Original ORIGINAL Article ARTICLE Korean Circulation J 2007;37:113-118 ISSN 1738-5520 c 2007, The Korean Society of Circulation 좌심실부전증이발생한급성심근경색증환자에서좌심실기능개선관련인자 전남대학교병원심장센터, 전남대학교의과학연구소 임상춘 이정애 정명호 최진수 신은숙 김계훈 김주한문재연 홍영준 안영근 조정관 박종춘 강정채 Predictive Factors for the Recovery of Left Ventricular Dysfunction in Patients with Acute Myocardial Infarction Sang Chun Lim, RN, Jung Ae Rhee, MD, Myung Ho Jeong, MD, Jin Soo Choi, MD, Eun Suk Shin, RN, Kye Hun Kim, MD, Ju Han Kim, MD, Jae Youn Moon, MD, Young Joon Hong, MD, Young Keun Ahn, MD, Jeong Gwang Cho, MD, Jong Chun Park, MD and Jung Chaee Kang, MD The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea ABSTRACT Background and Objectives:The left ventricular ejection fraction (LVEF) is known to be a significant prognostic factor for patients with acute myocardial infarction (AMI). The aim of this study was to investigate clinical or therapeutic factors associated with the recovery of a low LVEF for patients with AMI. Subjects and Methods: From January to December 2004, we enrolled 89 patients (mean age: 62.5±10.6 years, 43 males and 26 females) with AMI and who had a LVEF less than 50%. Forty five patients whose LVEF improved more than 10% were classified as group I (mean age: 62.4±10.4 years, 34 males and 11 females) and 44 patients whose LVEF was not changed or decreased were classified as group II (mean age: 62.3±10.9 years, 29 males and 15 females). The clinical variables, including risk factors and the pain-to-door time, the biochemical markers of myocardial injury, the coronary angiographic findings and the treatment-related variables, were compared between the two groups. Results:The cardiovascular risk factors were not different between the groups. The location of infarction, the success rate of percutaneous coronary intervention and the coronary angiographic lesion morphologies were not different between the groups. However, the pain-to-door time was significantly shorter in group I than in group Ⅱ (6.0±9.5 vs 22.4±7.5 hours, respectively, p=0.046). Improved control of risk factors was not associated with the recovery of LV function. The use of beta-blocker, statin, anti-platelet agents, vasodilators and diuretics were not different between the groups. However, the use of angiotensin converting enzyme inhibitor (ACEI) was more common in group Ⅰ than group Ⅱ (79.3% vs 47.4%, respectively, p=0.03). Conclusion:A shorter pain-to-door time and the use of ACEI were significant predictors of the recovery of LV dysfunction for patients with AMI. (Korean Circulation J 2007;37:113-118) KEY WORDS:Myocardial infarction;heart failure, congestive;angiotensin. 논문접수일 :2006 년 10 월 23 일수정논문접수일 :2007 년 2 월 7 일심사완료일 :2006 년 02 월 28 일교신저자 : 정명호, 501-757 광주광역시동구학동 8 번지전남대학교병원심장센터, 전남대학교의과학연구소전화 :(062) 220-6243 전송 :(062) 228-7174 E-mail:myungho@chollian.net 113
114 Korean Circulation J 2007;37:113-118 서 급성심근경색증은선진국에서입원하는환자의가장흔한진단중의하나로서우리나라에서도식생활의서구화와생활양식의변화로인하여그빈도가급증하고있으며, 주요한사망원인이되고있다. 1) 특히심근경색증은발병후 30일이내의조기사망률이 30% 에이르는치명적인질환이다. 2) 최근급성심근경색증의증상이나위험요인에대한국민들의인식이증가되고, 보다효과적인혈전용해제나경피적관상동맥중재술 (percutaneous coronary intervention: PCI) 을통한재관류요법등급성기치료의발전으로증가되는발병률에비해축적사망률은감소되고있는추세이다. 3)4) 그러나급성기치료후생존한환자들의경우에도심기능저하로인한심부전이나치명적인부정맥의발생, 혈관재협착, 후기사망등다양한문제가야기될수있기때문에, 급성기치료후회복된환자에서보다효율적인이차예방, 합병증및재발방지를위해예후인자에관한연구가필요하게되었다. 좌심실의수축기기능을반영하는좌심실구혈율은심근경색증환자의병원내임상경과뿐아니라퇴원후환자의장기예후와연관된중요한인자로알려져있다. 5-7) 따라서심근경색증후좌심실기능회복또는악화와연관된예측인자들을알게된다면환자의치료에도움을줄수있을것이다. 저자는본연구를통해급성심근경색증으로입원한환자들을대상으로내원전후의임상적특징이나치료와연관된인자및퇴원후심혈관질환위험인자 ( 고혈압, 당뇨병, 고지혈증, 흡연력, 비만등 ) 의조절여부가좌심실기능의회복에미치는영향을알아보고자하였다. 론 대상및방법 대상 2004 년 1월부터 12월까지전남대학교병원심장센터에서급성심근경색증으로진단되어치료를받고퇴원한환자중입원시에심초음파도로측정한좌심실구혈율 (left ventricular ejection fraction: LVEF) 이 50% 미만으로저하된 89명 (62.5±10.6 세, 남자 63명, 여자 26명 ) 의환자들을대상으로하였다. 임상경과중 LVEF 이 10% 이상개선된 45명의환자를 Ⅰ 군 (62.4±10.4 세, 남자 34명, 여자 11 명 ), LVEF 이변화가없거나악화된 44명의환자를 Ⅱ군 (62.3±10.9 세, 남자 29명, 여자 15명 ) 으로하였다. 방법심혈관질환의위험인자, 증상발생후병원에도착하기까지시간 (pain to door time), door to needle time, door to balloon time, 치료방법및투여약제, 혈청내심근표지자, 관상동맥조영술과연관된인자등이미치는영향을두군간에비교하였다. 심초음파도는입원시에시행한심초음파도를기준으로좌심실을 16분절로나누어국소벽운동의이상여부를분석하였다. 7) 변형된 Simpson 방법에의해좌심실구혈율과좌심실수축기말용적 (left ventricular end-systolic volume), 좌심실이완기말용적 (left ventricular end-diastolic volume) 을측정하였고, 승모판역류증여부및정도, 좌심실수축기및이완기말내경등을측정하였다. 퇴원후 6개월에추적심초음파도를시행하여입원시의심초음파소견과비교하였다. 자료분석모든자료는평균 ± 표준편차로나타내었다. 각군간의비교는 SPSS(Statistical Package for Social Science, version 12.0, U.S.A) 통계프로그램을사용하여분석하였다. 명목변수는 Chi-square 검정으로분석하였고, 연속변수는독립표본 T-검정을시행하였으며, p 값이 0.05 이하인경우통계학적으로유의하다고판정하였다. 결과 대상환자의임상적특징대상환자는 89명으로남자가 63명 (70.8%), 여자가 26명 (29.2%) 이었으며, 평균연령은 62.5±10.6 세였다. 심혈관질환의위험인자는흡연 45명 (50.6%), 고지혈증 40명 (44.9%), 고혈압 38명 (42.7%), 비만 34명 (38.2%), 당뇨병 25명 (28.1%) 등이었다. 경색의부위는전벽경색 59명 (66.3%), 하벽경색 26 명 (29.2%), 측벽경색 4명 (4.5%) 이었고, 급성 ST절상승심근경색증이 75명 (84.3%), 급성비ST 절상승심근경색증 14 명 (15.7%) 이었다. Pain to door time은평균 13.6±8.2시간, door to needle time 은 0.98±0.52 시간이었으며 door to balloon time 은 1.68±1.47 시간이었다. 치료의형태로는일차적 PCI 를시행받은환자가 47명 (52.8%), 선택적 (elective) PCI 를시행받은환자가 34명 (38.2%), 구제적 PCI 를시행받은환자가 8명 (9.0%) 이었다. 심초음파검사에서 LVEF 는 41.7±7.7% 였다. 두군간에나이, 성별, 위험인자, 경색부위및치료의형태등에는차이가없었으나 pain to door time 이 Ⅰ군에비해 Ⅱ군에서유의하게지연되어있었다 (Ⅰ군 : 6.3±9.7 시간, Ⅱ군 : 23.6±7.8시간, p=0.04)(table 1). 심근표지자내원시 creatinine kinase(ck) 는 937.9±2039 U/L, CK- MB는 41.1±64.9 U/L, 심근특이적 troponin-t(ctnt) 는 2.1±4.4 mg/dl, troponin-i(ctni) 는 13.5±25.5 mg/dl, C-reactive protein(crp) 는 2.6±4.1 mg/dl 이었고, 내원중최고치는 CK 2402.4±2920.8 U/L, CK-MB 164.7±400.5
Sang Chun Lim, et al:prognosis of Ischemic Heart Failure 115 U/L, ctnt 7.2±7.0 mg/dl, ctni 42.6±36.4 mg/dl, CRP 3.8±6.6 mg/dl 이었다. 심근손상의혈청학적표지자는두군간에차이가없었다 (Table 2). 심근손상이나부담의정도를반영하는혈중 N-terminal pro-bnp 수치도두군간에 Table 1. Baseline clinical characteristics Group I (n=45) Group II (n=44) Age (years) 062.4±10.40 62.3±10.9 0.81 Male (%) 34 (75.6) 29 (65.9) 0.61 Clinical diagnosis (%) 0.32 ASTEMI 39 (86.7) 36 (81.8) NSTEMI 06 (13.3) 08 (18.2) Risk factor (%) Smoking 24 (53.3) 21 (47.7) 0.12 Hypercholesterolemia 17 (37.8) 23 (52.3) 0.19 Hypertension 20 (44.4) 18 (40.9) 0.81 Obesity 20 (44.4) 14 (31.8) 0.32 Diabetes mellitus 15 (33.3) 10 (22.7) 0.48 Pain to door time (hour) 006.3±9.700 23.6±7.80 0.03 Types of treatment (%) 0.21 Early reperfusion therapy Thrombolysis 2 (4.4) 5 (11.1) 0.23 Door to needle time (min) 027.0±15.60 75.0±21.2 0.11 Primary PCI 31 (68.9) 29 (65.9) 0.76 Door to balloon time (min) 112.8±102.6 82.8±60.6 0.12 Elective PCI 12 (26.7) 10 (22.7) 0.67 CABG 01 (02.2) 03 (06.8) 0.30 LVEF 040.8±7.500 42.4±7.90 0.81 41-50% 25 (55.6) 25 (56.8) 31-40% 14 (31.1) 15 (34.1) 30% 06 (13.3) 04 (09.1) ASTEMI: acute ST elevation myocardial infarction, NSTEMI: non- ST elevation myocardial infarction, PCI: percutaneous coronary intervention, CABG: coronary artery bypass graft, LVEF: left ventricular ejection fraction Table 2. Comparison of biochemical markers of cardiac myocardial injury At admission Group I (n=45) Group II (n=44) p CK (U/L) 0892.4±1997.2 0982.1±2101.1 0.20 CK-MB (U/L) 0037.6±58.300 0046.1±66.900 0.43 ctnt (ng/ml) 0001.9±3.9000 0002.3±5.1000 0.30 ctni (ng/ml) 0011.7±22.800 00014.9±27.6000 0.62 CRP (mg/dl) 0002.5±3.8000 0002.8±4.3000 0.58 Peak value CK (U/L) 2256.5±2667.3 2687.8±3006.4 0.65 CK-MB (U/L) 0149.3±388.80 0175.3±422.60 0.61 ctnt (ng/ml) 0007.5±7.3000 0006.9±6.6000 0.19 ctni (ng/ml) 0039.6±35.400 0046.1±38.900 0.12 CRP (mg/dl) 0003.6±6.0000 0004.1±6.9000 0.35 CK: creatinine kinase, CK-MB: MB fraction of creatinine kinase, ctnt: cardiac specific troponin C, ctni: cardiac specific troponin I, CRP: C-reactive protein p 차이가없었다 (Ⅰ군: 2403.4±3224.4 vs Ⅱ군 : 3770.3± 7291.4 pg/ml, p=0.354). 심장초음파소견내원시시행된심장초음파에서좌심실의크기, 용적및 LVEF 로측정된좌심실의기능은두군에서차이가없었으며, 총벽운동지수로측정한경색의크기도두군에서차이가없었다 (Table 5). 6개월전후로시행된심장초음파검사에서좌심실의크기와용적은 Ⅰ군이 Ⅱ군에비해유의하게적었으며, 총벽운동지수도 Ⅰ군이 Ⅱ군에비해유의하게낮았다 (Table 5). 좌심실의용적이 20% 이상증가된좌심실재형성 (remodeling) 의빈도는 Ⅱ군에서유의하게높았다 (Ⅰ군 : 7/45 명, 15.6% vs Ⅱ군 : 19/44명, 43.2%, p=0.005). Table 3. Comparison of coronary angiographic characteristics Group I (n=45) Table 4. Comparison of the prescribed medications Group II (n=44) Infarct related artery (%) 0.36 LAD 29 (64.4) 31 (70.5) RCA 12 (26.7) 11 (25.0) LCx 04 (08.9) 02 (04.5) Number of involved vessel (%) 0.55 One vessel disease 25 (55.6) 21 (47.7) Two vessel disease 12 (26.7) 13 (29.6) Three vessel disease 08 (17.7) 10 (22.7) ACC/AHA types (%) 0.42 A 00 (000.) 00 (000.) B 1 25 (55.6) 19 (43.2) B 2 10 (22.2) 12 (27.2) C 10 (22.2) 13 (29.6) TIMI flow grade (%) 0.97 O 22 (48.9) 19 (43.2) I 06 (13.3) 05 (11.4) II 06 (13.3) 06 (13.6) III 11 (24.5) 14 (31.8) LAD: left anterior descending coronary artery, RCA: right coronary artery, LCx: left circumflex coronary artery, TIMI: thrombolysis in myocardial infarction, ACC/AHA: American College of Cardiology/ American Heart Association Group I (n=45) Group II (n=44) p Aspirin (%) 45 (100.0) 44 (100.0) 1.00 Clopidogrel (%) 45 (100.0) 44 (100.0) 1.00 Beta-blocker (%) 37 (082.2) 34 (077.3) 0.14 ACEI (%) 36 (080.0) 21 (047.7) 0.03 ARB (%) 06 (013.3) 21 (047.7) 0.02 Statin (%) 38 (084.4) 33 (075.0) 0.09 Nitrate (%) 27 (060.0) 32 (072.7) 0.13 Diuretic (%) 12 (026.7) 15 (034.1) 0.16 CCB (%) 01 (002.2) 02 (04.5) 0.31 ACEI: angiotensin converting enzyme inhibitor, ARB: angiotensin II receptor blocker, CCB: calcium channel blocker p
116 Korean Circulation J 2007;37:113-118 Table 5. Changes of echocardiographic parameters Baseline Follow-up Group I Group II p Group I Group II p LVEDD (mm) 52.6±6.60 54.0±8.30 0.412 52.1±7.20 56.8±13.7 <0.011 LVESD (mm) 40.9±7.40 42.4±7.80 0.351 36.6±6.90 40.5±10.9 <0.022 LVEDV (ml) 71.3±16.7 78.6±21.3 0.104 74.4±12.1 85.7±27.6 <0.002 LVESV (ml) 42.2±12.4 45.3±16.7 0.371 34.0±10.6 46.6±20.2 <0.001 LVEF (%) 40.8±7.50 42.4±7.90 0.812 54.3±10.6 45.6±8.40 <0.001 TWMS 25.6±5.40 25.1±6.70 0.524 19.4±4.70 22.6±8.90 <0.001 LVEDD: left ventricular end diastolic dimension, LVESD: left ventricular end systolic dimension, LVEDV: left ventricular end diastolic volume, LVESV: left ventricular end systolic volume, LVEF: left ventricular ejection fraction, TWMS: total wall motion score 관상동맥조영술및중재술소견관상동맥조영술에서경색관련혈관 (infarct related artery: IRA) 은좌전하행지 60명 (67.4%), 우관상동맥 23명 (25.9%), 좌회선지 6명 (6.7%) 이었고, 유의한협착이있었던혈관수는단일혈관질환 46명 (51.7%), 두혈관질환 25명 (28.1%), 세혈관질환이 18명 (20.2%) 이었다. American College of Cardiology/American Heart Association(ACC/AHA) 분류에의한병변의형태는 B 1 형 44명 (49.4%), B 2 형 22명 (24.7%), C 형이 23명 (25.9%) 이었고, Thrombolysis In Myocardial Infarction(TIMI) 분류에의한관상동맥혈류는 O 41 명 (46.1%), Ⅰ 11명 (12.4%), Ⅱ 12명 (13.5%), Ⅲ 25명 (28.0%) 이었다. PCI 후 84명 (94.4%) 의환자에서 TIMI Ⅲ 혈류를얻을수있었다. 관상동맥조영술에서특징이나 PCI 의성공률에서두군간에유의한차이는없었다 (Table 3). 치료약제와좌심실기능모든환자에서 aspirin 과 clopidogrel 이사용되었고, 베타차단제는 71 명 (79.8%) 에서투여되었다, 안지오텐신전환효소억제제는 moexipril 19 명 (45.2%), ramipril 11 명 (26.2%), cilazapril 6명 (14.3%), enalapril 3명 (7.1%), imidapril 3명 (7.1%) 로총 42명 (47.2%) 에서사용되었고, 안지오텐신수용체차단제는 losartan 17명 (40.5%), candesartan 15명 (35.7%), valsartan 4명 (9.5%), irbesartan 3명 (7.1%), eprosartan 3명 (7.1%) 로총 42명 (47.2%) 에서사용되었다. 칼슘길항제는 3명 (3.4%), 이뇨제는 27명 (30.3%), 스타틴제제는 71명 (79.8%), nitrate 제제는 59명 (66.3%) 에서사용되었다. 두군간에사용된약제는비슷하였으나, Ⅰ군환자에서 Ⅱ군에비해안지오텐신전환효소억제제의사용이유의하게많았고 (36/45 명 vs 21/44 명, p=0.03), 안지오텐신수용체차단제의사용은적었다 (6/45명 vs 21/44명, p=0.02)(table 4). 심혈관질환위험인자의변화와좌심실기능모든환자에서 6개월전후로심혈관질환위험인자의조절여부가재평가되었다. 흡연환자 45명중 29명은완전히금연을하였고, 나머지 16 명의환자도흡연의빈도와정도의감소를보였다. 수축기혈압은내원시 128.4±30.8 mmhg 에서 118.9±16.7 mmhg 로유의하게감소되었고 (p=0.028), 이 완기혈압은 81.5±17.4 mmhg 에서 67.1±9.3 mmhg 로유의하게감소되었다 (p<0.001). 총콜레스테롤은 199.3±39.6 mg/dl 에서 147.4±30.0 mg/dl 로 (p<0.001), 저밀도지단백콜레스테롤은 138.8±35.9 mg/dl 에서 93.3±28.4 mg/dl (p<0.001) 로서각각유의하게감소되었으나, 고밀도지단백콜레스테롤과중성지방은각각 45.4±13.1 mg/dl 과 117.3± 57.3 mg/dl에서 45.4±12.0 mg/dl 과 106.4±55.1 mg/dl 로서유의한변화는없었다. 환자의비만도도 24.0±2.8 kg/ m 2 에서 24.1±2.8 kg/m 2 으로유의한변화는없었다. 이러한위험인자들의개선은추적심초음파검사에서좌심실개선여부와는무관하였다. 고 심혈관계질환은현재우리나라의성인에서암, 뇌졸중에이어 3대사망원인중의하나이며생활수준의향상, 서구화된식생활, 생활습관의변화와평균수명의증가로인하여발생율은더욱더증가될것으로예상된다. 특히급성심근경색증은관상동맥이폐쇄되고 30분이경과하면심근괴사가시작되며, 그후시간이경과함에따라괴사되는심근의범위가지속적으로증가하므로성인급사를유발하는가장중요한질환으로서심근경색증이발생한후부터 1시간이내에심실세동이가장많이발생하여발병후조기사망률이 30% 에이르는치명적인질환이다. 2) 환자가증상발현후병원에도착하자마자혈전용해제나관상동맥중재술과같은재관류요법을빨리시행할수록사망률을낮추고장기임상경과에양호한영향을준다고알려져있으므로조기진단과조기치료가중요하다할수있다. 8)9) 급성심근경색증의초기진단은임상적인특징, 즉흉통의기간과흉통이일어나는장소, 동반증상과심전도소견의변화그리고혈청효소치의증가를측정하는것으로알수있다. 10-12) 심근효소의수치는경색후경과시간에따라그수치가변하는데본연구에서는 Ⅱ군이 Ⅰ군에비해수치는높았으나통계적인유의성은보이지않았다. 이는대상환자의수가적었고 Ⅰ군환자의경우도내원평균시간이 6시간이상으로심근손상이비교적진행되어온환자가많아그수치상통계적인차이는없었던것으로생각된다. 또한심초음 찰
Sang Chun Lim, et al:prognosis of Ischemic Heart Failure 117 파를통한좌심실기능의측정은급성심근경색증환자의예후를평가하는비교적객관적이고중요한지표로알려져있다. 13)14) Van t Hof 등 9) 은연구를통하여 3시간에서 6시간사이에관상동맥중재술을받은환자에서좌심실기능이유의하게개선되었음을보고하였고본연구에서도증상발현후병원도착시간이평균 6시간내외의환자군에서병원도착시간이 22시간내외의환자군보다 LVEF 이평균 10% 이상의개선을보여조기진단과조기치료가급성심근경색증환자의예후를개선하는중요한지표임을알수있었다. 최근들어심장질환에관한다양한홍보의영향으로급성심근경색증의증상이나치료, 신속하고적절한치료를받지않았을때의생명의위험성등이많이알려져있으나, 아직도증상발현후응급실도착시간이늦어치료후경과가좋지않은환자들이많이있음을본연구결과에서도알수있었다. 15)16) 그러므로심근경색증의가장중요한증상인흉통과빠른처치의중요성에대하여더욱자세하고정확한정보를홍보하여예방및치료가적절하게이루어져야될것으로생각된다. 특히급성심근경색증에서여성의경우에나이가많아허혈성심장질환의유병율이남성에비해 6~10 년정도차이를두고평형을이룬다고보고하고있으며, 17) 여성의경우심근경색증발병시고혈압, 당뇨병, 그리고울혈성심부전등의합병증이많아남성에비해높은병원사망률과 1년사망률을보이며심근경색증후심근경색증의재발, 협심증, 그리고울혈성심부전증이흔하다고알려져있다. 18-20) 관상동맥조영술소견이나좌심실구혈율은남녀간에차이가없음에도불구하고여성에서울혈성심부전증의발생이높다고하였다. 이러한원인으로는증상발현시고령인경우가많고당뇨병, 고혈압, 비만등을동반한합병증이많으며치료에있어서도소극적인점등이원인일것으로예측하고있다. 21)22) 여러연구에서고연령, 여성, 고혈압, 당뇨병, 흡연, 고지혈증, 흡연여부, 관상동맥병변이심한경우와관상동맥조영술성공후재관류율에따라좌심실기능이호전된다고보고하고있으나, 3)23-26) 본연구에서는유의하게나타나지않았다. 급성심근경색증발병후에는고혈압의동반여부와관계없이금기사항이없는한베타차단제, 스타틴계열의약물, 혈관확장제, 이뇨제의사용과안지오텐신전환효소억제제등의약물을사용하게된다. 특히베타차단제는심근경색증후에심근경색증의재발이나급사에의한사망률을줄일수있다고알려져있으며안지오텐신전환효소억제제는심장이나혈관에직접작용하지않고, 우리몸의레닌- 안지오텐신- 알도스테론시스템에작용하여혈압을올리고염분과수분을축적시켜체내에서수분이흐르지않고고여있게만들며혈관을확장시켜혈압을낮추는혈압강하작용도있지만동맥경화증의진행을지연시켜심장보호작용이있는것으로알려져, 심근경색증후특히좌심실수축기능이 40% 이하로저하된환자에서심부전에의한사망률과심근경색증의재발을방지하는데효과적으로사용할수있다. 27-30) 본연구에서 는치료약제중베타차단제, 스타틴계열의약물, 혈관확장제, 이뇨제등은좌심실기능개선에유의하지않았으나, 안지오텐신전환효소억제제는좌심실기능개선에유의함을나타내었다. 그러나본연구에서는전환효소억제제와안지오텐신수용체차단제의사용이두군간에차이가있었는데, 초기약제선택시특별한지침을가지고선택한것이아니었고그대상환자의수가적었으므로이결과가두약제간의차이인지명확히하기위해서는대규모의환자를대상으로비교하여야할것으로생각된다. 본연구의제한점으로는대상환자의수가 89명으로비교적적은집단의후향적인연구로명확한분석이어려웠고단일의료기관의 1년간환자중좌심실기능이 50% 미만의급성심근경색증환자로제한하여일부분만을조사하였기때문에급성심근경색증환자의좌심실기능의개선을정확하게측정하는데는한계가있다고할수있다. 앞으로이러한제한점을보완하여대규모의연구가시행된다면급성심근경색증환자에서좌심실기능을개선하는주요예측인자를정확히파악할수있을것으로사료된다. 요약 배경및목적 : 급성심근경색증환자에서좌심실구혈율은환자의예후와연관된중요한인자로알려져있다. 본연구를통해서급성심근경색증으로입원한환자에서좌심실구혈율의개선또는악화와연관된인자를파악하고자하였다. 방법 : 2004 년 1월부터 2004 년 12 월까지급성심근경색증으로진단된환자중입원치료후퇴원시에좌심실구혈율 (left ventricular ejection fraction: LVEF) 이 50% 미만으로저하된 89 명의환자 (62.5±10.6 세, 남자 63 명, 여자 26 명 ) 를대상으로하였다. 임상경과중 6개월후 LVEF 이 10% 이상개선된 45명의환자를 Ⅰ 군 (62.4±10.4 세, 남자 34 명, 여자 11 명 ), LVEF 이변화가없거나악화된 44명의환자를 Ⅱ 군 (62.3±10.9 세, 남자 29명, 여자 15명 ) 으로하여, 내원시심혈관질환의위험인자, 증상발생후병원에도착하기까지시간 (pain to door time), 치료방법및투여약제, 혈청내심근표지자, 관상동맥조영술과연관된인자등이미치는영향을두군간에비교하였고, 심초음파도는입원시에시행한심초음파도를기준으로퇴원후 6개월의심초음파도소견과비교하였다. 결과 : 내원시심혈관질환의위험인자중고혈압, 당뇨병, 흡연, 고지혈증및비만도등은두군간에차이가없었다. 심근경색증의위치나중재술성공여부및관상동맥병변의특성에서두군간에차이는없었으나, 증상발생후내원시간이 Ⅱ 군에서유의하게지연되어있었다 (Ⅰ 군 6.0±9.5 시간, Ⅱ 군 22.4±7.5 시간, p=0.046). 퇴원후고혈압의조절정도,
118 Korean Circulation J 2007;37:113-118 금연, 콜레스테롤감소등의심혈관위험인자조절여부는좌심실기능개선과무관하였고비만도는경과관찰중에두군모두에서개선되지않았다. 치료약제중베타차단제, 스타틴계열, 혈관확장제, 이뇨제등의사용은양군간에차이가없었으나, Ⅰ군에서 Ⅱ군에비해안지오텐신전환효소억제제의사용이유의하게많았고 (79.3% vs. 47.4%, p=0.03), 안지오텐신수용체차단제의사용은 Ⅱ군에서더많았다 (13.8% vs. 47.4%, p=0.02). 결론 : 급성심근경색증후좌심실기능의개선과연관된인자는증상발생후병원도착까지시간이짧은경우와안지오텐신전환효소억제제사용이었다. 중심단어 : 심근경색증 ; 심부전증 ; 안지오텐신. REFERENCES 1) Hyun DW, Kim KS, Synn YC, et al. Clinical characteristics of acute myocardial infarction died during hospitalization. Korean Circ J 1998;28:1518-26. 2) Stevenson RN, Ranjadayalan K, Umachandran V, Timmis AD. Significance of reciprocal ST depression in acute myocardial infarction: a study of 258 patients treated by thrombolysis. Br Heart J 1993;69:211-4. 3) Joung BY, Ha JW, Choi DH, et al. Age-related difference in longterm prognosis of acute myocardial infarction in women. Korean Circ J 2000;30:1245-56. 4) Hong YJ, Jeong MH, Park OY, et al. 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