연구단신, Brief report 1 2006-2017 년급성심장정지조사주요결과 질병관리본부질병예방센터만성질환관리과윤하정, 권윤형, 안주연, 김영택 * * 교신저자 : ruyoung@korea.kr, 043-719-7380 Main results of Sudden Cardiac Arrest Survey, 2006-2017 Yoon Hajung, Kwon Yunhyung, An juyeon, Kim Young Taek Division of Chronic Disease Control, Center for Disease Prevention, KCDC In 2008, Korea CDC introduced the Sudden Cardiac Arrest Survey to identify the incidence and survival rates of sudden cardiac arrests, in cooperation with the National Fire Agency. Since then, it has been publishing sudden cardiac arrest statistics each year. The results from 2006 to 2017 are as follows. There are about 30,000 cases of sudden cardiac arrests occurring annually. incidence (per 100,000 people) increased from 39.3 in 2006 to 41.5 in 2016, and thereafter slightly decreased to 39.4 in 2017. Survival of the sudden cardiac arrest patients increased 3.8 fold from % in 2006 to 8.7% in 2017. Neurological recovery rate increased 8.5 fold from % in 2006 to % in 2017. Bystander CPR rate and rate of return of spontaneous circulation (ROSC) before hospital arrival, which are the two indices closely related to survival result, showed increasing trends. The Sudden Cardiac Arrest Survey had confirmed one positive and one negative aspect of the current status. On the positive side, there had been a nationwide improvement in sudden cardiac arrest survival, and on the negative side, the regional disparity had widened. By disseminating results of this survey among community members, we hope to promote local community-based activities for improving the survival rates of cardiac arrest patients. Keywords: Heart arrest, Incidence, Cardiopulmonary resuscitation, Surveys and questionnaires 들어가는말 급성심장정지는혈액을순환시키는심장기능이갑자기정지되어신체기능이정상적으로작동하지않음으로써, 즉시치료하지않으면사망에이르게되는질환이다. 특히, 발생전까지도정상적인생활을하던사람에게급작스럽게발생하기때문에 적시적기에대처하기매우어려운질환으로, 신속한응급처치에따라생존결과가매우크게차이가난다. 급성심장정지를인지한목격자가올바른방법으로빠르게심폐소생술과자동심장충격기를사용하여적절히대처하고, 신고를받은 119구급대가이송및응급조치를신속하게처리하고, 의료기관에서통합적인치료가적절히시행된다면급성심장정지로사망상태에있던환자는 www.cdc.go.kr 1724
후유증없이완전하게회복될수있다. 반대로지역사회, 구급, 병원등어느한단계의처치라도늦어진다면, 환자가최종적으로사망하거나생존하더라도심각한후유장애가발생하여사회로복귀하지못하게된다. 이렇듯급성심장정지는치료의적시성이매우중요하며, 심장정지가발생해서단계적으로거치게되는지역사회, 병원전단계, 병원이서로유기적으로연결될때만환자의예후를향상시킬수있다. 급성심장정지의생존수준을향상시키기위해서는인구 사회학적, 지역적발생규모및양상뿐만아니라생존결과와이에영향을끼치는제반요인들에대한정확한자료가필요하다. 미국, 일본, 북유럽선진국가들은오래전부터국가를대표하는급성심장정지자료를등록 구축하고, 관련지표값과통계치를매년 사례전수에대해발생, 구급, 병원단계를포함하도록설계하였다. 2008년에질병관리본부가소방청 ( 당시행정안전부소방본부 ) 과협력하여급성심장정지발생현황, 대응과정, 생존결과를파악하는 급성심장정지조사 를도입하였으며, 소방청및시 도소방재난본부, 17개시 도보건당국및 254개시 군 구보건소, 그리고약 600개의료기관이참여하는국가차원의대규모조사사업으로 119구급대에서급성심장정지로판단한모든환자를대상으로의무기록조사를시행한다는데에그특징이있다. 이조사를도입한 2008년이후매년급성심장정지발생과대응, 생존에대해국가를대표하는통계를생산하고있고, 2011년에는국가통계로승인받았다. 그간 2006-2017년에발생한급성심장정지에대한조사결과 [3] 를소개하고자한다. 지속적으로산출하고있다. 미국의경우 (Cardiac Arrest Registry to Enhance Survival, CARES) 는우리와달리전수사례가아니고일부지역구급대및자발적인참여병원의사례를수집함으로써, 조사효율성과자료의질은높은반면대표성과실제성이낮다고할수있다 [1]. 일본에서는조사항목의대부분이구급대자료에국한되어있어병원단계의치료및결과를파악하기어렵다 [2]. 이러한외국사례의단점을극복하기위하여우리나라의급성심장정지조사는 몸말 급성심장정지조사체계 질병관리본부는조사계획수립과의무기록조사수행, 자료질 National Fire Agency Feedback of major indices results Provision of Rescue daily reports KCDC Chronic Disease Management Department Planning of program Carrying out surveys and data registration Insuring quality of data Standardizing survey questions and guidelines Analyzing and publishing statistical results National Cardiac Arrest Surveillance Advisory Committee Advice on surveillance system Advice on survey question development Review of data analysis results Support and promotion of related policies research and development Review of medical records Cooperation for the review Medical institutions Figure 1. Sudden Cardiac Arrest Survey System www.cdc.go.kr 1725
Table 1. General status of sudden cardiac arrest occurrence, 2006-2017 Unit: cases, cases per 100,000 people, % Types '06 '07 '08 '09 '10 '11 '12 '13 '14 '15 '16 '17 Case 19,480 20,353 21,905 24,442 25,909 26,382 27,823 29,356 30,309 30,771 29,832 29,262 Incidence ()* 39.3 39.7 41.4 44.4 4 4 44.7 45.4 4 4 41.5 39.4 Proportion of people aged 70 years and above Proportion of people where disease is a cause 38.7 39.1 4 4 44.4 45.9 47.5 47.5 49.2 50.1 49.5 50.2 56.2 54.6 7 70.0 7 7 7 71.4 72.4 73.7 74.8 75.2 * Incidence (): adjusted to compensate for different population composition in each year and region, by using standard population (2005 future estimated population, KOSTAT) 관리, 조사문항및조사지침표준화, 결과분석및주요지표산출과통계집발간등사업수행과관련한업무를수행하고있다. 또한, 관련부처및학 협회전문가로구성된국가심장정지조사 감시자문위원회에서는조사 감시체계정비, 조사문항개발에대한자문, 분석결과검토등을통해정책개발및연구활성화를지원하고 있다. 이러한모든과정은소방청과 17개시 도소방본부, 그리고전국약 600개병원의협조를통해이루어진다. 소방청은 17개시 도소방본부구급활동일지를제공하고있으며, 질병관리본부가전체구급활동일지에서급성심장정지사례를추출하고, 환자가이송된병원명등을표준화하여조사수행을위한데이터베이스로 Figure 2. Trends of sudden cardiac arrests www.cdc.go.kr 1726
Table 2. Current status of main indices in sudden cardiac arrests Unit : % Indices '06 '07 '08 '09 '10 '11 '12 '13 '14 '15 '16 '17 Survival rate * 2.5 3.3 3.3 4.1 4.4 4.8 4.8 6.3 7.6 8.7 4.3 4.7 5.2 5.3 7.1 8.7 10.0 Rate of neurological recovery * 0.9 2.7 3.6 2.0 3.1 6.1 * Survived arrest patients are divided by total arrest patients in the corresponding year, and written in percentage Adjusted to compensate for different population composition in each year and region, by using the patients population that suffered the sudden cardiac arrest in 2006 From 2015, the result of follow-up studies that confirmed the survival of patients transferred from the emergency room to other hospitals, has been reflected on the statistics 구축한다. 질병관리본부소속전문조사원은급성심장정지환자가이송된전국의약 600개병원을방문하여해당환자의의무기록을조사하고, 병원들은적극적으로협조하고있다 (Figure 1). 급성심장정지발생및생존현황 급성심장정지발생환자수는 2006년 19,480명에서 2017년 29,262명으로약 1.5배증가하였으며, 표준화발생률은 2006년인구 10만명당 39.3명에서 2016년 41.5 명, 2017년 39.4명으로 2016년까지증가하다가 2017년에소폭감소하였다. 지난 11년동안인구구조가 변화됨에따라, 급성심장정지환자의인구학적특징도변화가있었다. 2006년급성심장정지환자의 38.7% 이었던 70세이상노인비율은 2017년 50.2% 로크게증가하였고, 발생원인이 질병 인비율도증가하고있는추세이다 (Table 1, Figure 2). 급성심장정지환자의생존율과뇌기능회복률은매년증가하였다. 생존율은 2006년 % 에서 2017년 8.7% 로약 3.8배증가하였고, 혼자서일상생활이가능할정도로뇌기능이회복된환자의비율인뇌기능회복률은 2006년 % 에서 2017년 % 로약 8.5배증가하였다 (Figure 3). 생존율과뇌기능회복률향상의핵심요소인지역사회일반인심폐소생술시행률은 2008년 1.9% 에서 10.0 Survival rate Neurological recovery rate 2 Rate of bystander CPR Rate of ROSC before hospital arrival 9.0 8.7 2 8.0 7.6 20.0 Percentage (%) 7.0 6.0 4.0 2.0 0.0 6.3 4.8 4.8 4.4 4.1 3.6 3.3 3.3 2.7 2.5 0.9 '06 '07 '08 '09 '10 '11 '12 '13 '14 '15 '16 '17 Percentage (%) 1 10.0 0.0 16.8 14.1 1 9.1 6.9 6.9 7.6 2.7 1.9 0.9 3.5 3.7 3.1 1.9 '06 '07 '08 '09 '10 '11 '12 '13 '14 '15 '16 '17 Year Year Figure 3. Trends in survival rate and neurological recovery rate Figure 4. Trends in rate of bystander CPR and rate of return of spontaneous circulation (ROSC) before hospital arrival www.cdc.go.kr 1727
Table 3. Disparities in sudden cardiac arrest survey bystander cardiopulmonary resuscitation rate, 2006-2017 Unit: %, %p Region '06 '07 '08 '09 '10 '11 '12 '13 '14 '15 '16 '17 Total - - 1.9 2.7 6.9 9.1 1 14.1 16.8 2 Seoul - - 3.1 5.5 7.3 1 17.4 19.8 26.2 23.6 29.6 35.8 Busan - - 4.6 4.8 7.0 9.9 1 13.3 16.5 Daegu - - 4.1 5.5 6.1 9.6 1 18.3 23.6 3 Incheon - - 2.4 5.3 6.2 6.9 8.0 14.6 1 16.6 14.7 Gwangju - - 0.9 1.4 1.5 2.8 3.8 4.4 10.1 8.2 8.1 11.4 Daejeon - - 1.5 4.6 9.1 16.2 14.4 2 23.8 Ulsan - - 4.7 7.3 8.1 1 2 18.7 Sejong - - - - - - 3.8 7.1 1 13.7 Gyeonggi - - 2.2 2.7 4.0 6.8 8.5 1 16.3 18.9 25.3 Gangwon - - 2.1 2.8 3.7 4.1 8.4 1 15.2 16.2 18.5 Chungbuk - - 0.9 2.4 5.9 7.0 9.0 1 13.1 Chungnam - - 1.5 2.8 3.3 4.4 6.6 9.3 8.4 12.1 18.1 Jeonbuk - - 2.2 2.1 2.4 3.6 8.0 11.4 1 9.7 16.3 Jeonnam - - 1.5 3.2 6.4 6.3 6.1 8.9 Gyeongbuk - - 0.9 1.4 2.8 4.6 8.1 8.0 10.0 Gyeongnam - - 3.2 4.7 6.2 8.2 9.7 11.5 1 Jeju - - 1.4 2.5 1.9 3.5 5.4 8.5 1 17.9 17.0 16.6 Disparity (Max-Min) - - 2.5 4.5 6.3 1 14.6 17.2 23.6 17.3 23.5 26.9 Table 4. Disparities in sudden cardiac arrest survey rate of return of spontaneous circulation before hospital arrival, 2006-2017 Unit: %, %p Region '06 '07 '08 '09 '10 '11 '12 '13 '14 '15 '16 '17 Total 0.9 1.9 3.1 3.5 3.7 6.9 7.6 Seoul 1.5 2.0 2.8 4.1 4.5 6.2 7.7 8.7 Busan 0.9 2.0 4.6 5.6 6.7 10.2 11.5 Daegu 2.2 3.6 3.3 4.7 4.3 5.6 9.0 8.3 Incheon 1.9 2.0 3.8 3.3 3.8 5.5 7.5 9.6 Gwangju 0.2 2.0 2.4 5.2 3.8 5.6 4.5 9.4 9.0 Daejeon 1.4 3.1 5.6 4.8 4.3 7.3 8.5 Ulsan 2.5 4.0 4.3 6.4 4.7 9.3 8.6 Sejong - - - - - - 3.5 3.8 6.2 7.5 15.3 15.3 Gyeonggi 1.4 1.9 4.6 5.8 8.4 9.2 Gangwon 0.5 2.4 2.4 4.0 5.3 Chungbuk 2.1 3.3 2.1 4.7 4.8 Chungnam 1.4 1.5 4.4 2.5 5.8 6.3 Jeonbuk 0.5 1.5 4.1 3.7 4.7 4.4 4.7 4.1 5.7 Jeonnam 2.5 2.7 2.4 4.1 4.5 Gyeongbuk 0.9 1.5 0.9 2.4 2.7 2.2 3.6 4.4 Gyeongnam 1.4 2.5 2.5 3.2 4.6 5.7 Jeju 5.5 3.3 Disparity (Max-Min) 1.4 2.5 3.5 3.3 1 1 www.cdc.go.kr 1728
Table 5. Disparities in sudden cardiac arrest survey survival rate, 2006-2017 Unit: %, %p Total Region '06 '07 '08 '09 '10 '11 '12 '13 '14 '15 '16 '17 2.5 3.3 Seoul 6.4 6.3 8.3 8.8 9.2 8.6 9.8 11.4 12.7 Busan 2.0 2.0 3.5 3.6 4.5 4.4 5.3 5.7 7.6 9.1 9.9 Daegu 2.2 2.4 2.4 3.7 4.7 6.1 5.4 7.0 8.0 Incheon 4.3 4.5 4.1 4.0 5.8 5.3 6.7 5.8 7.2 8.2 1 Gwangju 3.2 2.0 3.1 4.6 4.0 4.1 4.6 7.6 9.2 1 Daejeon 4.4 8.1 6.6 6.8 7.9 7.3 7.1 8.4 9.8 Ulsan 1.4 1.9 0.5 2.7 4.4 3.3 3.8 4.5 6.4 10.9 11.4 Sejong - - - - - - 5.3 3.7 2.2 11.9 9.0 Gyeonggi 2.8 3.7 3.3 4.0 4.8 4.8 5.7 6.8 8.2 10.1 Gangwon 3.2 2.4 1.9 4.1 3.1 3.6 3.8 4.5 4.7 6.1 6.2 Chungbuk 1.4 2.0 1.5 2.5 3.8 2.8 5.3 6.2 Chungnam 2.5 1.9 1.9 3.5 6.1 6.7 Jeonbuk 2.4 1.5 2.1 4.4 3.2 4.8 6.5 Jeonnam 0.9 1.4 1.4 1.4 4.4 4.7 Gyeongbuk 1.4 4.3 4.1 Gyeongnam 0.2 0.5 1.9 2.1 4.5 5.5 6.7 Jeju 1.4 2.7 3.2 2.8 3.5 4.6 3.6 3.6 7.4 6.2 5.8 Disparity (Max-Min) 4.5 4.4 5.2 7.4 6.7 7.4 8.0 7.5 7.6 7.6 8.6 3.3 4.1 4.3 4.4 4.7 4.8 5.2 4.8 5.3 6.3 7.1 7.6 8.7 8.7 10.0 Table 6. Disparities in sudden cardiac arrest survey neurological recovery rate, 2006-2017 Unit: %, %p Total Region '06 '07 '08 '09 '10 '11 '12 '13 '14 '15 '16 '17 Seoul 1.5 3.3 5.8 6.0 7.1 Busan 0.0 1.9 2.2 3.1 4.6 5.3 5.6 Daegu 0.0 0.9 2.2 3.7 3.7 5.4 5.3 Incheon 1.4 2.1 2.2 3.8 3.8 4.5 5.6 Gwangju 0.2 0.9 2.1 2.2 2.2 3.7 4.8 6.4 Daejeon 1.5 1.4 1.4 1.9 3.8 3.3 4.0 4.3 Ulsan 2.1 0.9 1.5 4.0 6.2 8.6 Sejong - - - - - - 3.7 0.0 9.3 6.3 Gyeonggi 0.9 0.9 2.1 2.4 2.8 3.8 4.6 5.8 Gangwon 1.4 0.9 1.4 2.1 2.5 2.5 2.5 3.2 Chungbuk 1.4 2.5 3.1 3.6 Chungnam 0.0 0.0 0.1 0.9 1.9 4.0 Jeonbuk 0.2 0.1 1.4 2.0 2.2 2.7 3.3 4.8 Jeonnam 0.2 0.1 0.2 0.5 2.0 3.3 Gyeongbuk 0.2 0.1 0.5 0.9 0.9 2.7 2.7 Gyeongnam 0.1 0.2 0.5 0.5 1.5 2.7 3.1 4.4 Jeju 0.5 1.4 0.9 2.8 2.7 2.0 2.2 4.6 3.7 3.5 Disparity (Max-Min) 1.5 1.5 2.0 2.5 2.8 3.3 4.5 5.8 7.3 5.9 0.9 2.0 2.7 3.1 3.6 6.1 www.cdc.go.kr 1729
Table 7. Results of main sudden cardiac arrest indices and their disparities among city types, 2006-2017 Indices City types '06 '07 '08 '09 '10 '11 '12 '13 '14 '15 '16 '17 Bystander CPR rate (%) Gu of Special city - - 3.1 5.5 7.3 1 17.4 19.8 26.2 23.6 29.6 35.8 Gu of Metropolitan city* - - 1.9 2.8 3.5 6.4 8.8 12.8 15.2 17.7 22.0 Si with less than 300,0000 people - - 4.3 5.5 1 11.4 15.9 19.9 Urban rural consolidated Si - - 1.5 2.0 2.7 5.4 7.3 9.0 10.2 13.5 Gun - - 1.4 2.8 4.4 6.4 7.7 9.5 12.4 Disparity (Max-Min) - - 2.0 4.4 5.9 10.5 14.6 15.4 19.8 15.9 20.1 2 Rate of return of spontaneous circulation before hospital arrival (%) Gu of Special city 1.5 2.0 2.8 4.1 4.5 6.2 7.7 8.7 Gu of Metropolitan city* 0.9 1.9 1.9 3.6 4.1 4.5 5.5 8.2 8.8 Si with less than 300,0000 people 0.9 1.5 0.9 2.1 2.2 3.7 5.6 6.1 9.3 Urban rural consolidated Si 0.9 5.5 Gun 0.9 2.8 3.1 3.6 4.7 4.8 Disparity (Max-Min) 0.5 0.5 0.9 1.9 3.5 4.5 Survival rate (%) Gu of Special city 4.0 6.4 6.5 6.3 6.5 8.3 8.5 8.8 9.3 9.2 9.9 8.6 9.8 9.8 1 11.4 1 12.7 14.3 Gu of Metropolitan city* 2.8 3.8 3.8 3.8 4.6 4.7 5.2 5.7 6.0 5.6 6.1 6.8 7.5 8.4 9.2 9.9 10.9 Si with less than 300,0000 people 2.4 3.6 3.6 3.1 3.8 3.7 3.5 4.1 4.6 6.8 8.6 7.4 8.5 9.2 1 Urban rural consolidated Si 1.4 1.4 2.0 2.2 2.4 2.1 2.2 2.4 4.3 5.5 6.6 6.2 7.6 Gun 0.5 0.5 1.4 1.4 1.5 3.7 4.6 4.3 Disparity (Max-Min) 3.6 4.4 4.4 5.7 5.6 6.9 7.5 7.9 7.3 6.8 7.5 8.4 Neurological recovery rate (%) Gu of Special city Gu of Metropolitan city* 0.9 1.5 1.9 3.3 3.5 2.2 2.4 4.4 2.8 5.9 3.2 5.8 6.8 4.0 4.5 6.0 7.1 5.5 7.1 8.3 5.6 6.5 Si with less than 300,0000 people 0.5 1.9 2.1 3.3 4.6 3.2 4.0 6.3 Urban rural consolidated Si 1.5 2.2 2.7 3.5 Gun 0.1 0.1 0.1 0.1 0.2 0.2 0.5 1.9 2.5 2.1 3.7 Disparity (Max-Min) 1.5 1.4 2.8 3.1 4.1 * Si with More than 300,000 population, or Gu of Si with More than 500,000 population * Region with the highest values in the year Region with the lowest values in the year www.cdc.go.kr 1730
2017년 2% 로크게증가하였으며, 매년증가추세에있다. 구급대의처치능력을반영하는병원도착전자발순환회복률또한 2006 년 0.9% 에서 2017 년 7.6% 로 8.4배증가하였다 (Figure 4). 일반인심폐소생술시행률과병원도착전자발순환회복률의향상은급성심장정지환자의생존율과뇌기능회복률향상에기여하였다. 급성심장정지관련지역별현황 급성심장정지와관련한주요지표의값은지역간큰격차를보이고있다. 이러한지역간격차 ( 최대값-최소값 ) 의원인은명확하지않지만, 지역간격차가증가추세에있기때문에, 지역별 확인할수있었다. 연구결과 [4] 에의하면지역사회심폐소생술교육경험률이 10% 증가할때급성심장정지환자생존율이 1.4배증가한다는사실이밝혀졌다. 254개보건소가지역보건법에따라매년실시하는 지역사회건강조사 ( 주민건강통계 ) 의결과에따르면, 심폐소생술에대한일반주민의교육경험이전반적으로향상되고있으나지역간차이를보인다는결과 [5] 를고려했을때, 국가전체의생존향상뿐만아니라지역간격차를해소하기위한중앙정부와지방정부의정책활동강화가필요하다. 마지막으로, 급성심장정지조사를통해생산하는지역통계는급성심장정지환자의생존향상을위한지역사회활동을크게촉진하리라기대한다. 관련지표를생산하고이를지역사회에환류해주는것이중요하다. 일반인심폐소생술시행률, 병원도착전자발순환회복률의지역간격차는모두증가하였으며, 급성심장정지치료결과인생존율및뇌기능회복률의지역간격차또한지속적으로증가하고있는추세이다 (Table 3-6). 도시유형간격차에서일반인심폐소생술, 병원도착전자발순환회복, 생존과뇌기능회복등전체적으로상당한격차가있고, 그격차는증가하고있다. 특히, 서울특별시는다른도시유형에비해서전반적으로양호하고, 생존율과뇌기능회복률의개선폭이다른도시유형보다큰상황이다 (Table 7). 참고문헌 1. Bryan McNally, et al. CARES: Cardiac Arrest Registry to Enhance Survival. Annals of emergency medicine. 2009;54(5):674-683. 2. Kunihiro Mashiko, et al. An outcome study of out-of-hospital cardiac arrest using the Utstein template-a Japanese experience. Resuscitation. 2002;55:241-246. 3. 질병관리본부. 2006-2017 급성심장정지조사통계. 2018. 4. Ro YS, et al. Public awareness and self-efficacy of cardiopulmonary resuscitation in communities and outcomes of out-of-hospital cardiac arrest: A multi-level analysis. Resuscitation. 2016;102:17-24. 5. 질병관리본부. 2008-2016 지역건강통계한눈에보기. 2017. 맺는말 급성심장정지는치료의적시성이매우중요하며, 지역사회, 구급, 병원단계가유기적으로연결될때만환자의예후를향상시킬수있기때문에, 급성심장정지환자의생존결과는해당국가의응급의료체계전체를평가할수있는시금석이라고할수있다. 2008년급성심장정지조사사업이후, 급성심장정지와관련된문제를객관적으로파악할수있게되었으며, 지역간비교가능한지역통계를생산함으로써지역맞춤형정책이가능한근거자료를제공할수있게되었다. 이를통해국가전체로는급성심장정지생존결과가향상된반면, 지역간격차는오히려더커지고있는문제를 www.cdc.go.kr 1731