DOI: 10.4046/trd.2010.69.3.184 ISSN: 1738-3536(Print)/2005-6184(Online) Tuberc Respir Dis 2010;69:184-190 CopyrightC2010. The Korean Academy of Tuberculosis and Respiratory Diseases. All rights reserved. Original Article 혈역학적으로안정된폐색전증환자에서의임상적악화를예측하는전산화단층촬영상소견 울산대학교의과대학서울아산병원 1 응급의학교실, 2 영상의학교실, 3 호흡기내과학교실정상구 1, 김원영 1, 이충욱 2, 서동우 1, 이윤선 1, 이재호 1, 오범진 1, 김원 1, 임경수 1, 홍상범 3, 임채만 3, 고윤석 3 Chest CT Parameters to Predict the Major Adverse Events in Acute Submassive Pulmonary Embolism Sang Ku Jung, M.D. 1, Won Young Kim, M.D., Ph.D. 1, Choong Wook Lee, M.D. 2, Dong Woo Seo, M.D. 1, Youn Sun Lee, M.D. 1, Jae Ho Lee, M.D. 1, Bum Jin Oh, M.D. 1, Won Kim, M.D., Ph.D. 1, Kyoung-Soo Lim, M.D., Ph.D. 1, Sang-Bum Hong, M.D., Ph.D. 3, Chae-Man Lim, M.D., Ph.D. 3, Younsuck Koh, M.D., Ph.D. 3 Departments of 1 Emergency Medicine, 2 Radiology, 3 Respiratory and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Background: The purpose of this study was to determine the prognostic significance of chest computed tomographic (CT) parameters in acute submassive pulmonary embolism (PE). Methods: Between January 2006 and December 2009, 268 consecutive patients with acute submassive PE that was confirmed by chest CT with pulmonary angiography in emergency room were studied. One experienced radiologist measured CT parameters and judged the presence of right ventricular dysfunction. CT parameters were analyzed to determine their ability to predict a major adverse event (MAE). Results: There were 220 patients included and 61 (27.7%) had MAE. Left ventricular and right ventricular maximum minor axis (36.4±8.0 vs. 41.7±7.4, p<0.01; 45.7±9.4 vs. 41.5±7.6, p<0.01), superior vena cava diameter (19.2±3.4 vs. 18.0±3.4, p=0.02), azygos vein diameter (10.0±2.2 vs. 9.2±2.3, p=0.02), septal displacement (19 vs. 18, p<0.01) were significantly higher in MAE group than in no MAE group. Patients with MAE had high right ventricular/left ventricular dimension ratio (RV/LV ratio) compared to patients without MAE (1.34±0.48 vs. 1.03±0.28, p<0.01). The most useful cut-off value of RV/LV ratio for MAE was 1.3 and the area under the curve was 0.71 (0.62 0.79). Conclusion: RV/LV ratio on chest CT was a significant predictor of submassive PE related shock, intubation, in-hospital mortality, thrombolysis, thrombectomy within 30 days. Key Words: Pulmonary Embolism; Tomography; Prognosis 서 유럽과북미의다기관연구보고에따르면폐색전증의 3개월사망률은 15.3% 로매우높은것으로보고되고있으 Address for correspondence: Won Young Kim, M.D. Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea Phone: 82-2-3010-3350, Fax: 82-2-3010-3360 E-mail: wonpia@yahoo.co.kr Received: Jul. 16, 2010 Accepted: Aug. 13, 2010 론 며 1, 국내의급성폐색전증에대한전국실태조사보고에서도서구와비슷한 16.9% 의높은사망률을보였다 2. 더욱이내원당시혈역학적으로안정된폐색전증환자군에서도폐색전증관련사망률이 8% 까지도보고되고있어특히이환자군에대한평가와치료에대해많은논란과이에대한연구들이지속되어왔다 3-6. 많은연구들에서사망과관련된중요한인자는우심실부전으로인한순환기허탈로보고되고있다 6-9. 폐색전으로인하여폐동맥압력이증가하고, 이는순차적으로우심실의과부하와우심실부전을유발하여결국순환기허탈이발생하는것이다 7. Kasper 등 8 은우심실부전이폐색전 184
Tuberculosis and Respiratory Diseases Vol. 69. No. 3, Sep. 2010 증환자에서단기예후에가장중요한인자라고보고하였으며, 현재까지우심실부전을진단하기위한많은연구들이진행되었다 6-9. 심초음파검사는이런우심실부전을역동적으로진단할수있는가장좋은일차적검사로권고되어왔으나, 환자의상태나검사자의숙련도에따라많은차이를보일수있으며응급의료센터내에서언제나시행될수없다는등의한계점을가지고있다 9. 그에비하여폐색전증의진단에이용되는 computed tomographic pulmonary angiography (CTPA) 는폐색전의병변과위치를직접적으로보여줄뿐만아니라심장의혈역학적상태와다른장기의이상유무까지확인할수있으며, 심초음파검사와는달리환자및검사자에따른결과상의차이가크지않고, 24시간언제든빠른시간안에시행될수있는장점을가지고있다. 또한비교적객관적으로진단과동시에위험도를평가할수있기에폐색전증환자의초기위험도분류시심초음파검사를 CTPA 검사소견으로대체가능한지에대한연구들이진행되고있다 10,11. 이에저자들은본원응급의료센터를내원하여 CTPA 검사로진단되었던혈역학적으로안정된폐색전증환자들을대상으로, CTPA 소견중입원한달이내에발생할수있는주요유해사건들을예측할수있는지표들을찾아보고자본연구를시행하였다. 대상및방법 1. 대상 2006년 1월부터 2009년 12월까지본원응급의료센터내원시혈역학적으로안정된폐색전증 ( 수축기혈압이 90 mm Hg 이상이거나쇼크상태, 심폐소생술또는인공호흡기치료가시행되거나혈압유지를위해카테콜라민이 정주되지않았던환자 ) 으로진단받은 268명의환자들을대상으로후향적연구를시행하였다. 이중 CTPA 가판독에적합하지못하였던 11명과폐색전증이재발한환자 37 명을제외한 220명을최종적으로본연구의대상으로하였다 (Figure 1). 폐색전증의진단은응급의료센터에서시행된 CTPA 상에서세분절을포함한폐동맥가지에서관내충만결손 (intraluminal filling defect) 이최소한군데이상확인되었을때로하였다. 2. 방법모든대상환자들은응급의료센터에서시행된 CTPA 로폐색전증이확진되었다. 내원당시환자의성별, 연령, 증상, 과거병력, 초기생체징후, 초기실험실소견, 입원경과및사망유무를전자의무기록과의료보험기록등을통해조사하였다. CTPA 는흉곽입구 (thoracic inlet) 에서부터치골결합 (symphysis pubis) 위치까지시행되었다. CT 스캔은 ECG ungated 16-slice multidetector CT scanner (Sensation 16; Siemens, Forchheim, Germany) 가이용되었고, CT 영상 (1.5-mm collimation 16 detectors; pitch, 1; reconstruction interval, 1 mm) 은 120 ml의 nonionic contrast medium을정주하고 20초후에얻어졌다. 환자들은스캔하는동안깊은흡입후 10 12초간호흡을멈추도록교육받았다. β-blocker 는사용하지않았다. 영상의학과전문의가모든대상환자들의 CTPA 영상을재검토하여색전의유무, 우심실과좌심실단축의최장너비, 중심폐동맥, 대동맥, 상대정맥, 홀정맥, 하대정맥들의직경, 심실간종격의모양등을측정하여기술하였다. RV/LV ratio (ratio of right ventricular diameter to left ventricular diameter) 는심장의장축에직각으로, 심실간종격과심실근외벽간의거리가최장인 axial image 를찾아우심실과좌심실 Figure 1. Selection of patients. 185
SK Jung et al: CT parameters predict the adverse events in submassive pulmonary embolism 의너비간의비율 ( 심내막과종격간의거리 ) 로구했다 12. 주요유해사건은본원응급의료센터를통해입원후 1 달이내에폐색전증관련쇼크, 기도삽관, 혈압유지를위한카테콜라민정주, 심폐소생술, 사망, 혈전용해술, 혈전절제술등을시행한경우등으로정의하였다. 폐색전증관련쇼크는저혈량증과패혈증의증거가없으면서수축기혈압이 90 mm Hg 이하혹은기존혈압보다 40 mm Hg 이상감소되었던경우가 15분이상지속되었을때로정의하였다. 입원 1달이내에최소한가지이상의주요유해사건발생유무에따라대상환자들을주요유해사건이발생하였던군과발생하지않았던군으로분류하였고, 조사된각각의항목에대해비교분석하였다. 3. 통계모든통계분석은 SPSS for windows version 14.0 프로그램 (SPSS Inc., Chicago, IL, USA) 을이용하였다. 조사된항목은연속형변수의경우평균 ± 표준편차로표시하였고, 범주형변수의경우빈도수 (%) 로표시하였다. 군간의통계분석에서연속형자료에대하여 Student s t-test 또는 Mann-Whitney U 검정을사용하였고, 범주형자료에대하여 chi-square test 또는 Fisher s exact test를사용하였다. 중요변수에대한주요유해사건발생의예측도에대해 receiver operating characteristic (ROC) analysis를이용하였고그에대한유효성확인을위해 area under curves (AUC) 를계산하였다. 가장유효한예측변수에대해민감도와특이도를계산하였다. 단변량분석에서의미가있었던변수들과보정되어야할변수들에대해다변량로지스틱회귀분석을시행하여유효한예측변수들을확인하였다. 모든분석에있어서, p값이 0.05 미만인경우통계적으로유의한차이가있다고판정하였다. 결과폐색전증으로진단및혈역학적으로안정된대상환자 220 명중입원 1달이내에주요유해사건이발생하였던환자군은 61명 (27.7%), 발생하지않았던환자군은 159명 (72.3%) 이었다. 전체환자들에서혈전용해술 23명 (10.5%), 혈전절제술 3명 (1.4%), 사망 28명 (12.7%), 심폐소생술 12 명 (5.5%), 기도삽관 22명 (10%), 쇼크 35명 (15.9%) 으로조사되었다. 입원 1달이내에주요유해사건이발생하였던환자군과 발생하지않았던환자군간의비교시, 환자들의나이, 성별에서는유의한차이가없었다. 기저질환에있어서당뇨, 심혈관질환, 심부전, 심부정맥혈전, 악성종양, 만성폐쇄성폐질환, 뇌경색등에서도두군간에유의한차이는없었다 (Table 1). 본원내원당시이완기혈압과맥박등에서는두군간의차이를보이지않았으나, 수축기혈압에서는두군간에유의한차이를보였다 (115.6±27.5 mm Hg vs. 125.5± 19.4 mm Hg, p<0.01). 초기혈액검사상에서동맥혈산소포화도, 혈중 C-reactive protein (CRP), D-dimer 등에있어통계적으로유의한차이를보이는지표는없었다. CTPA 의측정인자들에서중심폐동맥과하대정맥의직경은두군간에차이가없었다. 그러나좌심실단축의최장너비는주요유해사건이발생한군에서유의하게짧았고 (36.4±8.0 mm vs. 41.7±7.4 mm, p<0.01), 우심실단축의최장너비와상대정맥, 홀정맥의직경에서는주요 Table 1. Baseline clinical characteristics and laboratory findings of the study patients on admission to the emergency department MAE (n=61) No MAE (n=159) p-value Age 64.6±10.9 61.7±15.4 0.18 Gender 0.56 Male 28 (45.9) 80 (50.3) Female 33 (54.1) 79 (49.7) Comorbidities Diabetes 10 (16.4) 31 (19.5) 0.60 Heart failure (EF<45%) 3 (4.9) 2 (1.3) 0.13 Deep vein thrombosis 4 (6.6) 27 (17.0) 0.05 Malignancy 26 (42.6) 68 (42.8) 0.99 COPD 1 (1.6) 6 (3.8) 0.68 Stroke 5 (8.2) 13 (8.2) 1.00 Initial vital sign SBP, mm Hg 115.6±27.5 125.5±19.4 0.00 DBP, mm Hg 75.4±22.1 80.0±14.2 0.07 Laboratory findings SaO 2, mm Hg 91.1±7.7 92.6±6.6 0.19 PaO 2, mm Hg 76.8±70.9 72.0±27.2 0.51 CRP, mg/dl 5.9±8.3 5.2±6.6 0.51 D-dimer, ug/ml 22.1±40.5 11.2±12.5 0.05 Values are expressed as mean±standard deviation or numbers (%). MAE: major adverse event; EF: ejection fraction; COPD: chronic obstructive pulmonary disease; SBP: systolic blood pressure; DBP: diastolic blood pressure; CRP: C-reactive protein. 186
Table 2. Computed tomographic measurements of the study population Tuberculosis and Respiratory Diseases Vol. 69. No. 3, Sep. 2010 Parameters MAE (n=61) No MAE (n=159) p-value LV maximum minor axis, mm 36.4±8.0 41.7±7.4 0.00 RV maximum minor axis, mm 45.7±9.4 41.5±7.6 0.00 Central pulmonary artery diameter, mm 31.8±5.7 32.1±5.5 0.74 Aorta diameter, mm 35.3±4.9 35.1±5.1 0.83 Superior vena cava diameter, mm 19.2±3.4 18.0±3.4 0.02 Azygos vein diameter, mm 10.0±2.2 9.2±2.3 0.02 Inferior vena cava diameter, mm 23.0±4.7 22.4±4.2 0.42 Interventricular septum displacement 0.00 Convex 18 (29.5) 93 (58.5) Flat 24 (39.3) 48 (30.2) Concave 19 (31.1) 18 (11.3) RV/LV ratio 1.34±0.48 1.03±0.28 0.00 Values are expressed as mean±standard deviation or numbers (%). MAE: major adverse event; LV: left ventricle; RV: right ventricle; RV/LV ratio: ratio of right ventricular diameter to left ventricular diameter. Table 3. Factors associated with occurrence of major adverse events in patients with acute submassive pulmonary embolism Variables Multivariate analysis Adjusted OR 95% CI p-value Figure 2. Receiver operating characteristic curve for predicting major adverse events with RV/LV dimension ratio on 16 slice multidetector scanner. 유해사건이발생한군에서유의하게길었다 (45.7±9.4 mm vs. 41.5±7.6 mm, p<0.01; 19.2±3.4 mm vs. 18.0±3.4 mm, p=0.02; 10.0±2.2 mm vs. 9.2±2.3 mm, p=0.02). 심실간종격의우심실로의전위모양빈도에서도주요유해사건이발생한군에서유의하게높았다 (19 vs. 18, p< 0.01). 각각의우심실과좌심실의최대단축의최장너비로구한 RV/LV ratio 에있어서도주요유해사건이발생한군에서유의한차이를보였다 (1.34±0.48 vs. 1.03±0.28, p<0.01) (Table 2). ROC curve 상주요유해사건발생예측에대한 RV/LV ratio의곡선하면적값은 0.707 (95% 신뢰구간 [confidence Age 1.01 0.98 1.03 0.63 Gender 1.15 0.58 2.25 0.69 Concave 1.28 0.52 3.17 0.59 interventricular septum Superior vena cava 0.98 0.87 1.10 0.71 diameter Azygos vein diameter 1.15 0.98 1.36 0.09 RV/LV ratio 7.96 2.73 23.16 0.00 OR: odds ratio; CI: confidence interval; RV/LV ratio: ratio of right ventricular diameter to left ventricular diameter. interval, CI], 0.626 0.787) 이었고가장유효한경계값은 1.3이었다 (Figure 2). 이경계값에대한민감도와특이도, 양성예측도, 음성예측도, 그리고정확도는각각 45.9% (95% CI, 0.33 0.59), 88.0% (95% CI, 0.82 0.93), 59.5% (95% CI, 0.44 0.74), 80.9% (95% CI, 0.74 0.87), 76.3% (95% CI, 0.71 0.82) 이었다. 단변량분석에서통계적인의미를보였던 CTPA 측정인자들을성별, 연령에보정하여다변량로지스틱회귀분석을시행하였을때, RV/LV ratio 만이주요유해사건발생에대한유의한독립예측인자였다 ( 우도비 7.96; 95% CI, 187
SK Jung et al: CT parameters predict the adverse events in submassive pulmonary embolism 2.73 23.16; p<0.01) (Table 3). 고찰본연구에서응급의료센터내원시혈역학적으로안정되었던폐색전증환자들에서입원한달이내에폐색전증관련쇼크, 기도삽관, 혈전용해술, 혈전절제술, 사망등의주요유해사건의발생을예측할수있는유용한예측인자는 CTPA 상의 RV/LV ratio였으며 ( 우도비 7.96; 95% CI, 2.73 23.16; p<0.00), 적절한경계값으로 1.3임을확인하였다 ( 민감도 45.9%; 특이도 88.0%; 양성예측도 59.5%; 음성예측도 80.9%; 정확도 76.3%). 급성폐색전증환자들에서혈역학적으로불안정한고위험군의환자들은혈전용해술이나혈전절제술등의침습적치료가권유되고있으나 13, 혈역학적으로안정된환자들에서의치료는아직논란이많다 14. 이에따라폐색전증환자의예후를결정할수있는예측인자에대한많은연구들이진행되었고, 우심실부전이환자의사망률을결정하는가장주요한독립예측인자로보고되었다 6-8,12,15,16. 특히 Kucher 등 16 은초기수축기혈압이 90 mm Hg 이상인 1,035명의폐색전증환자들에서진단후 24시간내에심초음파를시행후우심실부전이 30일사망률의독립예측인자임을밝혔고 ( 우도비 1.94; 95% CI, 1.23 3.06), van der Meer 등 6 은혈역학적으로안정된 510 명의폐색전증환자들에서 CTPA 상의우심실확장이 3개월사망률과관계가있다고보고하였었다 (p=0.04). 대부분의연구들에서 CTPA에서의우심실부전을시사하는요소로 RV/LV ratio 를사용하였으며, 이는심초음파검사소견과도비교하여밀접한연관성이있는것으로보고되었다 17. 그러나 RV/LV ratio 에대한기준치는 0.9에서부터 1.5까지다양하였다 6,12,17-19. 그중혈역학적으로안정된환자들에서의기준치는 1.0 또는 1.09 로혈역학적으로불안정한환자들을포함한연구들의기준치에비해비교적낮은경향을보였다 6,18. 이는혈역학적으로안정된환자에서의예후를예측할수있는 RV/LV ratio 의기준치로 1.3을제시한본연구와는차이가있는데이는이전의연구들이민감도와정확도가낮은 single spiral CT를주로사용하였었던반면에저자들의연구에서는보다정밀한 multi-dectector CT를사용하였기에발생한차이일수있을것이다. 우심실부전을확인하기위한여러가지노력들중에우심실단축의최대직경을측정하여우심실확장을진단하 려는연구들이있었다. Kasper 등 8 은심초음파상에서우심실이좌심실보다크거나우심실의이완기말직경이 30 mm 이상일경우를우심실확장으로정의하였었고, Collomb 등 18 은 CTPA 상에서폐색전증이없는환자에서의정상우심실최대직경을 42.3 mm로보고하였다. 본연구에서도우심실의최대직경에있어주요유해사건이발생하였던군은 45.7±9.4 mm로, 발생하지않은군 41.5±7.6 mm에비하여상대적으로길었었다 (p<0.00). 그러나이런우심실의절대적값은환자의성별, 신체조건, 직업, 검사자의경험등에따라영향을받을수있어우심실의확장만으로우심실부전을말하기에는부족한점이있다. 이전의연구에서심한폐색전증의경우우심실의최대단축의거리가심하게증가하는것을보고하였으나, 그와함께좌심실의직경도감소하여결국 RV/LV ratio 의두드러진증가를나타낸다고보고하였다 20. 실제심한폐색전증환자들의대부분은 RV/LV ratio가 1.5 이상인경우가많았다. 이를폐색전증에대한좌심실의 after-effect 로설명할수있어본연구에서처럼혈역학적으로안정된환자에서더중요하게인식되어야할부분으로생각된다. 본연구에서도두군을비교하였을때우심실확장의정도보다는 RV/LV ratio의증가비율이높아이를뒷받침하고있다 18,21. Jardin 등 21 은우심실벽의비후 (>6 mm) 로급성또는아급성을구분할수있다고보고하였고, Collomb 등 18 은홀정맥과상대정맥의직경증가가우심실의과부하와연관이높다고보고하였다. 본연구에서도단변량분석에서이와일치하는결과를보였으나, 다변량분석에서는 RV/ LV ratio에비해유의성이떨어지는것으로나타났다. 폐동맥색전지수는폐동맥의색전정도를정량화한, 객관적인방법으로소개되었다 22. Wu 등 23 은 60% 를기준으로할경우 2.32배의사망률증가를보고하였고, van der Meer 등 6 은 40% 의기준치에서 11.2배의사망률증가를보고하였다. 그러나영상의학과를전문으로하지않은임상의가실제적인임상에서적용하기에는쉽지않다. 현재까지는심초음파검사가우심실부전을동적이면서직접적으로진단할수있는가장좋은일차적검사로권고되어왔으나, 환자의특징 ( 비만, 만성폐쇄성폐질환, 늑막염등 ) 및검사자의숙련도에따라결과상의차이를보일수있고 24시간내내 ( 특히응급의료센터 ) 시행할수없다는등의한계점들을가지고있다 9. 더욱이우심실부전진단에대한몇몇연구에서는심초음파검사보다도 CTPA 의민감도와특이도가더높다는보고 ( 민감도 81% vs. 56%, 188
Tuberculosis and Respiratory Diseases Vol. 69. No. 3, Sep. 2010 특이도 47% vs. 42%) 들이있기에정상혈압폐색전증환자에서위험도분류시 CTPA 의중요성에대한관심이더욱증가될것이다 11. 본연구에서이전의연구들에서와같이사망률을연구의종결점으로정하지않고주요유해사건의발생으로정한이유는주요유해사건들의발생가능성이높은환자들을내원시확인할수있다면이런환자들에서집중적인환자감시를통해조기에적절한처치를받게함으로서폐색전증환자들의예후에긍정적인영향을미칠수있기때문이었다. 이와같은맥락으로 Araoz 등 24 은 RV/LV ratio 는원내사망률보다는집중치료실로의입실을예측하는가장중요한인자라고보고하였고, Quiroz 등 17 은 CTPA 상의우심실확장 (RV/LV ratio>0.9) 이임상적주요유해사건발생을예측할수있다고보고하였다. 본연구의제한점으로는첫째, 통계적인결과상으로는 RV/LV ratio가입원한달이내에주요유해사건발생을예측할수있는가장주요한독립예측인자이며 1.3을가장적절한경계값으로확인하였으나, 이에대한특이도와음성예측도가민감도나양성예측도보다높아실제임상에서는주요유해사건발생을예측할수있는인자로사용하기보다는발생가능성이적은환자들을찾아내어병동에서안전하게치료하는데에더유용할것으로보인다. 다만급성폐색전증환자의위험도분류에서임상적표지자, 우심실부전, 심근손상의 3가지항목을사용하도록유럽심장학회에서권고하였듯이, 민감도나양성예측도의향상을위해다른유효한인자들과함께분석할필요성이있다 14. 둘째, 폐색전증검사에사용된 multidetector CT의경우심전도와동기화되지않은상태로영상을얻어심장의동적요소가보정되지못한점이있다. 실제동기화되지않은 MDCT 는심장의이완기에대한참고치가없기때문에심실을측정하는데부적합하다는주장이있다. 셋째, 역동적으로운동하는심장의복잡한모양을정지된영상소견만으로정확히측정하기는어렵다. 그래서최근장비가발달하면서심실간의직경에대한비율 (RV/LV dimension ratio) 보다는심실간의용량에대한비율 (RV/LV volume ration) 을측정하려는노력이있으나본연구에서는심실간의용량에대한비율은측정하지못하였다. 넷째, 기저심폐질환에따른보정이필요하다. 기저심폐질환이있는경우심장의압박정도는건강한성인에비해높을것이다. 마지막으로, 본연구는후향적으로 CTPA 에서의예후인자에대해서만분석하였다는제한점이있다. 즉, CTPA 소견이외에도지금까지의연구들에서알려진 색전지수, 심근효소 (troponin, B-natriuretic peptide), 심초음파, 폐동맥색전지수, pulmonary embolism severity index 등과비교하지못하였으며이에대한전향적인연구가필요할것이다. 결론적으로, 응급의료센터내원시혈역학적으로안정되었던폐색전증환자들에서 CTPA 상 RV/LV ratio 는입원한달이내에폐색전증관련쇼크, 기도삽관, 혈전용해술, 혈전절제술, 사망등의주요유해사건의발생을예측할수있는가장주요한독립예측인자였다. 참고문헌 1. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999;353:1386-9. 2. Scientific Committee for National Survey of Acute Pulmonary Thromboembolism, Korean Academy of Tuberculosis and Respiratory Diseases. The national survey of acute pulmonary thromboembolism in Korea. Tuberc Respir Dis 2003;54:5-14. 3. Kucher N, Wallmann D, Carone A, Windecker S, Meier B, Hess OM. Incremental prognostic value of troponin I and echocardiography in patients with acute pulmonary embolism. Eur Heart J 2003;24:1651-6. 4. La Vecchia L, Ottani F, Favero L, Spadaro GL, Rubboli A, Boanno C, et al. Increased cardiac troponin I on admission predicts in-hospital mortality in acute pulmonary embolism. Heart 2004;90:633-7. 5. Kostrubiec M, Pruszczyk P, Bochowicz A, Pacho R, Szulc M, Kaczynska A, et al. Biomarker-based risk assessment model in acute pulmonary embolism. Eur Heart J 2005;26:2166-72. 6. van der Meer RW, Pattynama PM, van Strijen MJ, van den Berg-Huijsmans AA, Hartmann IJ, Putter H, et al. Right ventricular dysfunction and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3-month follow-up in patients with acute pulmonary embolism. Radiology 2005;235:798-803. 7. Ribeiro A, Lindmarker P, Juhlin-Dannfelt A, Johnsson H, Jorfeldt L. Echocardiography Doppler in pulmonary embolism: right ventricular dysfunction as a predictor of mortality rate. Am Heart J 1997;134:479-87. 8. Kasper W, Konstantinides S, Geibel A, Tiede N, Krause T, Just H. Prognostic significance of right ventricular afterload stress detected by echocardiography in patients with clinically suspected pulmonary embolism. Heart 1997;77:346-9. 189
SK Jung et al: CT parameters predict the adverse events in submassive pulmonary embolism 9. Burgess MI, Bright-Thomas RJ, Ray SG. Echocardiographic evaluation of right ventricular function. Eur J Echocardiogr 2002;3:252-62. 10. Ghaye B, Remy J, Remy-Jardin M. Non-traumatic thoracic emergencies: CT diagnosis of acute pulmonary embolism: the first 10 years. Eur Radiol 2002;12:1886-905. 11. He H, Stein MW, Zalta B, Haramati LB. Computed tomography evaluation of right heart dysfunction in patients with acute pulmonary embolism. J Comput Assist Tomogr 2006;30:262-6. 12. Ghuysen A, Ghaye B, Willems V, Lambermont B, Gerard P, Dondelinger RF, et al. Computed tomographic pulmonary angiography and prognostic significance in patients with acute pulmonary embolism. Thorax 2005; 60:956-61. 13. Task Force on Pulmonary Embolism, European Society of Cardiology. Guidelines on diagnosis and management of acute pulmonary embolism. Eur Heart J 2000; 21:1301-36. 14. Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008;29:2276-315. 15. Grifoni S, Olivotto I, Cecchini P, Pieralli F, Camaiti A, Santoro G, et al. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation 2000;101:2817-22. 16. Kucher N, Rossi E, De Rosa M, Goldhaber SZ. Prognostic role of echocardiography among patients with acute pulmonary embolism and a systolic arterial pressure of 90 mm Hg or higher. Arch Intern Med 2005;165:1777-81. 17. Quiroz R, Kucher N, Schoepf UJ, Kipfmueller F, Solomon SD, Costello P, et al. Right ventricular enlargement on chest computed tomography: prognostic role in acute pulmonary embolism. Circulation 2004;109:2401-4. 18. Collomb D, Paramelle PJ, Calaque O, Bosson JL, Vanzetto G, Barnoud D, et al. Severity assessment of acute pulmonary embolism: evaluation using helical CT. Eur Radiol 2003;13:1508-14. 19. Schoepf UJ, Kucher N, Kipfmueller F, Quiroz R, Costello P, Goldhaber SZ. Right ventricular enlargement on chest computed tomography: a predictor of early death in acute pulmonary embolism. Circulation 2004;110: 3276-80. 20. Contractor S, Maldjian PD, Sharma VK, Gor DM. Role of helical CT in detecting right ventricular dysfunction secondary to acute pulmonary embolism. J Comput Assist Tomogr 2002;26:587-91. 21. Jardin F, Dubourg O, Bourdarias JP. Echocardiographic pattern of acute cor pulmonale. Chest 1997;111:209-17. 22. Qanadli SD, El Hajjam M, Vieillard-Baron A, Joseph T, Mesurolle B, Oliva VL, et al. New CT index to quantify arterial obstruction in pulmonary embolism: comparison with angiographic index and echocardiography. AJR Am J Roentgenol 2001;176:1415-20. 23. Wu AS, Pezzullo JA, Cronan JJ, Hou DD, Mayo-Smith WW. CT pulmonary angiography: quantification of pulmonary embolus as a predictor of patient outcome--initial experience. Radiology 2004;230:831-5. 24. Araoz PA, Gotway MB, Trowbridge RL, Bailey RA, Auerbach AD, Reddy GP, et al. Helical CT pulmonary angiography predictors of in-hospital morbidity and mortality in patients with acute pulmonary embolism. J Thorac Imaging 2003;18:207-16. 190