대한내과학회지 : 제 79 권제 6 호 2010 관상동맥중재술을시술받은고령환자들의최근 10년간임상양상의변화 전남대학교의학전문대학원전남대학교병원심장센터, 보건복지부지정심장질환특성화연구센터 김민석 정명호 황승환 고점석 이민구 심두선 박근호 윤남식 윤현주 김계훈홍영준 김주한 안영근 조정관 박종춘 강정채 Clinical pattern changes in elderly patients who underwent percutaneous coronary intervention in the last ten years Min Suk Kim, M.D., Myung Ho Jeong, M.D., Seung Hwan Hwang, M.D., Jum Suk Ko, M.D., Min Goo Lee, M.D., Doo Sun Sim, M.D., Keun-Ho Park, M.D., Nam Sik Yoon, M.D., Hyun Ju Yoon, M.D., Kye Hun Kim, M.D., Young Joon Hong, M.D., Ju Han Kim, M.D., Youngkeun Ahn, M.D., Jeong Gwan Cho, M.D., Jong Chun Park, M.D., and Jung Chaee Kang, M.D. The Heart Center of Chonnam National University Hospital, The Heart Research Center Designated by Korea Ministry of Health and Welfare, Chonnam National University Medical School, Gwangju, Korea Background/Aims: The objective of this study was to observe changes in the clinical patterns of Korean patients over 65 years of age who received percutaneous coronary intervention (PCI) in the past 10 years. Methods: In total, 3,209 patients over 65 years of age [male:female; 1,950 (71.4±5.21 years):1,259 (72.5±5.47 years)] who underwent PCI between June 1999 and June 2009 were divided into four groups according to time period. Clinical characteristics, gender differences, coronary angiographic findings, and major adverse cardiac events (MACE) during a 1-year follow-up period were compared among the four groups. Results: The gender ratio was male-dominant and no significant change was observed over the observed time period [male (60.8):female (39.2%)], but the age increased [1999-2001:2002-2004:2005-2007:2008-2009=71.2±5.11:71.4±5.26:71.9±5.25: 72.6±5.57 years; p=0.001]. The prevalence of hypertension increased over time (p=0.028), but smoking decreased (p=0.002). Hypertension was the major risk factor for males, whereas obesity was the major risk factor for female patients. MACE-free 1-year survival increased over the observed period (p=0.014). Males had higher survival rates than females (p=0.007). MACE developed in 105 (3.27%) patients during the 1-year follow-up period and predictive factors for the development of MACE were being female (p=0.001), old age (p=0.008), hypertension (p=0.049), diabetes mellitus (p=0.004), smoking (p=0.009), and low Thrombolysis In Myocardial Infarction (TIMI) flow (p=0.048) by a multivariate analysis. Conclusions: The age of elderly patients undergoing PCI and the prevalence of hypertension increased, whereas smoking decreased over the last 10 years. Predictive factors for patients developing MACE during the one-year follow-up were associated with female gender, hypertension, diabetes mellitus, smoking, old age, and low TIMI flow. (Korean J Med 79:661-672, 2010) Key Words: Age; Coronary disease; Coronary angioplasty; Myocardial ischemia; Risk factor Received: 2010. 7. 30 Revised: 2010. 8. 20 Accepted: 2010. 9. 28 Correspondence to Myung Ho Jeong, M.D., Director of the Heart Research Center Nominated by Korea Ministry of Health and Welfare, Chonnam National University Hospital, 671 Jaebonro, Donggu, Gwangju 501-757, Korea E-mail: myungho@chollian.net * This study was supported by a grant of the Korea Healthcare Technology R&D project, Ministry for Health & Welfare, Republic of Korea (A084869). - 661 -
- The Korean Journal of Medicine: Vol. 79, No. 6, 2010 - 서 론 성은 1,259 명 (72.5±5.47 세 ) 이었다. 1990년대중반이후우리나라는급속히고령화사회로진입하였고, 고령인구가차지하는비중은매년증가추세에있는실정이다. 2010년 3월 4일대한민국통계청이발표한 2009 한국의사회지표 에따르면 2009년대한민국국민중 65세이상의고령인구는 5,193,000명으로전체인구 48,747,000 명중차지하는비율이 10.7% 를기록하였다 1). 이와같이고령인구비중은계속증가하고있으며, 이에따라고령인구의건강에대한연구의중요성이높아지고있다. 국민생활수준향상및평균연령상승에따라노인인구의주요사망원인질환의비율도변화하고있다. 실제로 2008년도 65세이상의노인인구의주요사망원인으로 10만명당 901.8명의사망률을보여순환기계통질환이 1위를차지하였다. 국내에서허혈성심장질환은 30년전만하더라도비교적드문질환이었지만현재는순환기질환으로입원하는환자중가장많은원인이되고있어, 고혈압, 심부전증, 부정맥과함께가장많이접하는질환이되었다. 이와같이국내에서심혈관계질환중허혈성심장질환의비중이증가하고있고이에대한치료방법의하나로서경피적관상동맥중재술 (percutaneous coronary intervention, PCI) 이시술되고있으며, 그시술건수는최근 10년사이에 6배이상으로꾸준히증가하고있는추세이다 2). 특히, 65세이상의고령환자에서 PCI 를시행하는빈도도증가하고있고, 고령화사회로급속히진입하고있는우리나라에서고령환자를대상으로허혈성심장병의발생위험인자를분석하고이에따른치료및임상경과를평가함이필요할것으로생각되었다. 이연구에서는고령의남성및여성환자의위험인자변화추이및유병률을분석하고, PCI 시술 1년후임상경과를관찰하여예후예측인자를분석하고자하였으며, 이를통하여고령환자의허혈성심장질환의발생을예방하고, 허혈성심장질환의치료에도움이되고자한다. 대상및방법 1. 대상 1999년 6월부터 2009년 6월까지전남대학교병원심장센터에서 PCI를받았던 65세이상의 3,425명의허혈성심장질환환자들중 1년이상추적관찰이가능하였고, 정확한자료분석이가능하였던 3,209명의환자를대상으로하였다. 평균나이는 71.9±1.39세였으며, 남성은 1,950명 (71.4±5.21세), 여 2. 방법기간에따른변화를확인하기위하여 1999년 6월 1일부터 2009년 6월 30일까지기간에따라서 1999년 6월 ~2001년 12월, 2002년 1월 ~2004년 12월, 2005년 1월 ~2007년 12월, 2008년 1 월 ~2009년 6월등 4개의군으로구분하였다. 각군간허혈성심질환의주요위험인자 ( 고혈압, 당뇨병, 이상지질혈증, 흡연, 연령, 비만 ) 의유무여부를통하여위험도별분류를시행하였다. 위험도기준은미국심장학회 (American Heart Association, AHA) 분류기준에준하여혈압, 이상지질혈증등조절및예방가능한인자에대해구분하였다. 고혈압의경우 2010 AHA 가이드라인 3) 에따라수축기혈압의경우 140 mmhg 이상을고도위험군, 130~139 mmhg 사이를중도위험군, 130 mmhg 미만을저위험군으로구분하였으며, 이완기혈압의경우 90 mmhg 이상을고도위험군, 85~89 mmhg 사이를중도위험군, 85 mmhg 미만을저위험군으로구분하였다. 위험도는수축기및이완기혈압의위험도간에높은쪽의위험도를택하였다. 당뇨병은 2010년미국당뇨병학회 (American Diabetes Association, ADA) 가이드라인 4) 에의하여 HbA1c 6.5%, 공복혈당 126 mg/dl, 75 g 경구당부하검사상혈중혈당 200 mg/dl 이상, 다음, 다뇨, 다갈등의고혈당증상과임의의혈당 200 mg/dl 중 1개이상을만족하는경우로정의하였다. 이상지질혈증의허혈성심장질환에대한위험도기준은 National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) 가이드라인 5) 에따라저밀도지단백콜레스테롤 (low density lipoprotein-cholesterol, LDL-C) 은 70 mg/dl 미만을저위험군, 71~130 mg/dl 를중등도위험군, 130 mg/dl 이상을고위험군으로나누었으며, 고밀도지단백콜레스테롤 (high density lipoprotein-cholesterol, HDL-C) 은 40 mg/dl 미만을고도위험군, 41~60 mg/dl 를중등도위험군, 61 mg/dl 이상을저위험군으로나누었으며, 총콜레스테롤 (total cholesterol, TC) 은 200 mg/dl 미만을저위험군, 201~239 mg/dl를중등도위험군, 240 mg/dl 이상을고위험군으로분류하였다. 본연구의대상환자군은모두 PCI를시행받았으므로 NCEP ATP III 가이드라인에따르면고위험군에해당되어, 고위험군중집중적인치료가필요한군으로분류한저밀도지단백콜레스테롤 71 mg/dl 이상의중등도위험군이상이거나, Triglyceride 200 mg/dl 이상이면서고밀도지단백콜레스테롤이 40 mg/dl 미만인환자군을이상지질혈증군으로분류하였다. 또한 2008 American College of Cardioolgy/American - 662 -
- Min Suk Kim, et al. Elderly patients underwent PCI - Diabetes Association (ACC/ADA) 가이드라인 6) 을바탕으로허혈성심장질환의위험도를가지고있는환자군의목표지질농도도달여부를확인하였다. 비만도는내원당시측정한키와몸무게를기준으로하여체질량지수 (body mass index, BMI) 를측정하였다. BMI score 24.9 kg/m 2 이하의정상체중을저위험군, 25~29.9 kg/m 2 사이의경도비만을중도위험군, 30 kg/m 2 이상의고도비만을고도위험군으로분류하였다 7). 허혈성심장질환의중증도평가를위해시술당시의진단명에따라안정형협심증 (stable angina pectoris, SAP), 불안정형협심증 (unstable angina pectoris, UAP), ST분절비상승심근경색증 (non ST-segment elevation myocardial infarction, NSTEMI), ST분절상승심근경색증 (ST-segment elevation myocardial infarction, STEMI) 등의순서로중증도를구분하였다. 시술후임상경과를평가하기위해 American College of Cardiology/ American Heart Association (ACC/AHA) 병변분류 8), 침범한 혈관의개수및삽입된스텐트개수를파악하였고, 시술성공여부및시술후 Thrombolysis In Myocardial Infarction (TIMI) flow 9) 를분석하였다. 이환자들의시술후 1년동안심장사망, 심근경색증, 재관류술등의주요심장사고 (major adverse cardiac event, MACE) 를관찰하였다. 3. 통계분석모든측정값은평균 ± 표준편차로표시하였으며통계처리는 SPSS 17.0 (Statistical package for the social sciences, SPSS-PC Inc. Chicago, IL, U.S.A.) 을이용하였다. 연속변수는평균 ± 표준편차로표시하였다. 군간비교는비연속변수의경우카이- 제곱교차분석 (Chi-square test), 연속변수의경우일원배치분산분석 (One-way ANOVA) 을이용하여분석하였다. 2개이상의독립변수에대한분석은이원분산분석 (Two-way ANOVA) 를우선하여이용하였으며, 이때상호작용효과의 Table 1. Baseline clinical characteristics according to the four observation periods Gender (M/F) 1999. 6. 1~2001. 12. 31 (n=279) 178 (63.8%)/ 101 (36.2%) 2002. 1. 1~2004. 12. 31 (n=876) 521 (59.5%)/ 355 (40.5%) - 663-2005. 1. 1~2007. 12. 31 (n=1277) 796 (62.3%)/ 481 (37.7%) 2008. 1. 1~2009. 6. 30 (n=777) 455 (58.6%)/ 322 (41.4%) p-value Age (years) 71.2±5.11 71.4±5.26 71.9±5.25 72.6±5.57 0.001 Hypertension (n, %) 81 (55.9) 414 (55.6) 661 (55.7) 437 (62.2) 0.028 Diabetes (n, %) 36 (25.5) 249 (33.6) 388 (32.6) 249 (35.4) 0.137 Smoking (n, %) 43 (32.1) 203 (28.2) 428 (36.1) 179 (25.5) 0.002 BMI (kg/m 2 ) 24.1±3.42 24.3±3.17 24.0±3.23 24.2±3.69 0.346 HbA1c (%) 6.6±1.32 6.6±1.39 6.5±1.46 6.5±1.27 0.452 ApoA1 (mg/dl) 119.1±26.10 119.7±25.74 121.1±25.09 120.9±26.38 0.575 ApoB (mg/dl) 95.3±25.48 95.4±25.05 94.1±25.18 95.6±25.59 0.667 TC (mg/dl) 182.5±41.27 181.6±42.68 185.0±43.20 183.5±48.79 0.485 HDL-C (mg/dl) 45.8±12.30 45.1±12.37 45.2±11.87 45.3±13.17 0.883 LDL-C (mg/dl) 124.5±36.17 118.0±36.25 120.3±33.73 122.1±38.25 0.090 Triglycerides (mg/dl) 126.3±139.60 124.8±104.87 116.8±80.57 123.5±95.66 0.303 hscrp (mg/dl) 0.9±2.04 1.2±2.82 1.1±2.56 1.1±2.83 0.525 Systolic BP (mmhg) 132.6±22.99 127.9±22.80 129.1±22.45 127.5±19.23 0.087 Diastolic BP (mmhg) 77.8±13.99 76.8±13.43 79.3±13.67 77.7±13.44 0.001 MACE-free survival (n, %) 148 (96.7) 781 (96.8) 1133 (95.1) 682 (97.8) 0.014 BMI, body mass index; HbA1c, hemoglobin A 1c; ApoA1, apolipoprotein A1; ApoB, apolipoprotein B; TC, total cholesterol; HDL-C, high density lipoprotein-cholesterol; LDL-C, low density lipoprotein-cholesterol; hscrp, high sensitivity C-reactive protein; BP, blood pressure; MACE, major adverse cardiac event. 0.204
- 대한내과학회지 : 제 79 권제 6 호통권제 604 호 2010 - - 664 -
- 김민석외 15 인. 고령환자에서관상동맥중재술 - 유의여부에따라일원분산분석을시행하였다. MACE 에대해유효위험인자의분석을위해이분형로지스틱회귀분석 (Binary logistic regression analysis) 을이용하였다. p 값은 0.05 미만에서통계적으로유의한것으로간주하였다. 결과 1. 임상적특징 1999년이후지속적으로남성의비율이여성의비율보다높았으나, 시간에따른성비의의미있는변화는관찰되지않았다 [ 남성 (60.8%): 여성 (39.2%), p=0.204]. 그러나평균연령의경우지속적인증가를보였다 (1999~2001년 : 2002~2004년 : 2005~2007년 : 2008~2009년 =71.2±5.11세 : 71.4±5.26세 : 71.9±5.25세 : 72.6±5.57세, p=0.001). 위험인자의유병률의경우고혈압은시간에따라유의한증가를보였으나 (p=0.028), 당뇨병은유의한증가가관찰되지않았다. 또한흡연의경우는유의한 감소가관찰되었다 (p=0.002). 진단의학검사실소견에서 apoprotein (Apo) A1, ApoB, HDL-C, TC, 중성지방 (triglyceride, TG), high sensitivity C-reactive protein (hscrp) 등은유의한변화는없었으며, BMI 도유의한변화는관찰되지않았다. 내원당시수축기혈압에는유의한차이가없었으나 (p=0.087), 이완기혈압에서유의한차이가있었다 (p=0.001). 시술후 1년생존율은유의하게증가되었다 (p=0.014, 표 1). 기간별로성별에따른임상양상의변화를분석하였을때, 평균연령은남녀간에기간의변화에따른의미있는차이가없었으나 (p=0.204), 흡연 (p=0.029) 과 BMI (p=0.016) 등은기간에따른유의한차이가관찰되었다. 전체연령군에서의미있는증가를보였던고혈압의경우는남녀간에유의한차이를보이지않았다 (p=0.174). 시술후생존율에있어서는기간에따라서성별간의생존율에차이가있었고여성에서낮았다 (p=0.007, 표 2). Table 3. Clinical diagnosis, coronary angiographic findings, percutaneous coronary intervention, and prognosis 1999. 6. 1~2001. 12. 31 (n=279) 2002. 1. 1~2004. 12. 31 (n=876) - 665-2005. 1. 1~2007. 12. 31 (n=1277) 2008. 1. 1~2009. 6. 30 (n=777) p-value Diagnosis 0.001 STEMI (n, %) 142 (50.9) 366 (41.8) 405 (31.7) 206 (26.5) NSTEMI (n, %) 21 (7.5) 93 (10.6) 209 (16.4) 204 (26.3) SAP (n, %) 18 (6.5) 75 (8.6) 173 (13.5) 115 (14.8) UAP (n, %) 98 (35.1) 342 (39.0) 490 (38.4) 252 (32.4) Infarct related artery 0.001 LM (n, %) 1 (0.4) 7 (0.8) 32 (2.5) 34 (4.4) LAD (n, %) 146 (52.3) 482 (55.2) 697 (55.3) 495 (64.2) LCX (n, %) 45 (16.1) 130 (14.9) 196 (15.5) 94 (12.2) RCA (n, %) 87 (31.2) 253 (29.0) 334 (26.5) 148 (19.2) Stent 0.002 BMS (n, %) 279 (100) 664 (75.8) 272 (21.3) 157 (20.2) DES (n, %) 0 (0) 212 (24.2) 1,005 (78.7) 620 (79.8) TIMI flow grade 0 (n, %) 3 (2.7) 23 (3.3) 23 (2.0) 61 (8.9) 1 (n, %) 3 (2.7) 10 (1.4) 11 (0.9) 15 (2.2) 2 (n, %) 25 (22.3) 58 (8.3) 134 (11.4) 98 (14.3) 3 (n, %) 81 (72.3) 605 (86.8) 1,003 (85.3) 511 (74.5) MACE-free survival (n, %) 148 (96.7) 781 (96.8) 1,133 (95.1) 682 (97.8) 0.014 STEMI, acute ST-segment elevation myocardial infarction; NSTEMI, acute non ST-segment elevation myocardial infarction; SAP, stable angina pectoris; UAP, unstable angina pectoris; LM, left main artery; LAD, left anterior descending artery; LCX, left circumflex artery; RCA, right coronary artery; BMS, bare metal stent; DES, drug eluting stent; TIMI, Thrombolysis In Myocardial Infarction; MACE, major adverse cardiac event.
- The Korean Journal of Medicine: Vol. 79, No. 6, 2010 - - 666 -
- Min Suk Kim, et al. Elderly patients underwent PCI - 2. 관상동맥조영술및중재술소견관상동맥조영술당시진단명은 4군을비교하면 STEMI 와 UAP는각각 50.9% 에서 26.5%, 35.1% 에서 32.4% 로서빈도가감소하고있으며, NSTEM와 SAP은각각 7.5% 에서 26.3%, 6.5% 에서 14.8% 로증가하고있다 (p=0.001). 표적혈관은좌전하행지 (left anterior descending artery, LAD), 우관상동맥 (right coronary artery, RCA), 좌회선지 (left circumflex artery, LCX), 좌주간지 (left main stem, LMS) 순서로이환되었으며, 기간에따른순서의변화는없었다. 삽입한스텐트는 1999~ Table 5. Clinical features according to the development of MACE during 1-year clinical follow-up MACE (-) (n=3104, 96.7%) - 667 - MACE (+) (n=105, 3.3%) p-value Gender (M/F) 1745 (63.6%)/999 (36.4%) 48 (45.7%)/57 (54.3%) 0.001 Age (years) 71.8±5.26 73.3±6.34 0.004 Hypertension (n, %) 1538 (58.2) 79 (75.2) 0.002 Diabetes (n, %) 891 (33.8) 64 (61.0) 0.003 Smoking (n, %) 827 (31.7) 52 (49.5) 0.001 BMI (kg/m 2 ) 24.1±3.36 24.6±3.13 0.276 Dyslipidemia (n, %) 1745 (85.3) 73 (86.9) 0.962 ApoA1 (mg/dl) 120.0±25.65 120.0±23.52 0.992 ApoB (mg/dl) 95.0±25.28 93.0±25.15 0.509 HbA1c (%) 6.5±1.38 6.6±1.34 0.390 HDL-C (mg/dl) 45.1±12.37 44.8±10.52 0.841 LDL-C (mg/dl) 120.7±37.71 114.0±30.22 0.05 TC (mg/dl) 183.3±44.38 184.0±43.14 0.890 TG (mg/dl) 120.8±92.96 117.7±78.75 0.734 hscrp (mg/dl) 1.1±2.72 1.2±2.45 0.789 Systolic BP (mmhg) 128.9±21.59 121.9±27.17 0.008 Diastolic BP (mmhg) 78.5±13.39 75.0±17.89 0.013 Clinical diagnosis 0.131 STEMI (n, %) 968 (35.3) 46 (43.8) 0.101 NSTEMI (n, %) 466 (17.0) 15 (14.3) 0.092 SAP (n, %) 306 (11.2) 15 (14.3) 0.087 UAP (n, %) 1,004 (36.6) 29 (27.6) 0.124 Infarct-related artery 0.664 LAD (n, %) 1,571 (57.7) 51 (50.0) 0.551 LCX (n, %) 400 (14.7) 16 (15.7) 0.627 LM (n, %) 65 (2.4) 4 (3.9) 0.812 RCA (n, %) 683 (25.1) 31 (30.4) 0.711 TIMI flow 0.001 0 (n, %) 103 (4.0) 6 (6.5) 0.001 1 (n, %) 35 (1.4) 4 (4.3) 0.005 2 (n, %) 306 (12.0) 4 (4.3) 0.002 3 (n, %) 2,108 (82.4) 77 (83.7) 0.374 MACE, major adverse cardial event; BMI, body mass index; ApoA1, apolipoprotein A1; ApoB, apolipoprotein B; HbA1c, hemoglobin A 1c; HDL-C, high density lipoprotein-cholesterol; LDL-C, low density lipoprotein-cholesterol; TC, total cholesterol; TG, triglyceride; hscrp, high sensitivity C-reactive protein; BP, blood pressure; STEMI, acute ST-segment elevation myocardial infarction; NSTEMI, acute non ST-segment elevation myocardial infarction; SAP, stable angina pectoris; UAP, unstable angina pectoris; LAD, left anterior descending artery; LCX, left circumflex artery; LM, left main artery; RCA, right coronary artery; TIMI, Thrombolysis In Mycocardiac Infarction.
- 대한내과학회지 : 제 79 권제 6 호통권제 604 호 2010 - - 668 -
- 김민석외 15 인. 고령환자에서관상동맥중재술 - Table 7. Multivariable analysis for the development of MACE during 1-year clinical follow-up Confidence Interval Odds ratio Lower Upper p-value Female 2.187 1.984 2.218 0.001 Diabetes 2.478 2.231 2.614 0.004 Older age (75 years) 2.732 2.413 3.137 0.008 Smoking 3.658 3.427 3.894 0.009 Low TIMI flow (2) 1.403 1.219 4.235 0.048 Hypertension (140/90 mmhg) 1.551 1.351 4.517 0.049 MACE, major adverse cardiac events; TIMI, Thrombolysis In Myocardial Infarction. 2001년에는모든환자에서일반금속스텐트 (bare metal stent, BMS) 를시술하였으나, 이후약물용출스텐트 (drug eluting stent, DES) 의시술비율이증가하였으며, 2008~2009년에는 DES의시술률이 79.8% 로증가하였다 (p=0.002, 표 3). 시술후 1년간 MACE 발생없는생존률은 1999~2001년 (96.7%) 에비해 2008~2009년 (97.8%) 로호전되는양상이관찰되었다 (p=0.014). 기간및성별에따른 MACE 발생없는생존률을비교하였을때남성이여성에비하여높았다 (p=0.007, 표 2, 표 4). 3. 임상경과관찰관상동맥중재술후 1년이내에 105명 (3.27%) 에서 MACE 가발생하였으며, 남성 48명 (45.7%), 여성 57명 (54.3%) 이었고, 평균연령은 73.3±6.34세로서생존한군의평균연령 (71.8±5.26 세 ) 보다많았다 (p=0.004). 고혈압 (p=0.002), 당뇨병 (p=0.003), 흡연 (p=0.001) 의유병률은 MACE가발생한군에서더높게나타났다. BMI 및이상지질혈증에대한검사실소견 (TC, LDL-C, TG, HDL-C, hscrp) 에서는양군에의미있는차이는관찰되지않았으나, 이상지질혈증의유병률은양군에서모두높게나타났다. 관상동맥조영술소견에서주요이환된혈관은양군에서모두 LAD, RCA, LCX, LMS 순서이었으며, 의미있는차이는관찰되지않았다. 진단명에있어서도양군간에의미있는차이는보이지않았으나 (p=0.131), 시술후 TIMI flow 는 MACE 가발생한군에서 TIMI flow가더낮았다 (p=0.001, 표 5). 4. 주요심장사고발생에관여하는인자관찰기간에따른 MACE 의위험인자의변화는 1999~2001 년은이환된혈관 (p=0.001), 시술후 TIMI flow (p=0.001), 내원 당시낮은수축기혈압 (p=0.039), 2002~2004년은여성 (p=0.003), 고령 (p=0.044), 당뇨병 (p=0.041), 흡연 (p=0.032), 2005~2007년은여성 (p=0.001), 고혈압 (p=0.007), 당뇨병 (p=0.012), 흡연 (p=0.043), 시술후낮은 TIMI flow (p=0.027), 시술당시낮은수축기혈압 (p=0.011), 2008~2009년은고령 (p=0.024) 등이유의한 MACE 의위험인자였다 ( 표 6). 전체대상고령환자에서 PCI를시술받고 1년이내에 MACE 발생에관련성이있는전반적인위험인자에대한로지스틱회귀분석결과, 여성, 고혈압 (140/90 mmhg 이상 ), 당뇨병, 흡연, 75세이상의고령및시술당시 TIMI flow 2점이하등이 1년이내에 MACE 의발생에관여하는유의한독립적인예측인자였다 ( 표 7). 고찰최근 10년간 PCI를시행받은 65세이상고령환자를대상으로허혈성심장질환환자의임상양상의변화및치료의차이와 PCI 소견의변화등을확인하였고, 1년이내 MACE 가발생한환자군을분석하였다. 전체환자군의평균연령및고혈압은지속적인증가추세를보이고있었으며, 흡연은감소하고있었다. 여성, 고령, 고혈압, 당뇨병, 흡연, PCI 시술후낮은 TIMI flow 등이 MACE 발생의유의한예측인자이었다. 2007년통계청자료에의하면 1998년에는전체사망자 240,254 명중 57,439명 (23.9%), 1999 년에는전체사망자 246,539명중 57,531명 (23.3%), 2000년에는전체사망자 247,346명중 58,554 명 (23.7%) 이순환기계질환으로사망하였고, 이중 1998 년 13.2%, 1999년 15.2%, 2000년 17.5% 가허혈성심장질환으로인한사망이었으나, 이는 2000년이후에는심장질환으로 - 669 -
- The Korean Journal of Medicine: Vol. 79, No. 6, 2010 - 인한사망자중허혈성심장질환이원인인경우가 2004년에는 22%, 2005년은 24%, 2006년에이르러서는 25% 로지속적인증가추세를보이고있다. 심장질환은한국인 4대사망원인중하나가되었으며, 최근에는고혈압, 허혈성심장질환이급증하고있고, 협심증, 심근경색증등의허혈성심장질환이성인사망률의주요한원인이되고있다 10,11). 이에따라허혈성심장질환에대한구체적이고체계적인연구를위하여 2005년대한순환기학회 50주년기념사업으로전국 40여개대학병원에서한국인급성심근경색증의현황에대한등록연구 (Korea Acute Myocardial Infarction Registry, KAMIR) 가시작되었으며, 이를통하여한국실정에맞는허혈성심장질환의예방및치료에대한연구를진행하고있다 12). 지난 10년간한국에서 PCI를시술받은고령환자에서남녀간의주요위험인자는고혈압이지속적인증가를보이고있었으나, 기간에따른남녀간의유병률에는차이를보이지않았다. 고령환자에서 SAP와 NSTEMI 환자는증가하였고 UAP와 STEMI 환자는감소하였다. 남성에서는고혈압이가장중요한위험인자였으며, 여성에서는비만이가장중요한위험인자였다. 여성에서는폐경기이후발생하는에스트로겐의감소등의호르몬의변화와남성에비하여상대적으로체지방비율이높은점이비만의원인으로보고하였다 13,14). 시술후 1년이내주요심장사고에의한사망률은여성이남성에비해 20% 정도높았고, 이는 KAMIR 의연구결과와해외에서보고된바와비슷하다 2,15-20). 1년이내주요심장사고로사망하는환자군과생존한군에대하여단변량분석을시행한결과, 남성보다는여성에서사망한경우가더많았으며, 사망한환자군은생존한군에비해평균연령이높게나타났다. 또한사망한군의임상진단명에서심근경색증의비율이높게관찰되었다. 다변량분석에서는 1년이내주요심장사고가발생하는환자들에서고혈압, 당뇨병, 흡연의유병률이현저하게높게나타났으며, 시술당시 TIMI flow 가낮은환자들에서도주요심장사고발생이높았다. 이를통하여 75세이상의고령, 여성, 고혈압, 당뇨병, 흡연, 시술당시 TIMI flow 2점이하등을보이는환자들은시술후에도 MACE 발생률이높음을확인할수있었다. 10년동안관찰기간에따른 MACE 위험인자의변화를분석한결과, 여성, 흡연, 당뇨병, 고혈압, 시술당시낮은 TIMI flow 및낮은수축기혈압등이위험인자이었다. 각기간에따라위험인자의분포는차이를보이고있었으나, 다변량분석을통해위험인자로확인된인자들범위내에서차이를보이고있었다. Radovanvic과 Erne 21) 이 1997년부터 2009년까지 31,010명의허혈성심장질환환자를대상으로시행하였던 AMIS (Acute Myocardial Infarction in Switzerland) study에서도이와비슷한보고를하였으며, 위험인자로서평균연령은 65세이상으로본연구에서는 75세이상이유의한위험인자였던것에비하여낮은연령대를보였다. 그러나 MACE 의위험인자는외국의여러연구에서보고된바와비슷한양상을보여주었다 22,23). Yoo 등 24) 과 Seldis 등 25) 은 10년이상당뇨병의유병기간이길어질경우당뇨병성신경병증, 신장병증등의합병증이증가하고이로인하여 PCI 시술후더불량한예후에영향을주어 MACE 발생을증가시킨다고보고한바있다. AHA 가이드라인 4) 에서는수축기혈압을 130 mmhg 미만으로조절할것을권장하고있으며, ACC/ADA 가이드라인 7) 에서는 ApoB 는 80 mg/dl 미만, Non-HDL은 100 mg/dl 미만으로조절할것을권장하고있다. KAMIR 연구결과에의하면한국인에서발생하는 69% 의환자에서 NCEP ATP III 가이드라인에따르면이상지질혈증이있음이밝혀진바있다 26). 따라서고령환자에서철저한혈압, 혈당및혈중지질농도의조절은생존율향상에필요하며, 시술당시높은 TIMI flow를획득하기위한노력이필요할것으로생각되었다 27). 본연구의제한점은첫째, PCI 시술을시행받은환자들만을대상으로한점둘째, 실제 PCI를받았던환자들중추적관찰이되지않은환자들이 3,425명중 216명 (6.3%) 으로서비교적많았다는점셋째, 단일센터의환자군을대상으로하였으므로지역적특성을배제하기어렵다는점등이다. 그러나 10년이라는비교적오랜기간임상양상의변화및관상동맥중재술소견의변화를확인하였으며, 시술후 1년이내 MACE 발생의주요위험인자를분석하여고령의허혈성심장질환환자에서생존율의향상을위하여필수적으로조절하여야할인자를확인한점등에본연구의의의를둘수있다. 본연구의결과를바탕으로고령의허혈성심장질환환자에서주요위험인자중고혈압, 비만이최근 10년사이에 10% 정도의증가를보이고있으며, 이는구미선진국과비슷한수준으로우리나라에서도허혈성심장질환의위험도가급속히증가하고있음을확인할수있었다 28-30). 따라서 PCI를시술받은한국인고령환자에서적절한약물치료와식이조절및꾸준한운동으로혈압, 비만및이상지질혈증등을조절하고, 금연을할수있도록환자들에게교육하고관리하는일이중요할것으로생각되었다. 남성에서는고혈압, 여성에서는비만이증가하는위험인자이어서, 성별에따 - 670 -
- Min Suk Kim, et al. Elderly patients underwent PCI - 른차별화된관리를시행함으로써고령환자의예후를개선시킬수있다고예상할수있었다. 요 목적 : 우리나라에서허혈성심장질환의유병률이높아지고있으며, 관상동맥중재술 (percutaneous coronary intervention, PCI) 이중요한치료방법의하나로서시행되고있다. 본연구를통하여최근 10년간 PCI를시행받은 65세이상의고령환자들의임상양상의변화를확인하였다. 방법 : 1999년 6월부터 2009년 6월까지 PCI를시행받은 65세이상의 3,209명 [ 남성 : 여성 1950명 (71.4±5.21세):1,359명 (72.5±5.47세)] 의환자를대상으로하여기간에따라 4개의군으로나누었다. 네군간의임상적특징, 성별간의차이, 관상동맥조영술및 PCI 소견의차이, 시술후 1년이내주요심장사고의발생을분석, 비교하였다. 결과 : 지난 10년간 PCI를시술받은고령환자의성비는지속적으로남성의비율이높았다 [ 남성 (60.8%): 여성 (39.2%)]. 평균연령은지속적으로증가하였으며, 위험인자의경우고혈압의유병률은증가하였으며 (p=0.028), 흡연은감소하였다 (p=0.002). 1년이내주요심장사고의발생률은지속적으로감소하였으며 (p=0.014), 남성은여성보다높은생존율을보였다 (p=0.001). PCI 후 1년이내의주요심장사고는 105명 (3.27%) 에서발생하였다. 주요심장사고의발생예측인자로는여성 (p=0.001), 75세이상의고령 (p=0.008), 고혈압 (p=0.049), 당뇨병 (p=0.004), 흡연 (p=0.009), 시술후낮은 TIMI flow (p=0.048) 등이었다. 결론 : PCI를시술받은고령환자의평균연령은지속적으로증가하였으며, 고혈압은지속적으로상승하였고, 흡연은감소하였다. 1년이내주요심장사고의발생과관련된유의한인자들은여성, 고령, 고혈압, 당뇨병, 흡연, 시술후낮은 TIMI flow 등이었다. 중심단어 : 연령 ; 관상동맥질환 ; 관상동맥중재술 ; 심근허혈 ; 위험인자 약 REFERENCES 1) Korea National Stat Office. Social indicators in Korea. 2009 2) Cho JM, Kim CJ, Shin WS, Cho EJ, Park CS, Kim PJ, Lee JM, Ihm SH, Rhim HY, Chang K, Moon KW, Kim YJ, Jung HO, Kim HY, Park JW, Jin SW, Jeon HK, Oh YS, Yoo KD, Jeon DS, Baek SH, Lee GW, Youn HJ, Lee MY, Chung WS, Park JC, Seung KB, Rho TH, Kim CM, Park IS, Chae JS, Kim JH, Choi KB, Hong SJ. Clinical features and prognostic factors in Korean patients hospitalized for coronary artery disease. Korean J Med 73:142-150, 2007 3) Rosendorff C, Black HR, Canno CP, Gersh BJ, Gore J, Izzo JL Jr, Kaplan NM, O'Connor CM, O'Gara PT, Oparil S. Treatment of hypertension in the prevention and management of ischemic heart disease: a scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention. Circulation 115:2761-2788, 2007 4) American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 33(Suppl 1):S62-S69, 2010 5) Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr, Clark LT, Hunninghake DB, Pasternak RC, Smith SC Jr, Stone NJ. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment panel III guidelines. Circulation 110:227-239, 2004 6) Brunzell JD, Davidson M, Davidson M, Furberg CD, Goldberg RB, Howard BV, Stein JH, Witztum JL. Lipoprotein management in patients with cardiometabolic risk: consensus statement from the American Diabetes Association and the American College of Cardiology Foundation. Diabetes Care 31:811-822, 2008 7) Lee YE, Park JE, Hwang JY, Kim WY. Comparison of health risks according to the obesity types based upon BMI and waist circumference in Korean adults: the 1998-2005 Korean national health and nutrition examination surveys. Korean J Nutr 42:631-638, 2009 8) Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE 2nd, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-st-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol 50:E1-E157, 2007 9) Chesebro JH, Knatterud G, Roberts R, Borer J, Cohen LS, Dalen J, Dodge HT, Francis CK, Hillis D, Ludbrook P. Thrombolysis in myocardial infarction (TIMI) trial, phase I: a comparison - 671 -
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