, Browne KF, Marco J, Rothbaum D, Stone GW, O Keefe J, Overlie P, Donohue B, Chelliah N, Timmis GC, Vlietstra RE, Strzelecki M, Puchrowicz-Ochocki S, O Neill WW. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. N Engl J Med 1993;328: ) Michels KB, Yusuf S. Does PTCA in acute myocardial infarction affect mortality and reinfarction rates?: a quantitative overview (meta-analysis) of the randomized clinical trials. Circulation 1995;91: Korean Circulation J 2003;33(4):

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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