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Original ORIGINAL Article ARTICLE Korean Circulation J 2007;37:64-71 ISSN 1738-5520 c 2007, The Korean Society of Circulation 한국인급성심근경색증등록연구에서성별에따른임상적특징과초기치료의차이 대한순환기학회한국인급성심근경색증등록연구 이기홍 정명호 안영근 김종현 채성철 김영조 허승호 성인환홍택종 최동훈 조명찬 김종진 승기배 정욱성 장양수 조정관박승정 한국인급성심근경색증등록연구자 Sex Differences of the Clinical Characteristics and Early Management in the Korea Acute Myocardial Infarction Registry Ki Hong Lee, MD, Myung Ho Jeong, MD, Young Keun Ahn, MD, Jong Hyun Kim, MD, Shung Chull Chae, MD, Young Jo Kim, MD, Seung Ho Hur, MD, In Whan Seong, MD, Taek Jong Hong, MD, Dong Hoon Choi, MD, Myeong Chan Cho, MD, Chong Jin Kim, MD, Ki Bae Seung, MD, Wook Sung Chung, MD, Yang Soo Jang, MD, Jeong Gwan Cho, MD, Seung Jung Park, MD and other Korea Acute Myocardial Infarction Registry Investigators Korea Acute Myocardial Infarction Registry of Korean Circulation Society ABSTRACT Background and Objectives:The first on-line registration of Korea Acute Myocardial Infarction patients (KA- MIRs) has been carried out throughout the 41 primary percutaneous coronary intervention (PCI) centers that are supported by the Korean Circulation Society (KCS), as reported in the memorandum of the 50th Anniversary of the KCS. Subjects and Methods:Between Nov 2005 and June 2006, 4905 patients were enrolled in KAMIR and 4110 eligible patients (2855 males and 1255 females; mean age=64.3±13.5 years) were analyzed. The treatment strategy for acute myocardial infarction (AMI) was analyzed according to the gender differences in the area of acute ST segment elevation myocardial infarction () and non-st segment elevation myocardial infarction (NS- TEMI). Results:For the initial selection of a treatment strategy for, primary PCI was more commonly performed in males than females (69.8% vs. 68.3%, respectively, p=0.008), but age was the most important predictors after multivariate adjustment. During the hospital stay, PCI regardless of its subtype was more commonly done in the males than in the females with both and N (: 89.1% vs. 84.9%, respectively, p=0.004; N: 74.7% vs. 63.5%, respectively, p<0.001). The success rate of PCI in patients was not different between the genders (95.0% vs. 93.6%, respectively, p=0.399), but that of N was higher in the males than the females (96.9% vs. 95.8%, respectively, p=0.004). Conclusion:For the initial treatment of AMI in Korea, females are treated more conservatively than males, but age was the most important predictor for invasive treatment. The success rate of PCI was higher for the males than the females. (Korean Circulation J 2007;37:64-71) KEY WORDS:Sex;Myocardial infarction;angioplasty;thrombolytic therapy;stents. 논문접수일 :2006 년 12 월 14 일수정논문접수일 :2007 년 1 월 25 일심사완료일 :2007 년 02 월 08 일교신저자 : 정명호, 501-757 광주광역시동구학동 8 번지전남대학교병원심장센터전화 :(062) 220-6243 전송 :(062) 228-7174 E-mail:myungho@chollian.net 64

Ki Hong Lee, et al:korea AMI Registry 65 서 심혈관계질환은선진국에서뿐만아니라우리나라에서도꾸준히증가하고있고가장많은사망원인중의하나로자리잡고있다. 심혈관계질환중급성심근경색증은모든심혈관계질환으로인한사망의 50% 이상을차지하고있고꾸준한증가추세를보이고있다. 1)2) 한국인급성심근경색증현황을파악하여이에대한관리체계를확립하기위해한국인급성심근경색증환자등록 (Korea Acute Myocardial Infarction Registry: KAMIR) 연구가대한순환기학회창립 50주년기념사업으로시작되었다. 급성심근경색증의임상특징, 치료방법, 예후에있어성별의차이에관한관심이증대되었고많은연구결과가보고되었다. 임상특징에있어여성이남성보다훨씬비특이적인증상을많이보이고, 3)4) 흉통보다는오히려다른곳 ( 턱, 목, 어깨, 상완, 수부, 배부등 ) 의통증을호소하고오심, 구토, 호흡곤란이남성보다많음이보고되었다. 5) 또한여성은남성에비해나이가많고고혈압, 당뇨병등관상동맥질환의위험인자가많은것으로알려져있다. 6-8) 이러한여성급성심근경색증환자에서많이보이는비특이적증상, 고령, 그리고동반관상동맥질환위험인자들이남성환자들보다불량한예후의원인으로설명된다. 급성심근경색증후예후에관하여원내사망률과장기사망률은여성에서높다고알려져있으나, 9-12) 나이와관상동맥위험인자등을보정한후사망률에차이가없다는상반된결과도보고되었다. 13-15) 우리나라에서 1990 년대급성심근경색증환자의원내사망률은여성에서높은것으로알려져있으나, 나이와관상동맥위험인자들의영향을보정한후유의한차이를보이지않았다. 16) 급성심근경색증치료방법에있어여성에서혈전용해제치료및경피적관상동맥중재술이적게시행된다고보고되었다. 7-10) 이러한치료방법의차이는여성의급성심근경색증후높은사망률의한원인으로설명되기도한다. 그러나최근의몇몇연구에서남성과여성간의치료방법에있어차이가없다고보고되었다. 17-19) 본연구에서는한국인급성심근경색증의현황에대한등록연구를통하여 ST 분절상승급성심근경색증 (ST segment elevation Acute Myocardial Infarction: ) 과비-ST 분절상승급성심근경색증 (non-st segment elevation Acute Myocardial Infarction: N) 환자각각에서남녀간의임상적특징과치료방법의차이에대해알아보고자하였다. 론 대상및방법 한국인급성심근경색증의현황에대한등록연구 (Korea Acute Myocardial Infarction Registry: KAMIR) 우리나라급성심근경색증사망률의위험요인에대한체계 적인연구를통하여발생률예방을위한대책으로서단편적이고일회적이아닌국내 41개일차적관상동맥중재술이가능한병원 (primary PCI center) 에서인터넷을이용한급성심근경색증에대한데이터베이스의구축과등록연구가 2005 년 11 월부터대한순환기학회 50 주년기념사업으로시작하였다. 본연구는환자가증상이발생한후앰뷸런스를부르거나의료기관에가겠다고행동을결심하는시간, 전화후앰뷸런스도착시간, 환자후송시간 ( 앰뷸런스병원도착시간 ), door to needle time( 혈전용해제투여시 ), door to balloon time (primary or rescue PCI 시 ), 각환자의위험인자, 그외에치료약제및방법, 1개월후사망여부등을인터넷을통해등록한후이를분석하여한국인에서급성심근경색증환자의위험인자를파악하고한국실정에맞는급성심근경색증의치료지침을설정하여한국인급성심근경색증의예방및효율적인치료지침을마련하고자하였다. 대상 2005 년 11월부터 2006 년 6월까지 KAMIR 에등록된 4,905 명의급성심근경색증환자중완벽한자료분석이가능한 4,110 명의환자를대상으로하였다. 평균나이는 64.3±13.5 세였으며남성은 2,855 명, 여성은 1,255 명이었다. 방법임상증상, 심전도소견, 임상화학적검사를통하여 와 N 로구분하였다. 이들환자들의내원당시정보, 내원당시임상양상, 생명징후, 위험인자, 초기치료방법, 관상동맥조영술소견, 입원기간중치료방법등을 와 N 각각의영역에서남녀별로구분하여비교분석하였다. 초기치료방법은 PCI, thrombolysis, conservative treatment 로구분하였다. PCI 는 primary PCI, early invasive PCI, rescue PCI, elective PCI 등으로구분하였다. Primary PCI 는내원 12시간이내에 PCI 를시행한경우, 12시간은경과하였으나지속적으로증상이있어 PCI 를시행한경우, 36시간이내에심인성쇼크가발생하여 PCI 를시행한경우로정의하였다. Early invasive PCI 는 N 환자에서증상이남아있어응급으로 PCI 를시행한경우로정의하였다. Elective PCI 는증상이없어병원의스케쥴에따라 PCI 를시행한경우로정의하였다. 통계분석연속변수의차이는 student s t-test 를이용하여분석하였으며불연속변수의차이는 χ 2 검정을이용하여분석하였다. 연속변수는평균 ± 표준편차로표시하였다. 심근경색증초기치료에영향을미치는인자를보정하기위하여다변량로지스틱회귀분석 (multivariate logistic regression analysis) 을시행하였다. 통계분석은 SPSS-PC 12.0(Statistical package for the social sciences, SPSS-PC Inc. Chicago, IL,

66 Korean Circulation J 2007;37:64-71 Table 1. Baseline clinical characteristics N Male Female Male Female Age (years) 0060.4±13.500 71.8±10.3* 0062.2±12.900 70.7±11.6* Typical symptom (n,%) 1571 (89.6%) 590 (86.5%) 822 (81.6%) 382 (73.9%)* Pain (n,%) 1562 (90.0%) 595 (88.1%) 823 (82.3%) 405 (78.5%) Dyspnea (n,%) 0488 (28.5%) 231 (34.7%) 295 (29.8%) 205 (40.0%)* Past IHD (n,%) 0227 (12.9%) 089 (13.0%) 240 (23.8%) 115 (21.8%) Hypertension (n,%) 0717 (41.3%) 397 (58.2%)* 497 (49.5%) 344 (65.6%)* Diabetes (n,%) 0396 (22.9%) 208 (30.6%)* 287 (28.5%) 187 (36.1%) Dyslipidemia (n,%) 0117 (07.9%) 057 (09.9%) 108 (12.2%) 056 (12.1%) Smoking (n,%) 1372 (78.9%) 112 (16.5%)* 747 (74.8%) 065 (12.5%)* Glucose (mg/dl) 0169.4±76.800 183.5±87.9* 0154.5±72.800 168.6±88.1 LDL-C (mg/dl) 0116.9±40.800 125.7±41.5* 0115.5±46.500 123.5±48.3 NT-proBNP (pg/ml) 1904.6±5024.2 04245.5±7856.0* 2703.5±5960.5 05767.6±9133.6* *: p<0.001, : p<0.05, : p<0.01. IHD: ischemic heart disease, LDL-C: low density lipoprotein-cholesterol, NT-proBNP: N-terminal pro-btype natriuretic peptide U.S.A) 을이용하였다. P 값은 0.05 미만에서통계적으로유의한것으로간주하였다. 결과 임상적특징 와 N 모두에서여성이남성에비해나이가많았다 (: 60.4±13.5 세 vs. 71.8±10.3 세, p<0.001; NS- TEMI: 62.2±12.9세 vs. 70.7±11.6세, p<0.001). 내원당시전형적심근허혈증상을호소했던경우는 와 NS- TEMI 모두에서여성이남성에비해그빈도가적었다 (: 89.6% vs. 86.5%, p=0.032; N: 81.6% vs. 73.9%, p<0.001). 관상동맥질환의위험인자중고혈압과당뇨병은 와 N 모두에서여성이남성에비해빈도가많았고, 흡연율은 와 N 모두에서남성이여성보다높았다. 검사실소견중혈당, 저밀도지단백콜레스테롤 (low density lipoprotein-cholesterol: LDL-C), N-terminal Pro-B-type natriuretic peptide(nt-probnp) 은 와 N 모두에서여성이남성에비해높았다 (Table 1). 관상동맥조영술소견이환된관상동맥은 에서여성과남성모두좌전하행지 (left anterior descending artery), 우관상동맥 (right coronary artery), 좌회선지 (left circumflex artery), 좌주간지 (left main stem) 순서로이환되었고 N 에서남성역시같은이환순서를보였으나여성은좌전하행지, 좌회선지, 우관상동맥, 좌주간지순으로이환되었다. 이환된관상동맥의수는 에서여성과남성모두 2개혈관질환, 1개혈관질환, 3개혈관질환순서를보였고, N 에서남성과여성모두 와같은순서를보였다. TIMI flow grade 는, N 모두에서남성과여성이관상동맥중재 Table 2. Coronary angiographic findings N Male Female p Male Female p Number of diseased vessels (%) 0.791 0.816 1 38.3 39.0 30.0 28.6 2 51.3 51.6 42.9 44.7 3 10.4 09.5 27.1 26.7 Infarct related artery (%) 0.919 0.169 LM 01.4 01.5 02.2 04.2 LAD 51.3 51.6 42.9 44.7 LCX 10.4 09.5 27.1 26.7 RCA 36.9 37.5 27.8 24.3 TIMI flow grade 0 50.4 at initial CAG (%) 52.5 0.119 24.0 25.6 0.071 Final TIMI flow grade 2 (%) 95.8 95.4 0.665 97.7 94.7 0.010 Final TIMI flow grade 3 (%) 91.1 87.0 0.006 94.4 91.3 0.060 : acute ST-segment elevation myocardial infarction, N: acute non ST-segment elevation myocardial infarction, LM: let main artery, LAD: left anterior descending artery, LCX: left circumflex artery, RCA: right coronary artery 술시술전후로유의한차이를보이지않았다. 그러나전체심근경색증환자를대상으로하였을때관상동맥중재술시행전 TIMI flow grade 0를보이는환자는여성이남성보다유의하게많았고 (41.1% vs. 41.8%, p=0.011), 관상동맥중재술시술후 TIMI flow grade 3를보이는환자는남성이여성보다유의하게많았다 (92.2% vs. 88.7%, p=0.002). PCI 시술전 TIMI flow grade 0는 에서 N 보다 2배정도많았다 (Table 2). 급성심근경색증의초기치료 에서 Primary PCI 와혈전용해요법은남성에서여성보다많이시행되었고 (69.8% vs. 68.3%, 12.4% vs. 9.0%;

Ki Hong Lee, et al:korea AMI Registry 67 p=0.008 % 100 p=0.004 p<0.001 p=0.001 100% 90% 218 (12.4) 48 (2.7) 62 (9.0) 20 (2.9) 90 80 70 60 50 89.1 84.9 74.7 63.5 83.7 75.4 40 80% 265 (15.0) 136 (19.8) 30 20 70% 10 0 N Total 60% 1230 (69.8) 469 (68.3) Male Female 0% Male Thrombolysis Facilitated PCI Table 3. Predictors of initial invasive treatment by multivariate analysis Female Conservative treatment Primary PCI Fig. 1. Initial therapeutic strategy in acute ST-segment elevation myocardial infarction. PCI: percutaneous coronary intervention. N OR (95%CI) p OR (95%CI) p Female gender 0.87 (0.67-1.14) <0.316 0.89 (0.69-1.14) 0.352 Age 0.67 (0.52-0.86) <0.002 0.77 (0.61-0.97) 0.024 Cardiogenic shock 1.61 (1.08-2.40) <0.022 0.91 (0.55-1.52) 0.724 HTN 1.01 (0.79-1.28) <0.943 1.16 (0.93-1.46) 0.201 Diabetes 1.01 (0.77-1.32) <0.968 0.81 (0.64-1.04) 0.096 Killip class 0.73 (0.51-1.03) <0.070 0.56 (0.38-0.82) 0.003 Past history of MI 0.76 (0.47-1.23) <0.259 0.68 (0.46-0.99) 0.049 HF 0.39 (0.17-0.92) <0.031 0.53 (0.30-0.94) 0.031 (NYHA III/IV) PVD 0.77 (0.25-2.37) <0.643 1.97 (0.90-4.29) 0.088 CVD 0.48 (0.32-0.72) <0.001 0.94 (0.62-1.42) 0.756 : acute ST-segment elevation myocardial infarction, N: acute non ST-segment elevation myocardial infarction, HTN: hypertension, MI: myocardial infarction, HF: heart failure, NYHA: New York heart association, PVD: peripheral vascular disease, CVD: cerebrovascular disease, CI: confidence interval respectively, p=0.008), 보존적치료는여성에서남성보다많이시행되었다 (15.0% vs. 19.8%, p=0.008). N 에서초기침습적치료와보존적치료는남녀간의유의한차이는없었다 (Fig. 1). 급성심근경색증의초기치료선택에영향을미치는인자를다변량로지스틱회귀분석 (Multivariate logistic regression) 을시행하여보정하였을때 와 NST- EMI 모두에서남녀간의차이를보이지않았다. 하지만 에서심인성쇼크가있을때, 나이가많을때, NYHA class Ⅲ/Ⅳ 의심부전이있을때, 뇌혈관질환의과거력이있을때 Fig. 2. The rate of percutaneous coronary intervention during hospitalization. : acute ST segment elevation myocardial infarction, N: acute non-st segment elevation myocardial infarction. 좀더보존적으로치료하였다. N 에서는나이가많을때, 심근경색증의과거력이있을때, NYHA class Ⅲ/Ⅳ 의심부전이있을때, Killip class 가높을수록보존적으로치료하였다 (Table 3). Platelet glycoprotein Ⅱb/Ⅲa inhibitor는 에서 12.8%, N 에서 9.9% 사용하였다. 성별에따른사용률을비교하였을때, 에서는남성에서여성보다유의하게많이사용하였고 (14.2% vs. 9.5%, p=0.002), N 에서는남녀간의유의한차이는없었다 (10.3% vs. 9.2%, p=0.513). 경피적관상동맥중재술입원기간전체에걸쳐 primary PCI, facilitated PCI, rescue PCI 를포함한모든종류의 PCI 시행률을비교하였을때 와 N 모두에서남성이여성보다많이시행하였다 (: 89.1% vs. 84.9%, p=0.004; N: 74.7% vs. 63.5%, p<0.001)(fig. 2). PCI 성공률은 에서 94.6%, N 에서 96.6% 이었다. 남성과여성의차이를비교하였을때 PCI 성공률은 에서남성 95.0%, 여성 93.6% 로서유의한차이를보이지않았고 (p=0.399), N 에서남성 96.9%, 여성 95.8% 로서남성에서유의하게높은성공률을보였다 (p=0.004)(table 4). 관상동맥중재술에서삽입한스텐트로서일반금속스텐트, sirolimus coating stent(cypher stent ), paclitaxel coating stent(taxus stent ) 를비교하였다. 에서남성과여성의스텐트종류는차이를보이지않았지만, N 에서는남성이여성보다약물용출스텐트삽입률이높았다 (92.2% vs. 90.8%, p=0.022)(fig. 3). 관상동맥우회술 에서 44명 (1.9%), N 에서 44명 (2.9%) 이관상동맥우회술 (coronary arterial bypass graft: CABG) 을시

68 Korean Circulation J 2007;37:64-71 N Male (%) 9 34.9 56.2 7.8 32.3 59.9 Female (%) 9.7 35.1 55.2 9.21 40.6 50.2 p=0.878 p=0.022 Table 5. One month clinical follow-up for the development of major adverse cardiac event N Male Female p Male Female p Cardiac 04 (0.6%) 5 (1.8%) 0.076 03 (0.8%) 05 (2.6%) 0.084 death MI 04 (0.6%) 1 (0.4%) 0.660 03 (0.8%) 03 (1.6%) 0.399 Re-PCI 01 (0.1%) 1 (0.4%) 0.510 04 (1.1%) 00 (0.0%) 0.151 CABG 01 (0.1%) 0 (0.0%) 0.524 03 (0.8%) 02 (1.1%) 0.769 Total 10 (1.5%) 7 (2.6%) 0.384 13 (3.5%) 10 (5.3%) 0.213 MACE : acute ST-segment elevation myocardial infarction, N: acute non ST-segment elevation myocardial infarction, MI: myocardial infarction, PCI: percutaneous coronary intervention, CABG: coronary arterial bypass graft, MACE: major adverse cardiac event Total 34.6 8.7 56.7 Table 4. Results of percutaneous coronary intervention Male Female (n=1,511) (n=575) 행하였다. PCI 실패후 에서 emergency CABG 는 3명 (0.1%), elective CABG 는 2명 (0.1%) 에서시행하였으며, NS- TEMI 에서 emergency CABG 는 1명 (0.1%), elective CABG 는 1명 (0.1%) 에서시행하였다. 남성과여성에서 CABG 시행률차이를비교하였을때 에서남성 1.7%, 여성 2.2% 로서유의한차이를보이지않았고 (p=0.414), N 에서도역시남성 2.9%, 여성 2.7% 로서유의한차이를보이지않았다 (p=0.808). 1개월후임상경과관찰소견 1개월후발생한주요심장사건 (major adverse cardiac event: MACE) 을 cardiac death, myocardial infarction, re- PCI, CABG 로분류하여조사하였다. Cardiac death 는 p N Male Female (n=720) (n=312) 0.399 0.004 Successful 95.0 93.6 96.9 95.8 PCI (%) Suboptimal 03.3 04.5 02.5 01.3 PCI (%) Failed PCI (%) 01.7 01.9 00.6 02.9 : acute ST-segment elevation myocardial infarction, N: acute non ST-segment elevation myocardial infarction, PCI: percutaneous coronary intervention 37.6 Taxus BMS Cypher 9.4 53 p=0.199 Fig. 3. Stent types in percutaneous coronary intervention. : acute ST segment elevation myocardial infarction, N: acute non-st segment elevation myocardial infarction, Taxus: taxus stent, BMS: bare metal stent, Cypher: cypher stent. p 에서 9명 (0.9%), N 에서 8명 (1.4%), myocardial infarction 은 에서 5명 (0.5%), N 에서 6명 (1.1%), re- PCI는 에서 2명 (0.2%), N에서 4명 (0.7%), CABG 는 에서 1명 (0.1%), N 에서 5명 (0.9%) 에서시행하였다. 성별에따른 MACE 발생률을비교하였을때, N 모두에서각각의사건에대해남성과여성의차이가없었으며, 전체 MACE 발생률은 에서남성 1.5%, 여성 2.6% 로서차이가없었으며 (p=0.384), N 에서남성 3.5%, 여성 5.3% 로서역시차이가없었다 (p=0.213) (Table 5). 고찰 최근 30년간우리나라는급속한사회경제적인발전과더불어서구화된식습관과생활양식으로인해관상동맥질환이급증하고있다. 또한심혈관계질환은한국인 3대사망원인으로서꾸준히증가하고있다. 1)2) 선진국에서는관상동맥질환의중요성을인식하고이에대한체계적인관리체계를구축하고국가적인프로그램 (healthy heart program) 을도입하여허혈성심질환의예방및치료를효율적으로관리하고있지만우리나라에서는대부분단편적이고일회적인연구가대부분이다. 이러한필요성을기반으로 2005 년대한순환기학회 50주년기념사업으로한국인급성심근경색증의현황에대한등록연구 (Korea Acute Myocardial Infarction Registry: KAMIR) 가시작되었다. 본연구에서는 KAMIR 에등록된환자를분석하여최근우리나라의급성심근경색증환자의성별에따른임상양상과치료의차이를알아보았다. 또한현재우리나라에서는 ST 분절상승심근경색증이비-ST 분절상승심근경색증보다많지만비-ST 분절상승심근경색증이꾸준히증가하고있으므로 ST 분절상승심근경색증과비-ST 분절상승심근경색증각각의영역에서성별에따른차이를알아보았다. 많은연구결과와마찬가지로본연구에서도 ST 분절상승심근경색증과비-ST 분절상승심근경색증모두에서여성의평균나이가남성보다많았으며동반질환역시고혈압, 당뇨

Ki Hong Lee, et al:korea AMI Registry 69 병등은여성에서많았다. 6-8) 또한흡연률은남성에서여성보다높았다. 이는우리나라에서의 1990 년대우리나라급성심근경색증에대한연구와같은결과를보였다. 16) 이러한남녀의차이는여성의높은급성사망이경색후예후와연관된것으로설명된다. 또한임상양상에있어여성은남성보다비특이적인증상을많이보였다. 이는급성심근경색증초기치료에있어여성에서좀더보존적인치료를시행함을일부설명한다. Culic 등 20) 은급성심근경색증여성에서고령과높은당뇨유병률이비특이적증상과연관있다고설명했다. Kosuge 등 5) 은여성에서많이보이는비특이적증상들은근골격계, 위장관계, 신경계증상으로오인될수있고이로인해급성심근경색증진단에있어오진할수있음을경고했다. 그러므로여성에서급성심근경색증이의심되는경우더욱면밀한검사를시행해야하며특히심전도에서 ST 분절상승이보이지않는경우에도심근경색증의가능성을생각하여야한다. 내원당시흉통역시여성이남성보다적게호소하였다. Kosuge 등 5) 은흉통의강도역시여성에서남성보다더적게호소함을보고했다. Meischke 등 21) 은여성이심근경색증의증상을느꼈을때자신이심장에이상이있다고인지하는비율이훨씬낮다고했다. 이러한연구결과들은여성이심근경색증의증상들이비특이적일뿐만아니라증상이있더라도이를인지하는비율이낮기때문에여성에서심근경색증발생후병원내원시간이길고이로인해급성심근경색증후사망률도높게된다. 급성심근경색증발생후내원당시의치료에있어본연구는여성이남성보다좀더보존적으로치료함을보여주었다. 그러나초기치료선택에있어영향을미치는인자를보정한후에는많은연구결과와마찬가지로남녀간의차이가없었으며, 1990 년대우리나라치료방법의차이와일관된결과를보여주었다. 16-19) 나이가많을때, 심부전이동반되어있을때에 ST 분절상승심근경색증과비-ST 분절상승심근경색증모두에서보존적으로치료하였고동반위험인자중고혈압과당뇨병은초기치료선택에영향을미치지않았다. 따라서심근경색증초기치료선택에있어성별보다는나이가결정적으로작용하며, 여성에서더보존적으로치료하게보이는것은결국여성환자의나이가많음에서기인함을알수있다. 급성심근경색증의초기치료로서관상동맥중재술이우수한치료방법임이많은연구결과를통해입증되었고증상발현으로부터 3시간이내병원에도착하여관상동맥중재술까지시간이 90분이내이면관상동맥중재술을시술할것을추천한다. 22) 본연구는 1990 년대우리나라에서시행했던급성심근경색증의치료와비교하였을때, 16) 최근우리나라는일차적관상동맥중재술과혈전용해요법의선택에있어일차적관상동맥중재술이훨씬많이시행되고있음을보여준다. 관상동맥중재술을시술하는병원과관상동맥중재술전문의가증가하였지만관상동맥중재술이불가능한지역에서의급성 심근경색증환자의수도꾸준히증가하였다. 급성심근경색증에대한지역병원에서초기치료뿐만아니라관상동맥조영술이가능한병원으로의이송시간까지고려해볼때심근경색증에대한치료방법과체계가지역병원까지점차확립되어가고있음을확인할수있다. 또한입원기간중관상동맥중재술은 ST 분절상승심근경색증과비-ST 분절상승심근경색증모두에서 90% 이상시행되었고남성이여성보다유의하게많이시행하였다. GUSTO II-B PTCA substudy 에서 Tamis-Holland 등 11) 은혈전용해요법에비하여관상동맥중재술에서얻을수있는이익이남성보다여성에서훨씬더큼을제시했다. 우리나라가급속하게서구화되고는있지만서양과다른유교적분위기와사회경제적여건이우리나라여성심근경색증환자에서보존적치료를시행할수밖에없었던임상적상황을제공할수있다. 하지만여성환자에서고령이지만관상동맥중재술을시행함으로써얻을수있는이익을고려할때좀더적극적인치료가필요하다. 관상동맥조영술에서이환된관상동맥, 이환된관상동맥의수는남성과여성의차이가보이지않았고, 이결과는이전의많은연구결과와일치한다. 11)12)23) TIMI flow grade 는 ST 분절상승심근경색증과비-ST 분절상승심근경색증각각의경우에서관상동맥중재술시행전후의차이는보이지않았고이결과역시이전의많은연구결과와일치한다. 11)23)24) 그러나모든심근경색증환자들을대상으로했을때여성이남성보다관상동맥중재술시술전 TIMI flow grade 0를보이는환자가많았을뿐만아니라시술후 TIMI flow grade 3를보이는환자도적었다. 관상동맥재개통의지연은심근괴사를진행시킬뿐만아니라관상동맥내혈전생성도촉진시키게된다. 25)26) 또한 TIMI 3 flow grade 의획득은급성심근경색증후사망률의독립적예측인자이다. 따라서우리나라여성은남성보다시술후 TIMI flow grade 3 획득이적음을통해급성심근경색증후높은사망률을일부설명할수있다. 약물용출스텐트는관상동맥중재술에있어새로운영역을제시했으며급격히발전하고있다. 약물용출스텐트는수많은임상시험과장기추적관찰을통해재협착방지를위한방안으로서각광받고있다. 이중 sirolimus coating stent (Cypher stent ) 와 paclitaxel coating stent(taxus stent ) 의재협착방지효과와단기간안정성에대해가장널리알려져있고, 27-30) KAMIR 에서는이두개의스텐트와일반금속스텐트에대해등록하고있다. 국내에서도 Cypher 스텐트와 Taxus 스텐트의효과와안정성, Cypher 스텐트와 Taxus 스텐트의비교연구결과가발표되었지만대부분연구규모가작으며단기간추적검사결과들이다. 본연구는관상동맥중재술을시행하는 90% 이상의환자들이약물용출스텐트를시행받고있음을보여주었다. 이미우리나라에서약물용출스텐트삽입이널리시행되고있음을감안할때각각스텐트의임상효과와장기추적결과에대한연구를 KAMIR study 를통해알수있을것으로기대한다.

70 Korean Circulation J 2007;37:64-71 1998 년미국의 National Registry of Myocardial Infarction, 2000 년영국의 SAMII study, 2002 년독일의 MITRA study, 세계보건기구가유럽을중심으로수행한 MONICA project 등범국가적인급성심근경색증에대한등록과이를통한급성심근경색증에대한체계적관리가제시되고있다. 우리나라에서처음으로실시하는 KAMIR study 를통해우리나라급성심근경색증환자의현황과효율적관리체계가성립되기를기대한다. 요약 배경및목적 : 우리나라에서최초로인터넷을이용한급성심근경색증환자의등록 (Korea Acute Myocardial Infarction Registry: KAMIR) 이 2005 년 11월부터전국 41개의일차적관상동맥중재술이가능한병원 (primary PCI center) 을중심으로시작되었다. KAMIR 에서우리나라급성심근경색증환자치료에있어성별의차이가있는지알아보고자하였다. 방법 : 2005 년 11월부터 2006 년 6월까지 KAMIR 에등록된환자 4,905 명중완벽한자료분석이가능한 4,110 명 ( 남성 2,855 명, 여성 1,255 명, 나이 64.3±13.5 세 ) 을대상으로하였다. ST 분절상승심근경색증 (ST-elevation myocardial infarction: ) 과비-ST 분절상승심근경색증 (non-st elevation myocardial infarction: N) 각각의영역에서성별에따른치료방법의차이를분석하였다. 결과 : 초기치료의선택에있어남성이여성보다일차적관상동맥중재술 (percutaneous coronary intervention: PCI) 을많이시술받았으나 (69.8% vs. 68.3%, 15.0%, p=0.008), 초기치료의선택에있어고려해야하는다른인자들을보정한후에는유의한차이를보이지않았다. 입원기간전체에걸쳐실시된 PCI 는, N 모두남성에서여성보다많이시행되었다 (: 89.1% vs. 84.9%, p=0.004; N: 74.7% vs. 63.5%, p<0.001). 삽입되는스텐트종류는 에서남성과여성의차이가없었지만 N 에서남성이여성보다약물용출스텐트를더많이시행받았다 (92.2% vs. 90.8%, p=0.022). PCI 성공률은 에서남성과여성간의차이가없었지만, N 에서남성에서유의하게높았다 (96.9% vs. 95.8%, p=0.004). 결론 : 한국인급성심근경색증의초기치료에있어서여성이남성보다보존적으로치료받았고, 이는여성환자의나이가많았기때문이었다. PCI 성공률은남성에서여성환자보다높았다. 중심단어 : 성별 ; 심근경색증 ; 치료 ; 관상동맥중재술 ; 혈전용해요법. 본연구는대한순환기학회창립 50 주년기념연구사업으로진행되었음. Korea Acute Myocardial Infarction Registry (KAMIR) Investigators: 정명호, 김영조, 김종진, 조명찬, 안영근, 김종현, 채성철, 허승호, 성인환, 홍택종, 최동훈, 채제건, 류제영, 김두일, 채인호, 윤정한, 구본권, 김병옥, 이명용, 김기식, 황진용, 오석규, 이내희, 정경태, 탁승제, 배장호, 나승운, 박금수, 한규록, 안태훈, 김무현, 양주영, 임종윤, 권현철, 박성욱, 고영엽, 주승재, 김수중, 진동규, 조진만, 조정관, 정욱성, 장양수, 승기배, 박승정. REFERENCES 1) Kim IS. The present condition and trend of five major causes of death in Korean. Korean J Med Assoc 1995;38:132-45. 2) Suh I, Jee SH, Kim IS. Changing pattern of cardiovascular diseases in Korea. Korean J Epidemiol 1993;15:40-6. 3) Meischke H, Larsen MP, Eisenberg MS. Gender differences in reported symptoms for acute myocardial infarction: impact on prehospital delay time interval. Am J Emerg Med 1998;16:363-6. 4) Patel H, Rosengren A, Ekman I. Synptoms in acute coronary syndromes: does it make a difference? Am Heat J 2004;148:27-33. 5) Kosuge M, Kimura K, Ishikawa T, et al. Differences between men and women in terms of clinical features of ST-segment elevation acute myocardial infarction. Circ J 2006;70:222-6. 6) Vaccarino V, Parsons L, Every NR, Barron HV, Krumholtz HM. Sex-based differences in early mortality after myocardial infarction. N Engl J Med 1999;341:217-25. 7) Maynard C, Litwin PE, Martin JS, Weaver WD. Gender differences in the treatment and outcome of acute myocardial infarction. Arch Intern Med 1992;152:972-6. 8) Kostis JB, Wilson AC, O Dowd K, et al. Sex differences in the management and long-term outcome of acute myocardial infarction: a statewide study: MIDAS Study Group: Myocardial Infarction Data Acquisition System. Circulation 1994;90:1715-30. 9) Kudenchuk PJ, Maynard C, Martin JS, Wirkus M, Weaver WD. Comparison of presentation, treatment, and outcome of acute myocardial infarction in men versus women (the Myocardial Infarction Triage and Intervention Registry). Am J Cardiol 1996; 78:9-14. 10) Chandra NC, Ziegelstein RC, Rogers WJ, et al. Observations of the treatment of women in the United States with myocardial infarction: a report from the National Registry of Myocardial Infarction-I. Arch Intern Med 1998;158:981-8. 11) Tamis-Holland JE, Palazzo A, Stebbins AL, et al. Benefits of direct angioplasty for women and men with acute myocardial infarction: results of the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes Angioplasty (GUSTO II-B) Angioplasty Substudy. Am Heart J 2004;147:133-9. 12) Oe K, Shimizu M, Ino H, et al. Effects of gender on the number of diseased vessels and clinical outcome in Japanese patients with acute coronary syndrome. Circ J 2002;66:435-40. 13) Fiebach HN, Viscoli CM, Horwitz RI. Differences between women and men in survival after myocardial infarction: biology or methodology? JAMA 1990;263:1092-6. 14) Gottlieb S, Moss AJ, McDermott M, Eberly S. Comparison of post hospital survival after acute myocardial infarction in women and men. Am J Cardiol 1994;74:727-30. 15) Karlson BW, Herlitz J, Hartford M. Prognosis in myocardial infarction in relation to gender. Am Heart J 1994;128:477-83. 16) Moon KW, Lee MY, Chung WS, et al. Sex differences in early

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