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Original ORIGINAL Article ARTICLE Korean Circulation J 2005;35:115-122 ISSN 1738-5520 c 2005, The Korean Society of Circulation 한국인관상동맥의직경및단면적 : 정상치와결정인자 한림대학교의과대학내과학교실 김응주 유지연 천원석 한성우 최영진 유규형 임종윤 Coronary Artery Size in Korean: Normal Value and its Determinants Eung Ju Kim, M.D., Ji Youn Yoo, M.D., Won Seok Cheon, M.D., Sung Woo Han, M.D., Young Jin Choi, M.D., Kyu Hyung Ryu, M.D. and Chong Yun Rhim, M.D. Division of Cardiology, Department of Medicine, Hallym University, Anyang, Korea ABSTRACT Background and Objectives:Although the size of the coronary artery is known to be closely related to the outcome of coronary artery bypass grafting and percutaneous coronary intervention, its normal value and determinants have not been examined in Koreans. Subjects and Methods:One hundred and twenty seven normal coronary arteriograms were carefully selected from 3,412 studied consecutively. Of these, 53 women and 23 men, with no abnormalities in their cardiac function and not using nitrates, were studied. The lumen diameter was measured at 10 segments in the epicardial coronary arteries. Results:For men, the mean lumen diameter of the proximal left anterior descending and left circumflex coronary arteries were 3.88±0.39 and 3.45±0.47 mm, respectively, and were not affected by the anatomic dominance. However, the left main and proximal right coronary arteries varied between 4.44±0.49 and 5.18±0.32 mm (p<0.05) and 3.29±0.60 and 4.05±0.42 mm (p<0.05), respectively, by the anatomic dominance. Women had a smaller mean coronary artery size than men [for diameter, -7% (p<0.01);for cross-sectional area, -13% (p<0.01)], and the left ventricular (LV) mass was significantly associated with coronary artery diameter (p<0.05). From a multiple linear regression analysis, gender was an only independent predictor of the coronary artery size (p<0.05). Conclusion:We revealed normal coronary artery dimensions in Koreans. Although, body size, hypertension, use of calcium channel blockers, anatomic dominance and age had no effect on the size of the coronary artery, but the LV mass and gender were shown to have an effect. The multivariate regression analysis showed gender was an only independent predictor of the coronary artery size. (Korean Circulation J 2005;35:115-122) KEY WORDS:Coronary arteries;koreans. 서 관상동맥의크기는관동맥우회로술의수술전후사망률과역상관관계가있으며경피적관동맥중재시술 (percutaneous coronary intervention; PCI) 후의재협착율이나재개통술비율 (target lesion revascularization; TLR) 등성적과도깊은연관이있는것으로알려져있다. 1-8) 관동맥의직경은혈 논문접수일 :2005 년 1 월 17 일심사완료일 :2004 년 1 월 26 일교신저자 : 최영진, 431-070 경기도안양시동안구평촌동 896 한림대학교의과대학내과학교실전화 :(031) 380-3877 전송 :(031) 386-2269 E-mail:cyj@hallym.or.kr 론 류와관련된혈관벽의전단력에좌우되고, 심근의산소요구량을증대시키거나심근의비후를야기하는환경등에영향을받으며유전적인인자에의해서도영향을받는다. 9-11) 관동맥직경의결정인자로는체표면적 (body surface area; BSA), 체질량지수 (body mass index; BMI), 키, 몸무게등의전신적특성뿐아니라심장의무게, 좌심실질량 (left ventricular mass; LV mass) 등이제시된바있으며, 성, 인종, 종족간에도차이가있는것으로알려져있으나, 보고마다약간의차이가있다. 2)3)9-20) 한국인관상동맥의형태학적연구로는몇몇보고가있었으나, 심장질환이없는정상관상동맥을대상으로해부학적우세를나누고그에따른각관상동맥의구획별정상직경을측정한연구는없었다. 21)22) 115

116 Korean Circulation J 2005;35:115-122 따라서저자등은심장질환이없는한국인성인의정상관상동맥의각분절별직경을측정하고, 관동맥크기에영향을미치는결정인자들을확인함으로써다양한신체적, 생리적, 병리적상태의 ( 예, 미만성동맥경화, 확장성심근증등 ) 관동맥직경에대한한국인의정상참고치로활용함을목적으로본연구를수행하였다. 대상및방법 대상한림대학교성심병원에서최근 4년간 (2000 년 3월 ~2004 년 7월 ) 시행한관상동맥조영술 3,412 예중, 2명의혈관조영술전문관찰자에의해관동맥내경의불규칙한변연이나협착이전혀없다고판정된 127 예의정상관상동맥을대상으로하였다. 이중좌심실구혈율이 45% 미만이거나, 의미있는심장판막질환, 조영술도중나이트레이트제제를투여한경우, 조영술당일서방형나이트레이트제제를복용한경우를제외한 76예가최종연구대상이었다. 관상동맥직경측정및해부학적우세분류관상동맥의내경은, 좌주간지의가운데부위와좌전하행지, 좌회선지및우관동맥의각근위부, 중간부, 원위부에서가장직경이큰지점을각각측정하였다. 각관동맥의분절별해부학적경계는 Bypass Angioplasty Revascularization Investigation(BARI) 연구수행자들이취하였던정의에따랐다 (Fig. 1). 23) 일반적으로각혈관의중첩을피하기위해좌주간지, 우관동맥, 좌회선지는좌전사위 (LAO view), 좌전하행지는우전사위 (RAO view) 를취하였으나, 각혈관의기시 MRCA DRCA PRCA DLAD MLAD PLAD LMCA PLCX MLCX DLCX Fig. 1. Coronary artery map used for measurement. LMCA: left main coronary artery, PLAD/MLAD/DLAD: proximal/mid/distal left anterior descending artery, PLCX/MLCX/DLCX: proximal/mid/distal right coronary artery. 부나주행의굴곡정도의다양성을고려하여, 최적의촬영위치를취하였다. 9)11)15) 또한영상변두리에위치하는혈관의직경이 pincushion distortion 에의해실제보다확장되어보이는것을방지하기위해가능한한영상의중앙에혈관이위치했을때심장이완기에서혈관의직경을측정하였다. 11)15)16)20) 이미알고있는카테터끝의직경을측정기준으로삼아심도자용표준디지털 quality control analysis 소프트웨어 ( 지멘스, 독일 ) 를이용하여 2명의독립적인관찰자가측정하였다. 관동맥의우세는 Coronary Artery Surgery Study(CASS) 에서제시한정의에따라서후하행동맥과좌심실의후측벽에분포하는후측분지 (posterolateral branch) 가우관동맥에서기시하는경우를우측우세 (right dominance), 양혈관이좌관동맥에서기시하는경우를좌측우세 (left dominance), 후하행동맥은우관동맥에서후측분지는좌관동맥에서각각기시하는경우를균형우세 (balanced dominance) 로분류하였다. 24) 신체지수의측정및심초음파를이용한측정환자의기본적인인구통계학적특성을조사하고신체지수를측정하였다. 즉, 키 (cm), 체중 (kg) 을측정하고체표면적과체질량지수를계산하였다. 체표면적 (m 2 )=[ 키 (cm) 체중 (kg)/3600] 1/2, 체질량지수 (kg/m 2 )= 체중 (kg)/ 키 2 (m 2 ) 심장초음파는표준흉골연단면도와심첨단면도를이용하여좌심실구혈율을구하고, 좌심실후벽과중격의두께및좌심실의확장기말과수축기말직경을측정하였다. 좌심실질량은공인된공식에의해계산하였다. 25) : 좌심실질량 (g)=1.04[( 좌심실확장기말직경 + 좌심실후벽두께 + 심실중격두께 ) 3 -( 좌심실확장기말직경 ) 3 ] 0.8+0.6, 또한좌심실질량지수 (LV mass index; g/m 2 ) 는좌심실질량을체표면적으로나누어계산하였다. 통계분석모든자료는평균 ±1 표준편차로표시하였으며, 통계분석에는윈도우용 SPSS 10.0(Statistical Package for Social Science) 프로그램을이용하였다. 두군간의비교는명목변수인경우카이제곱법을이용하였고연속변수인경우 Student s T 검정과비모수적 Mann-Whitney 검정을이용하였다. 해부학적우세별세군사이의비교는분산분석의비모수적통계기법인 Kruskal-Wallis 검정을행하였고, 관동맥직경에영향을미치는연속변수의결정인자를찾기위한단변량분석을위해단순선형회귀분석을, 다변량분석을위해다중선형회귀분석을시행하였다. 통계학적유의성은 p값이 0.05 미만인경우로하였다.

Eung Ju Kim, et al:coronary Artery Size in Koreans 117 환자의임상적특성 결 대상환자의평균연령은 50.4±11.9 세 (20~80 세 ) 였으며, 총대상환자 76명중여성이 53명 (69.7%) 이었다. 고혈압은 26명 (34.2%), 당뇨병은 7명 (9.2%) 이있었으며, 관상동맥의확장에영향을미칠수있는칼슘통로차단제는 13명 (17.1%) 이복용하고있었다. 관상동맥조영술은대부분비전형적흉통에대한검사 (58 명, 76.3%) 를목적으로시행하였고그외호흡곤란 (11명, 14.5%), 부정맥 (5명, 6.6%) 등이시행이유였다. 관상동맥의해부학적우세는우측이 52명 (68.4%) 으로가장많았으며균형우세와좌측우세가각각 18명 (23.7%), 6명 (7.9%) 이었다. 포함된남녀대상사이에연령, 당뇨병, 고혈압, 칼슘통로차단제복용, 관동맥의해부학적우세의분포는통계학적으로유의한차이가없었으나키, 체중, 체표면적및좌심실질량은유의하게남성이컸다. 그러나, 좌심실구혈율이나, 좌심실질량지수는남녀간유의한차이가없었다 (Table 1). 관상동맥의크기남성의경우, 좌전하행지근위부의내경은각우세별측정값의평균이 3.9±0.4 mm, 좌회선지근위부의내경은평균이 3.5±0.5 mm 였으며각각은해부학적우세에영향을받지않았다. 그러나좌주간지는우측우세의경우 4.4± 0.5 mm, 균형우세에서 4.7±0.3 mm, 좌측우세의경우 5.2±0.3 mm 로측정되어통계학적으로유의하게우세간차 과 Table 1. Baseline clinical characteristics (n=76) Male (n=23) Female (n=53) p Age* 0046.7±12.7 0052.0±11.2 <0.110 Height, cm* 168.9±5.8 156.7±5.6 <0.001 Weight, kg* 0073.8±15.2 060.8±9.1 <0.001 BSA, m 2 * 001.72±0.39 001.32±0.21 <0.001 BMI, kg/m 2 * 025.7±5.4 024.8±3.6 <0.630 LV mass, g* 0176.2±48.8 0155.4±46.5 <0.048 LVMI, g/m 2 * 0105.7±35.5 0121.5±35.6 <0.120 EF, %* 061.4±7.2 060.5±8.5 <0.850 DM 01 (04.3%) 06 (11.3%) <0.670 Hypertension 04 (17.4%) 22 (41.5%) <0.060 CCB use 03 (13.0%) 10 (18.9%) <0.740 Dominance <0.440 Right 16 (69.6%) 36 (68.4%) Balanced 04 (17.4%) 14 (26.4%) Left 03 (13.0%) 03 (05.7%) BSA: body surface area, BMI: body mass index, LV: left ventricle, LVMI: LV mass index, EF: ejection fraction, DM: diabetes mellitus, CCB: calcium channel blocker. *: by Mann-Whitney test, : by χ 2 test 이가있었다 (p=0.02). 우관동맥근위부의경우도, 우측우세는 4.1±0.4 mm 였으나, 균형우세및좌측우세모두 3.3± 0.6 mm로측정되어우측우세가유의하게내경이큼을알수있었다 (p=0.02). 각혈관의중간분절과원위부에서측정한혈관의내경은좌전하행지와좌회선지의경우해부학적우세별유의한차이가없었으며, 우관동맥만이우측우세가유의하게다른우세에비해컸다 (p<0.01)(table 2). 여성에서는, 좌주간지내경의우세별측정값의평균이 4.5±0.6 mm 였으며좌전하행지와좌회선지근위부내경의우세별측정값의평균은각각 3.6±0.5 mm, 3.3±0.6 mm 로서해부학적우세별통계학적으로유의한차이는없었다. 반면, 근위부우관동맥의경우우측우세에선 3.7±0.5 mm, 균형우세에선 3.1±0.4 mm, 좌측우세에선 3.2±0.4 mm 로측정되어유의하게우측우세에서의내경이다른우세에 Table 2. Lumen diameter (mm) of coronary artery segments in normal men Location RD (n=16) BD (n=4) LD (n=3) p LMCA 4.4±0.5 4.7±0.3 5.2±0.3 <0.03 PLAD 3.9±0.4 3.8±0.2 3.8±0.2 <0.95 MLAD 3.0±0.4 2.9±0.2 3.3±0.1 <0.31 DLAD 2.4±0.2 2.3±0.3 2.7±0.1 <0.06 PLCX 3.3±0.5 3.5±0.3 4.0±0.1 <0.06 MLCX 3.0±0.5 2.9±0.2 3.1±0.6 <0.90 DLCX 2.4±0.4 2.4±0.2 2.6±0.6 <0.95 PRCA 4.1±0.4 3.3±0.6 3.3±0.6 <0.03 MRCA 3.6±0.4 2.9±0.5 2.7±0.2 <0.01 DRCA 3.2±0.4 2.5±0.4 2.4±0.2 <0.01 LMCA: left main coronary artery, PLAD/MLAD/DLAD: proximal/ mid/distal left anterior descending artery, PLCX/MLCX/DLCX: proximal/mid/distal right coronary artery, RD: right dominance, BD: balanced dominance, LD: left dominance. By Kruskal-Wallis test Table 3. Lumen diameter (mm) of coronary artery segments in normal women Location RD (n=36) BD (n=14) LD (n=3) p LMCA 4.5±0.6 4.4±0.6 5.4±1.10 <0.17 PLAD 3.6±0.6 3.6±0.3 4.0±0.70 <0.41 MLAD 3.0±0.4 2.9±0.3 3.1±0.30 <0.58 DLAD 2.3±0.3 2.3±0.3 2.2±0.10 <0.89 PLCX 3.1±0.5 3.5±0.6 4.2±1.30 <0.08 MLCX 2.7±0.4 3.2±0.6 3.6±0.70 <0.01 DLCX 2.2±0.4 2.7±0.5 2.8±0.40 <0.01 PRCA 3.7±0.5 3.1±0.4 3.2±0.40 <0.01 MRCA 3.3±0.5 2.8±0.4 3.0±0.30 <0.01 DRCA 3.0±0.4 2.5±0.4 2.4±0.13 <0.01 LMCA: left main coronary artery, PLAD/MLAD/DLAD: proximal/ mid/distal left anterior descending artery, PLCX/MLCX/DLCX: proximal/mid/distal right coronary artery, RD: right dominance, BD: balanced dominance, LD: left dominance. By Kruskal-Wallis test

118 Korean Circulation J 2005;35:115-122 Table 4. Cross-sectional area (mm 2 ) of coronary artery segments in normal men Location RD (n=16) BD (n=4) LD (n=3) p LMCA 15.6±3.1 17.6±2.3 21.1±2.7 <0.03 PLAD 12.2±2.9 11.1±1.4 11.4±1.0 <0.95 MLAD 07.4±2.0 06.7±1.1 08.4±0.6 <0.31 DLAD 04.5±0.9 04.2±1.1 05.8±0.6 <0.06 PLCX 09.0±2.5 09.5±1.8 12.5±0.4 <0.06 MLCX 07.1±2.4 06.7±1.1 07.9±2.9 <0.90 DLCX 04.5±1.5 04.6±1.5 05.3±2.4 <0.95 PRCA 13.0±2.7 08.7±3.1 08.8±3.2 <0.03 MRCA 10.4±2.1 06.7±2.3 05.9±0.9 <0.01 DRCA 08.1±2.0 05.2±1.7 04.4±0.8 <0.01 LMCA: left main coronary artery, PLAD/MLAD/DLAD: proximal/ mid/distal left anterior descending artery, PLCX/MLCX/DLCX: proximal/mid/distal right coronary artery, RD: right dominance, BD: balanced dominance, LD: left dominance. By Kruskal-Wallis test Table 5. Cross-sectional area (mm 2 ) of coronary artery segments in normal women Location RD (n=36) BD (n=14) LD (n=3) p LMCA 15.8±4.2 15.4±5.1 23.1±9.4 <0.17 PLAD 10.3±3.4 10.0±1.7 12.8±3.9 <0.41 MLAD 07.0±1.7 06.8±1.3 07.7±1.3 <0.58 DLAD 04.3±1.2 04.1±1.0 03.9±0.4 <0.89 PLCX 07.8±2.5 09.7±3.9 14.5±8.7 <0.08 MLCX 06.0±1.9 08.3±3.1 10.4±4.0 <0.01 DLCX 04.0±1.3 05.8±2.4 06.3±1.7 <0.01 PRCA 10.8±2.8 07.8±2.1 07.9±1.8 <0.01 MRCA 08.6±2.6 06.4±1.7 06.9±1.3 <0.01 DRCA 07.1±2.1 05.2±1.6 04.5±0.3 <0.01 LMCA: left main coronary artery, PLAD/MLAD/DLAD: proximal/ mid/distal left anterior descending artery, PLCX/MLCX/DLCX: proximal/mid/distal right coronary artery, RD: right dominance, BD: balanced dominance, LD: left dominance. By Kruskal-Wallis test 비해컸다 (p<0.01). 각관동맥중간분절과원위부의경우좌전하행지는우세별차이가없었으나, 좌회선지는좌측우세가우관동맥은우측우세가다른우세의동일부위에비해의미있게컸다 (Table 3). 모든혈관내경의측정은두명의관찰자가독립적으로수행했으며, 관찰자간평균오차는 0.11±0.02 mm였다. 본연구는정상관상동맥만을대상으로하였으므로, 동맥의단면은원형이고따라서그단면적은 πd 2 /4(D: 내경 ) 로계산할수있다고가정하였다. 9)20) 공식에의거각관동맥의부위별단면적을구하였으며, 성별해부학적우세에따른차이는관동맥내경측정에서의결과와같았다 (Table 4, 5). 관상동맥크기결정인자관상동맥의분포는해부학적우세등의특징에따라각각 Table 6. Univariate analysis for TVD and TCA Table 7. Multiple linear regression models predicting TVD and TCA TVD p for TVD TCA p for TCA Sex* <0.01 <0.01 Hypertension <0.50 <0.46 CCB <0.37 <0.37 Dominance <0.19 <0.16 Age <0.58 <0.53 BSA <0.10 <0.13 BMI <0.49 <0.53 LV mass <0.04 <0.04 LVMI <0.32 <0.26 Height <0.10 <0.14 Weight <0.19 <0.25 CCB: calcium channel blocker, BSA: body surface area, BMI: body mass index, LV: left ventricle, LVMI: LV mass index, TVD: total vessel diameter= (PLAD+PLCX+PRCA) diameter, TCA: total coronary area= (PLAD+PLCX+PRCA) cross-sectional area (PLAD: proximal left anterior descending artery, PLCX: proximal left circumflex artery, PRCA: proximal right coronary artery). *: student t-test, : Mann-Whitney U-test, : Kruskal-Wallis test, : simple linear regression β p β p Sex -0.876 0.015-4.814 0.019 Age -0.082 0.519-0.088 0.490 Hypertension -0.001 0.994-0.011 0.933 LV mass -0.220 0.080-0.230 0.068 BSA -0.077 0.614-0.058 0.704 LV: left ventricle, BSA: body surface area, TVD: total vessel diameter= (PLAD+PLCX+PRCA) diameter, TCA: total coronary area= (PLAD+PLCX+PRCA) cross-sectional area (PLAD: proximal left anterior descending artery, PLCX: proximal left circumflex artery, PRCA: proximal right coronary artery) 매우다양하므로그크기에영향을미치는결정인자를찾기위해관상동맥크기의대표매개변수로총혈관직경과총관동맥단면적을이용하였다. 총혈관직경은좌전하행지, 좌회선지, 우관동맥각근위부직경의합으로정의하였고, 총관동맥단면적은각좌전하행지, 좌회선지, 우관동맥근위부단면적의합으로정의하였다. 9)11)15)20) 단변량분석을통해관상동맥의크기에영향을미치는인자로서성, 고혈압유무, 칼슘길항제사용유무, 해부학적우세, 연령, 체표면적, 체질량지수, 좌심실질량, 좌심실질량지수, 키, 체중등을검증하였다. 여성은남성에비해총혈관직경은 7%(10.4±1.3 mm vs 11.2±1.0 mm, p<0.01), 총관동맥단면적은 13%(28.9±7.5 mm 2 vs 33.1±5.9 mm 2, p< 0.01) 가유의하게작았으며, 그외엔좌심실질량만이통계학적으로유의하게관상동맥의크기와연관이있었다 ( 총혈관직경과총관동맥단면적에대해모두, p=0.04)(table 6). 또한다중회귀분석을이용하여성, 연령, 고혈압유무, 좌심실

Eung Ju Kim, et al:coronary Artery Size in Koreans 119 질량, 체표면적과같은임상적해부학적영향인자중성만이통계학적으로유의하게관상동맥의크기를독립적으로예측할수있음을확인하였다 ( 총혈관직경, p=0.015; 총관동맥단면적, p=0.019)(table 7). 고찰 본연구는관상동맥조영술 3,412 예중 127 예의정상관상동맥을대상으로좌심실구혈율이 45% 미만이거나, 의미있는심장판막질환, 조영술도중나이트레이트제제를투여한경우, 조영술당일서방형나이트레이트제제를복용한경우를제외한 76예를분석하였다. 해부학적우세의분포는후하행동맥과좌심실의후측벽에분포하는후측분지가우관동맥에서기시하는우측우세가 52예 (68.4%), 양혈관이좌관동맥에서기시하는좌측우세가 6예 (7.9%) 였으며, 후하행동맥은우관동맥에서후측분지는좌관동맥에서각각기시하는균형우세가 18예 (23.7%) 로서다른보고들에비해균형우세가조금많았다. 21)26) 관상동맥직경에대한연구들은과거대부분사후부검을통해진행되어, 사후평활근의팽창성변화가관동맥의실제직경에영향을미쳤을가능성이있으며관류상태의역동적인혈관의변화를반영하지못하였다. 3)13)19)20) 혈관조영술에의한살아있는인간생체의관상동맥내경의측정은비교적최근에시작되어 MacAlpin 등 11) 은소수의정상인군과심장질환있는환자군등에서관상동맥내 12지점의내경을측정하여보고한바있다. 이후여러연구에서혈관조영술을이용해관상동맥내경에관한보고를한바있으나, 15)16)22) 심장질환과동맥경화가없는정상인의관상동맥을해부학적우세별로나누어각관상동맥의크기를측정한연구는 Dodge 등 9) 의연구가유일하였다. 혈관조영술에의한관상동맥의내경은알려진바와같이경피적관동맥중재시술혹은관상동맥우회로술등의성적과깊은관련이있으므로실제임상적으로중요한지표이다. 1-8) 따라서정상관상동맥의각분절별내경의측정은다양한신체적, 생리적, 병리적상태의 ( 예, 미만성동맥경화, 확장성심근증등 ) 관동맥직경에대한정상참고치로서의미가크다. 본연구는다른연구들과측정방법혹은대상군에있어약간의차이는있지만그측정값은다른혈관조영술에의한연구들의보고와대체로비슷하였다. 9)11)15)16)22) 예를들면, 본연구의우측우세남성의좌주간지내경은 4.4±0.5 mm였으며, Dodge 등 9) 은 4.5±0.5 mm로보고하였다. 한편해부학적우세의구분을하지않았던 MacAlpin 등 11) 은 4.3±0.6 mm로보고하였고, 남녀의구분및해부학적우세의구분 없이백인종 (Caucasian) 과인도아시아인으로나눈 Lip 등 16) 의결과는각각 5.5 mm와 4.0 mm, 국내의이등 22) 은 4.0 mm 였다. 우측우세남성의근위부좌전하행지와좌회선지및근위부우관동맥의경우본연구는각각 3.9±0.4 mm, 3.3± 0.5 mm, 4.1±0.4 mm였고, Dodge 등 9) 은 3.7±0.5 mm, 3.4±0.5 mm, 4.0±0.6 mm였다. MacAlpin 등 11) 은우세의구분없이 3.5±0.5 mm, 3.1±0.7 mm, 3.4±0.4 mm 로보고하였고, Lip 등 16) 은백인종은 4.4 mm, 3.2 mm, 3.4 mm, 인도아시아인은 3.2 mm, 3.0 mm, 3.0 mm로보고했으며, 국내의이등 22) 은근위부우관동맥에대해서만 3.6 mm로보고하였다. 이상의보고를분석해보면대개체표면적이한국인보다큰서구인을대상으로진행됐던측정과비교해, 본연구대상들의관동맥내경이대체로비슷하며다른아시아인에비해서는오히려큰경향을보였다. 그러나총혈관직경의경우해부학적우세별로의미있는통계학적차이가없어남녀성별로만구분하여측정한본연구의결과는남자 11.2±1.0 mm, 여자 10.4±1.3 mm로서 Dhawan 등 15) 이조사한백인남성 72명의평균 13.8 mm, 아시아인남성 70 명의평균 12.8 mm에비해좀더작은경향을보이기도해뚜렷이체표면적혹은인종간의차이로설명할수는없다고본다. 또한, 유일한국내자료인이등 22) 의보고와비교해서도약간큰값을보였는데이등은남녀및해부학적우세의구분없이모든측정값을평균하여보고한것으로당뇨, 좌심실질량, 체표면적등의임상적특성에대한자료도없으므로본연구의결과와단순비교하는것은곤란하다고생각한다. 최근에는다양한기술적발달로침습적으로는혈관내초음파를통하여, 부분침습적으로는경식도초음파를이용하여관상동맥의단면적을측정한연구들도있었다. Kucher 등 10) 은경식도초음파를통해좌주간지와우관동맥의근위부단면적을측정한바있으나, 수평적거리를측정하는데있어서외측해상도 (lateral resolution) 가떨어져특히우관동맥측정값의정확도가낮고근위부외에는다른분절에접근할수없다는단점이있다. 혈관내초음파를이용한연구들은그측정방법의정확도에도불구하고, 관상동맥중재시술직전나이트레이트제제를쓴상태에서측정했던것으로서, 혈관내초음파를통해병변근위부관상동맥내에동맥경화가없음을확인했다해도건강한사람의관상동맥크기를정확히반영할수는없다. 또한, 중재시술의목표가되는혈관의병변근위부밖에접근할수없다는한계가있었다. 17)18) 그러나, 본연구의혈관내경을이용한단면적도출 [D 2 /4(D: 내경 )] 은같은공식을이용한 Leung 등 20) 의보고나혈관내초

120 Korean Circulation J 2005;35:115-122 음파를이용한연구들, 17)18) 경식도초음파를이용한연구의결과와대체로유사하였다. 10) 관동맥의직경은혈류와관련된혈관벽의전단력에좌우되고, 심근의산소요구량을증대시키거나심근의비후를야기하는환경등에영향을받으며유전적인인자에의해서도영향을받는다. 9-11) 관동맥직경의결정인자로는체표면적, 체질량지수, 키, 몸무게등의전신적특성뿐아니라심장의무게, 좌심실질량등이제시된바있으며, 성, 인종, 종족간에도차이가있는것으로알려져있으나, 보고마다약간의차이가있다. 2)3)9-20) 심근의질량은신체크기와깊은연관이있고, 27)28) 심근의양이관상동맥크기에대한예측인자라는사실은오래전부터조사방법에관계없이알려져왔다. 3)9-14)20) 그러나, 연령의경우심장의질량을보정하고도혈관크기에대해독립적인예측인자라는보고도있는반면 13)19) 그렇지않다는보고도있으며 9)11) 반대로역상관관계에있다는보고도있었다. 20) 전신크기의지표중하나인체표면적의경우에도대개관동맥의크기와양성관계를보였지만 2)15)16)18)19) 본연구에서와같이직접적인관련이없는경우도있었다. 20) 그외키, 체중, 체질량지수가관상동맥크기에대해영향을미친다는보고와 2) 그렇지않다는보고, 20) 관상동맥의굴곡이클수록내경도크다는보고와 3) 영향없다는보고도있었다. 9) 아시아인과백인종을비교한연구에서는관상동맥의크기는유의하게백인종이컸으나체표면적을고려보정했을경우두인종사이에고유한관상동맥크기의차이는발견할수없었다. 15)16) 그러나, 흑인종의경우백인종에비해독립적으로관동맥의크기가컸다는보고도있어 19) 인종간의차이가관상동맥크기에대해독립적인예측인자인지여부도아직확실하지않다. 또한남녀간의관상동맥크기차이에대해서도보고마다다양하다. 즉, 두성간에관동맥크기의차이는없다는보고와 13) 체표면적, 혹은연령과체표면적, 혹은좌심실질량, 혹은체표면적과좌심실질량으로보정하고도차이가있었다는보고들과 2)9)10)17)18) 체표면적으로보정했을경우엔차이가없었다는보고 11) 등연구마다서로일치하지않는결과를보였다. 그러나, 대개의연구에서성은독립적인관상동맥크기에대한예측인자로서간주되었으며본연구에서도같은결과를보였다. 본연구는단변량분석을통해성, 고혈압유무, 칼슘길항제사용유무, 해부학적우세, 연령, 체표면적, 체질량지수, 좌심실질량, 좌심실질량지수, 키, 체중등이관상동맥의크기에영향을미치는지를검증하였으며이중통계학적으로유의한것은성과좌심실질량뿐이었다. 또한성, 연령, 고혈압유무, 좌심실질량, 체표면적에대해다중선형회귀분석을시행하여유일하게성만이독립적인관상동맥크기예 측인자임을확인하였다. 혈관조영술을이용하여심장질환없는건강한성인생체의정상관상동맥을대상으로해부학적우세까지고려해관찰한연구로는 Dodge 등 9) 의연구가유일하였으나, 그연구에서는좌심실의크기와심벽의두께에대한충분한정보의부재로좌심실질량에대한영향을배제못했으며, 유일하게체표면적에대해서만보정하여성이관동맥크기의차이에영향을미친다고주장함으로써통계적검증력에한계가있었다. 한편, 경식도초음파와혈관내초음파를통해측정한관동맥크기를대상으로좌심실질량그리고체표면적과좌심실질량에대해동시에보정하여성이독립적인관동맥크기의예측인자임을보인기타연구들이있었지만이들연구의경우전술한바와같이측정방법과대상의한계가있으며, 해부학적우세에대한고려는배제돼있었다. 10)18) 따라서혈관조영술을이용하여심장질환없는건강한성인생체의정상관상동맥을대상으로해부학적우세를고려해관찰한결과를토대로좌심실질량을포함체표면적, 성, 연령, 고혈압유무등과같은전신적, 임상적, 해부학적특성들상호간의간섭을보정한다중회귀분석으로성이관동맥크기에대한독립적예측인자임을제시한연구로서는본연구가최초이다. 관상동맥크기에있어성고유의차이에대한기전은아직정확히알려진바없으나여성호르몬인에스트로겐의혈관확장기능과동맥경화에대한억제기능이영향을미쳤을수있다. 즉, 에스트로겐이관상동맥의발생과성장에영향을미치거나혹은만성적인혈관운동감수성을변화시켰을가능성이있는것이다. 18) 그러나, 관상동맥의해부학적차이에영향을미치는성의역할에대하여는추가적인연구가필요할것으로사료된다. 본연구의제한점으로는, 첫째, 대상군이과연정상인집단을대표할수있는가에대한문제이다. 즉, 단일병원에서시행한단면적연구로서도시의대학병원을방문하여혈관조영술을시행받은대상군을전체정상인집단으로일반화시키는것은어려울수있다. 또한, 관상동맥촬영결과정상이었으며유의한심장판막질환이나좌심실기능의저하가없는사람을대상으로하였지만, 검사를받은대상들은비전형적흉통, 호흡곤란, 부정맥등의이유가있었으며일부고혈압, 당뇨등의질환이있었던사람으로서이들이과연 정상인 군을대표한다고단언키는어려울것이다. 그렇지만과거의여타혈관조영술을이용한연구들의경우도거의 100 명미만을대상으로발표됐듯이증상이없는건강한대조군을모집해관상동맥조영술을시행하는것은윤리적으로나현실적으로거의어렵고실제조영술상정상이아

Eung Ju Kim, et al:coronary Artery Size in Koreans 121 닐수도있으므로검사방법이갖는정상대조군모집에대한한계점이있다. 둘째, 관상동맥조영술상관동맥내경의불규칙한변연이나협착이전혀없다고판정한정상소견을보였더라도혈관내초음파를통해동맥경화반의부재를확인하진못하였으므로미만성동맥경화반에의한협착을간과했을가능성이있다. 그러나정상관상동맥에대하여유도철사를진입시켜침습적으로혈관내초음파를사용한다는것역시윤리적으로나비용적으로어려운부분이다. 셋째, 혈관조영술을이용하여측정한관상동맥의크기는실제혈관의직경이아닌그내경이라는점이다. 그러나, 임상에서실제적으로이용하는중요한지표는대부분혈관의내경이므로그측정값자체의의미는보다현실적일수있다. 넷째, 본연구의경우일부좌심실비후환자를따로제외시키지않음으로써전체적인혈관내경의크기에영향을미쳤을수있다. 본연구는심장질환없는한국인의정상관상동맥의크기를측정하여다양한생리적, 병리적상태에대한참고기준치를제시한것으로서보다많은기관이참여해자료를모은다면좀더객관적이고보편적인표준을만들수있을것으로생각된다. 요약 배경및목적 : 관상동맥의크기는관동맥우회로술이나경피적관동맥중재시술의성적과깊은연관이있는중요한임상지표이다. 따라서저자등은심장질환없는한국인정상관상동맥의분절별직경을측정하고, 관동맥크기에영향을미치는결정인자들을확인함으로써다양한신체적, 생리적, 병리적상태의관동맥직경에대한한국인의정상참고치로활용함을목적으로본연구를수행하였다. 방법 : 본원에서최근 4년간시행된일련의 3,412 예의관상동맥조영술검사중 127 예의정상관상동맥을대상으로좌심실구혈율이 45% 미만이거나, 의미있는심장판막질환, 조영술도중나이트레이트제제를투여한경우, 조영술당일서방형나이트레이트제제를복용한경우를제외한 76예에서연구를진행하였다. 좌주간지의가운데부위와좌전하행지, 좌회선지및우관동맥의각근위부, 중간부, 원위부에서가장직경이큰지점을각각측정해정상치를얻었으며총혈관직경과총관동맥단면적을이용해관상동맥의크기에영향을미치는임상적, 해부학적특성을구하였다. 결과 : 남성의경우, 근위부좌전하행지와좌회선지의직경이각 각 3.9±0.4 mm, 3.5±0.5 mm로서해부학적우세에따른차이는없었다. 반면좌주간지는 4.4±0.5 mm에서 5.2± 0.3 mm(p<0.05), 우관동맥의내경은 3.3±0.6 mm 에서 4.1± 0.4 mm로해부학적우세에따라유의한차이가있었다 (p< 0.05). 여성은좌주간지와근위부좌전하행지, 좌회선지의직경이각각 4.5±0.7 mm, 3.6±0.5 mm, 3.3±0.6 mm였으며우세별로유의한차이는없었다. 그러나, 근위부우관동맥의내경은 3.1±0.4 mm에서 3.7±0.5 mm(p<0.01) 로우세에따른차이가유의하였다. 성, 고혈압유무, 칼슘길항제사용유무, 해부학적우세, 연령, 체표면적, 체질량지수, 좌심실질량, 좌심실질량지수, 키, 체중등의임상적, 해부학적특성중관상동맥의크기에영향을미치는인자는좌심실질량과성이었으며, 다중회귀분석을통해검증한관상동맥크기를예측할수있는독립적인특성은성이유일하였다. 결론 : 심장질환없는한국인의정상관상동맥의크기를측정하였으며이는다양한생리적, 병리적상태에대하여그참고기준치로서의의미를지닌다. 여러임상적해부학적변수중관상동맥의크기에영향을미치는인자는성과좌심실질량이었으며특히성의경우다중회귀분석으로다른인자들의영향을보정하고도독립적인예측인자임을확인하였다. 중심단어 : 관상동맥 ; 한국인. REFERENCES 1) Fisher LD, Kennedy JW, Davis KB, et al. Association of sex, physical size, and operative mortality after coronary artery bypass in the Coronary Artery Surgery Study (CASS). J Thorac Cardiovasc Surg 1982;84:334-41. 2) O Connor NJ, Morton JR, Birkmeyer JD, Olmstead EM, O Connor GT. Effect of coronary artery diameter in patients undergoing coronary bypass surgery. Circulation 1996;93:652-5. 3) Hutchins GM, Bulkley BH, Miner MM, Boitnott JK. Correlation of age and heart weight with tortuosity and caliber of normal human coronary arteries. Am Heart J 1977;94:196-202. 4) O Connor GT, Morton JR, Diehl MJ, et al. Differences between men and women in hospital mortality associated with coronary artery bypass graft surgery. Circulation 1993;88:2104-10. 5) Mintz GS, Popma JJ, Pichard AD, et al. Intravascular ultrasound predictors of restenosis after percutaneous transcatheter coronary revascularization. J Am Coll Cardiol 1996;27:1678-87. 6) Foley DP, Melkert R, Serruys PW. Influence of coronary vessel size on renarrowing process and late angiographic outcome after successful balloon angioplasty. Circulation 1994;90:1239-51. 7) Hoffmann R, Mintz GS, Mehran R, et al. Intravascular ultrasound predictors of angiographic restenosis in lesions treated with Palmaz-Schatz stents. J Am Coll Cardiol 1998;31:43-9. 8) Saucedo JF, Popma JJ, Kennard ED, et al. Relation of coronary artery size to one-year clinical events after new device angioplasty of native coronary arteries (a New Approach to Coronary Intervention [NACI] registry report). Am J Cardiol 2000;85: 166-71.

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