대한내과학회지 : 제 77 권제 5 호 2009 원저 09-002 급성 ST 분절상승과 ST 분절비상승심근경색증환자의예후비교 전남대학교병원심장센터순환기내과, 임상시험센터, 전남대학교심혈관계특성화사업단 김민철 안영근 조경훈 박동진 김현국 김성수 정해창조재영 박근호 심두선 윤남식 윤현주 김계훈 홍영준박형욱 김주한 정명호 조정관 박종춘 강정채 Comparison of the prognosis of patients with acute ST-elevation and non-st-elevation myocardial infarction Min Chul Kim, M.D., Youngkeun Ahn, M.D., Kyung Hun Cho, M.D., Dong Jin Park, M.D., Hyun Kuk Kim, M.D., Sung Soo Kim, M.D., Hae Chang Jeong, M.D., Jae Young Cho, M.D., Keun Ho Park, M.D., Doo Sun Sim, M.D., Nam Sik Yoon, M.D., Hyun Ju Yoon, M.D., Kye Hun Kim, M.D., Young Joon Hong, M.D., Hyung Wook Park, M.D., Ju Han Kim, M.D., Myung Ho Jeong, M.D., Jeong Gwan Cho, M.D., Jong Chun Park, M.D., and Jung Chaee Kang, M.D. Department of Cardiovascular Medicine, Heart Center, Clinical Trial Center, Chonnam National University Hospital, Cardiovascular Research Institute, Chonnam National University, Gwangju, Korea Background/Aims: Acute ST-elevation myocardial infarction (STEMI) and non-st-elevation myocardial infarction (NSTEMI) have different therapeutic strategies. This study assessed the risk factors, therapeutic strategies, clinical outcomes, and prognostic factors of STEMI and NSTEMI. Methods: Patients admitted to our hospital with a diagnosis of acute myocardial infarction between November 2005 and December 2006 were evaluated. We analyzed their baseline clinical characteristics, angiographic characteristics, in-hospital mortality, and major adverse cardiac events (MACE) during clinical follow-up for 1 year in patients with STEMI and NSTEMI. Results: There were 447 STEMI patients and 186 NSTEMI patients. Smoking was the most common risk factor in both groups. In the STEMI group, primary percutaneous coronary intervention was performed in 85.0% and thrombolysis was performed in 7.2% of the patients. In the NSTEMI group, an early invasive strategy was chosen in 66.7% of the patients. The in-hospital mortality rate was 3.8% in the STEMI group and 3.2% in the NSTEMI group. The rates of MACE at 6 months and 1 year did not differ significantly between the groups (17.7% vs. 17.3% and 22.8% vs. 20.2%, respectively). Independent predictors of prognosis were diabetes mellitus, smoking, and left ventricular ejection fraction (LVEF) <40% on admission in the NSTEMI group, and serum troponin I in the STEMI group. Troponin I was the only predictor of prognosis in the STEMI group (p=0.047 vs. p=0.139). Conclusions: Patients with STEMI and NSTEMI had similar clinical outcomes during a 1-year clinical follow-up. Of the predictors of prognosis, troponin I is the only one in STEMI. (Korean J Med 77:582-592, 2009) Key Words: Myocardial infarction; Prognosis Received: 2009. 1. 3 Accepted: 2009. 6. 29 Correspondence to Youngkeun Ahn, M.D., Department of Cardiovascular Medicine, Heart Center, Chonnam National University Hospital, 671 Jaebongro, Dong-gu, Gwangju 501-757, Korea E-mail: cecilyk@chonnam.ac.kr - 582 -
- Min Chul Kim, et al. Prognosis in patients with acute myocardial infarction - 서론관상동맥질환중심근경색은내과적응급질환으로초기처치방법및시간에따라예후가크게변한다. 12 전극유도심전도상 ST 분절상승급성심근경색증 (ST-elevation myocardial infarction, STEMI) 은대개병원내원 30분내에혈전용해술을시행하거나, 90분내에재관류치료를하는것을최우선으로하고있다 1). 이에반해 12전극유도심전도상 ST 분절상승이없는 ST 분절비상승급성심근경색증 (non-stelevation myocardial infarction, NSTEMI) 은위험요인에의거, 증상발현 48시간내에관상동맥조영술을시행하는것이일반적이다 2). 불안정성협심증과심근경색증을비교한연구에서는심근경색증이장기예후가좋지않은것으로나타났으나 3), STEMI와 NSTEMI 의 1년추적관찰결과를보고했던연구에서예후는두군에서유사한것으로나타났다 4-6). STEMI는 NSTEMI 에비해내원시심인성쇼크, 심실세동, 심실빈맥, 완전방실차단등합병증을동반한비율이높아빠른처치가되지않으면치명적결과를낳으므로치료가지연되는경우는거의없으나 7-9), 내원시합병증을동반하지않는 NSTEMI의경우응급재관류술보다는선택적재관류술을시행하는경향이다. 본연구에서는급성심근경색 (myocardial infarction, MI) 으로 1년간전남대병원을내원한환자의주요심장사건 (major adverse cardiac events, MACE) 을분석하고이들결과에영향을미치는인자들을규명하여 STEMI와 NSTEMI의예후인자에대해비교하였다. 대상및방법 1. 연구대상 2005년 11월부터 2006년 12월까지급성심근경색진단하에치료를받았던환자 633예 (I군-STEMI 447예, 63.7±12.3세, 남 : 여 335:112; II군-NSTEMI 186예, 64.6±11.9세, 남 : 여 124: 62) 를대상으로하였다. 퇴원 6개월뒤 STEMI군에서 406예, NSTEMI군에서 166예가추적관찰되었으며, 퇴원 1년뒤최종추적관찰군에서는 STEMI 399예, NSTEMI 159예의주요심장사건에대해비교분석하였다. 2. 연구방법고혈압, 당뇨병, 고지혈증, 가족력, 흡연등의위험인자및 혈액검사 ( 심근효소치, 고감도 C-반응성단백, N말단뇌나트륨이뇨펩티드, 혈중지질검사등 ) 그리고관상동맥조영술소견및추적기간동안의주요심장사건에대해비교분석하였다. 주요심장사건은사망, 급성심근경색증의재발, 재관류술, 관상동맥우회술로하였다. 내원당시의혈압, 심전도소견, 입원기간내시행한이면성심초음파검사상의좌심실구혈률을측정하였으며, 급성심근경색증진단후치료방향과병변혈관개수, 경색관련동맥 (infarct-related artery) 에대해분석하였다. NSTEMI의치료전략은입원시각 48시간내관상동맥조영술을시행했던조기침습적치료전략 (early invasive management), 48시간이후관상동맥조영술을시행했던조기보존적치료전략 (early conservative management) 으로구분하였고, 관상동맥조영술을시행했던환자에서유의한협착을보인병변을모두재혈관화했던경우를 total revascularization으로정의하였다. 입원기간내발생한주요합병증은심실세동, 심실빈맥, 심인성쇼크, 방실차단, 심방세동등으로하였다. 첫 6개월간 STEMI 환자군의 8예, NSTEMI 환자군의 5예가추적관찰실패로분석에서제외되었으며, 총사망자수는 STEMI군에서 33명 ( 원내사망 17명포함 ), NSTEMI군에서 15명 ( 원내사망 6명포함 ) 이었다. 다음 6개월간추가로 STEMI 환자군의 2예, NSTEMI 환자군의 2예가추적관찰실패로제외되었으며각각의군에서 5명의환자가사망하여관찰에서제외되었다. 입원기간내사망환자와추적관찰기간내사망환자는 MACE 에추가하였다. 모든혈액검사, 심전도소견은관상동맥조영술, 혈전용해제치료전에분석하였다. 또한입원시그리고퇴원후사용된약물을알아보았다. 3. 통계분석연속변수는평균 ± 표준편차로표시하였고, 통계처리는 SPSS for windows15.0 (Statistical Package for the Social Sciences, SPSS INC, USA) 을이용하였으며, 통계처리는 unpaired sample t-test와 Chi-square analysis를이용하여시행하였고, 다변량로지스틱회귀분석 (multiple logistic regression analysis) 을이용하여주요심장사건에영향을미치는인자를평가하였다. 모든자료는 p value가 0.05 미만일때유의하다고판정하였다. 결과 1. 임상적특성 - 583 -
- 대한내과학회지 : 제 77 권제 5 호통권제 591 호 2009 - Table 1. Baseline clinical and laboratory findings in the STEMI and NSTEMI groups STEMI (n = 447) NSTEMI (n = 186) p Age (years) 63.7±12.3 64.6±11.9 0.626 Male, n (%) 335 (74.9) 124 (66.7) 0.040 Body mass index (kg/m 2 ) 23.9±3.0 23.9±2.9 0.928 History, n (%) Hypertension 206 (46.1) 92 (49.5) 0.484 Diabetes mellitus 120 (26.8) 62 (33.3) 0.102 Smoking 297 (66.4) 110 (59.1) 0.084 Hyperlipidemia (total cholesterol >200 mg/dl) 131 (29.3) 55 (29.6) 0.947 Family history of coronary artery disease 13 (2.9) 9 (4.8) 0.238 Prior angina 15 (3.4) 11 (5.9) 0.185 Prior myocardial infarction 10 (2.2) 9 (4.8) 0.121 Prior PCI 20 (4.5) 11 (5.9) 0.426 Prior CABG 1 (0.2) 4 (2.2) 0.028 Symptoms and hemodynamics on admission Heart rate (beats/min) 74.6±19.9 77.8±16.6 0.153 Systolic blood pressure (mmhg) 128.9±31.8 137.7±27.2 0.301 Diastolic blood pressure (mmhg) 80.5±19.8 86.6±16.2 0.449 Killip class, n (%) I 338 (75.6) 139 (74.7) 0.840 II 58 (13.0) 24 (12.9) 0.980 III 25 (5.6) 17 (9.1) 0.115 IV 26 (5.8) 6 (3.2) 0.232 Echocardiogram findings Left ventricular EF (%) 54.9±12.5 55.7±12.4 0.615 Laboratory findings Creatinine (ml/min) 1.1±0.9 1.2±1.1 0.083 Creatine kinase-mb (U/L) 126.7±126 51.6±88.5 <0.001 Troponin I (ng/ml) 74.8±88.4 24.2±37.9 <0.001 Total cholesterol (mg/dl) 177.5±37.2 178±42.9 0.042 Triglyceride (mg/dl) 121.1±68 111.8±70.7 0.563 HDL-C (mg/dl) 46±11 44.8±12.5 0.183 LDL-C (mg/dl) 116.7±34.9 117.8±39.5 0.137 High sensitivity CRP (mg/dl) 2.4±3.6 1.6±2.1 0.008 NT-pro-BNP (pg/ml) 2,465±5,221 3,737±7,565 <0.001 STEMI, ST-segment elevation myocardial infarction; NSTEMI, non-st-segment elevation myocardial infarction; PCI, percutaneous coronary intervention; CABG, coronary artery bypass graft; EF, ejection fraction; HDL-C, high density lipoprotein-cholesterol; LDL-C, low density lipoprotein cholesterol; CRP, C-reactive protein; NT-pro BNP, N-terminal pro-brain natriuretic peptide. 대상환자는 I군과 II군모두에서남자가더많았으며 [335 명 (74.9%) vs. 124명 (66.7%)] I군의비율이높았다 (p=0.040). 평균연령은 I군에서 63.7±12.3세, II군에서 64.6±11.9세로유의한차이는없었다. 위험인자로는흡연, 고혈압, 당뇨, 고지혈증, 관상동맥질환과거력, 가족력순으로빈도가높았으며양군에서차이는없었다. 증상발현에서내원시까지의시간에서양군은차이가없었으며, 내원시수축기혈압및 이완기혈압역시양군에서차이가없었다. 내원당시 Killip class는 class I이 I군에서 338예 (75.6%), II군에서 139예 (74.7%), class IV가 I군에서 26예 (5.8%), II군에서 6예 (3.2%) 로양군에서유의한차이는없었다 ( 각각 p=0.84, p=0.232, 표 1). 내원시시행한이면성심초음파검사상좌심실구혈률 (left ventricular ejection fraction, EF) 은 I군에서 54.9±12.5%, II 군에서 55.7±12.4% 로양군에서차이는없었다. 내원시시 - 584 -
- 김민철외 19 인. 급성심근경색증환자의예후 - Table 2. Medical therapy on admission (left) and at discharge (right) in the STEMI and NSTEMI groups Admission Discharge Medical therapy, n (%) STEMI (n=447) NSTEMI (n=186) p STEMI (n=447) NSTEMI (n=186) p Aspirin 443 (99.1) 185 (99.5) 1.00 447 (100.0) 447 (100.0) 1.00 Clopidogrel/Ticlopidine 444 (99.3) 183 (98.4) 0.37 414 (92.6) 161 (86.6) 0.022 Cilostazol 339 (75.8) 112 (60.2) <0.001 328 (73.4) 115 (61.8) 0.004 Calcium channel blocker 33 (7.4) 30 (16.1) 0.001 32 (7.2) 22 (11.8) 0.06 Beta blocker 386 (86.4) 159 (85.5) 0.80 351 (78.5) 146 (78.5) 1.00 ACE inhibitor 371 (83.0) 152 (81.7) 0.73 326 (72.9) 136 (73.1) 1.00 ARB 86 (19.2) 33 (17.7) 0.74 79 (17.7) 35 (18.8) 0.73 Nitrate 439 (98.2) 182 (97.8) 0.75 266 (59.5) 107 (57.5) 0.66 HMG-CoA inhibitor 400 (89.5) 147 (79.0) 0.001 388 (86.8) 143 (76.9) 0.003 Diuretics 147 (32.9) 59 (31.7) 0.85 83 (18.6) 38 (20.4) 0.58 Unfractionated heparin 442 (98.9) 183 (98.4) 0.70 LMWH 314 (70.2) 101 (54.3) <0.001 Abciximab 211 (47.2) 34 (18.3) <0.001 Tirofiban 12 (2.7) 13 (7.0) 0.022 STEMI, ST-segment elevation myocardial infarction; NSTEMI, non-st-segment elevation myocardial infarction; ACE inhibitor, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; HMG-CoA, 3-hydroxy-3-methylglutaryl coenzyme A; LMWH, low-molecular-weight heparin. 행한혈액검사에서심근효소치는 I군에서높게나타났다 [troponin I (74.8±88.4 vs. 24.2±37.9 ng/ml, p<0.001), troponin T (7.8±9.5 vs. 2.7±4.2 ng/ml, p<0.001), creatine kinase (2,060.9± 2,046.4 vs. 742.0±960.4 U/L, p<0.001), creatine kinase-mb (126.7±126.1 vs. 51.6±88.5 U/L, p<0.001)]. 고감도 C-반응성단백치는 I군에서 2.4±3.6 mg/dl, II군에서 1.6±2.1 mg/dl 로 I 군에서높았으며 (p=0.008), N말단뇌나트륨이뇨펩티드수치는 II군에서높았다 (2,465±5,221 vs. 3,737±7,565 pg/ml, p< 0.001, 표 1). 입원시와퇴원시 cilostazol은 I군에서처방된횟수가많았으며 [339 (75.8%) vs. 112 (60.2%), p<0.001, 328 (73.4%) vs. 115 (61.8%), p=0.004)], HMG coa reductase inhibitor 역시 I군에서처방이많았다 [400 (89.5%) vs. 147 (79.0%), p=0.001, 388 (86.8%) vs. 143 (76.9%), p=0.003, 표 2]. 2. 초기치료전략과관상동맥조영술소견 I군의 380예 (85.0%) 에서일차성경피적관동맥중재술을시행하였으며, 32예 (7.2%) 에서혈전용해술을시행하였다. II군에서내원 48시간이내경피적관동맥중재술을시행한예는 124예 (66.7%) 였으며, 54예 (29.0%) 에서 48시간이후에시행하였다. 양군에서보존적치료를택한경우는각각 30 예 (6.7%), 8예 (4.3%) 였다 ( 표 3). 관상동맥조영술소견상세혈관을침범한경우나좌주간지를침범한빈도수는양군에차이가없었으며, 경색관련동맥이좌전하행지인경우가 I군에서 215예 (50.4%), II군에서 65예 (38.0%) 로 I군에서더높았다 (p=0.007). 좌회선지는각각 10.3%, 28.7% 로 II군에서높았다 (p<0.001). 병변은 ACC/AHA 기준 B1의형태가 I군에서많았다 [156예(36.5%) vs. 41예 (22.3%), p<0.001]. 처음관상동맥조영술시 TIMI flow 등급상 0을보이는경우가 I군에서많았다 [224예(52.5%) vs. 51예 (30.0%), p<0.001, 표 3]. 관상동맥조영술을시행한경우내원시부터풍선확장시까지의시간 (door to balloon time) 은 I군에서 323.9±863.0분, II 군에서 2,354.2±2,883.9분으로 I군에서더짧았다 (p<0.001). 시술후 TIMI flow 등급 3을보이는경우는 I군에서 399예 (94.3%), II군에서 154예 (90.1%) 로 I군에서더많았으며 (p< 0.001), total revascularization된경우도 I군에서유의하게많았다 [333예(78.0%) vs. 117예 (63.6%), p<0.001, 표 4]. 3. 입원기간내합병증과추적관찰시나타난주요심장사건입원기간내합병증발생비율은사망이 I군에서 17예 - 585 -
- The Korean Journal of Medicine: Vol. 77, No. 5, 2009 - Table 3. Therapeutic strategies and angiographic variables in the STEMI and NSTEMI groups STEMI (n=447) NSTEMI (n=186) p Treatment, n (%) Primary PCI 380 (85.0) Rescue PCI after thrombolysis 32 (7.2) Elective PCI 5 (1.1) Early invasive treatment 124 (66.7) Early conservative treatment 54 (29.0) Medical treatment 30 (6.7) 8 (4.3) 0.276 Coronary artery disease, n (%) 1 vessel 219 (51.2) 69 (39.8) 0.002 2 vessels 105 (24.7) 50 (29.0) 0.544 3 vessels 79 (18.5) 39 (23.1) 0.503 Left main, isolated 0 (0) 2 (1.1) 0.091 Left main, complex 24 (5.6) 13 (7.0) 0.579 Infarct-related artery, n (%) Left main stem 7 (1.6) 5 (2.9) 0.34 Left anterior descending artery 215 (50.4) 65 (38.0) 0.007 Right coronary artery 161 (37.7) 52 (30.4) 0.11 Left circumflex artery 44 (10.3) 49 (28.7) <0.001 Lesion type *, n (%) B1 156 (36.5) 41 (22.3) <0.001 B2 120 (28.1) 56 (30.4) 0.560 C 151 (35.4) 74 (40.4) 0.236 TIMI flow grade, n (%) 0 224 (52.5) 51 (30.0) <0.001 1 18 (4.2) 7 (3.8) 0.814 2 89 (20.8) 53 (31.1) 0.037 3 96 (22.5) 60 (35.1) 0.009 STEMI, ST-segment elevation myocardial infarction; NSTEMI, non-st-segment elevation myocardial infarction; PCI, percutaneous coronary intervention; TIMI, thrombolysis in myocardial infarction. * Lesion type according to the American College of Cardiology/American Heart association classification. (3.8%), II군에서 6예 (3.2%) 였으며심인성사망은 I군 16예 (3.6%), II군 5예 (2.7%) 로유의한차이는없었다. 비심인성사망은각각 1예로주요출혈에의한쇼크, 폐렴으로인한패혈성쇼크가원인이었다. 심인성쇼크 [49예(11.0%) vs. 13예 (7.2%)], IABP 삽입 [40예(8.9%) vs. 9예 (4.8%)], CABG 시행 [9 예 (2.0%) vs. 5예 (2.7%)] 여부에는차이는없었으나방실차단은 I군에서 35예 (7.8%), II군에서 2예 (1.1%) 로 I군에서발생비율이많았다 (p<0.001). 그외 STEMI에서출혈 8예, 폐혈증 1예, 아나필락시스 1예발생하였으며, NSTEMI에서급성신 부전, 출혈이 1예발생하였다 ( 표 5). 치료시작후 6개월추적관찰결과상 I군에서 406예, II군에서 166예가가능하였으며, 나머지는사망, 추적관찰실패로인해중도탈락되었다. 6개월관찰결과사망은 I 군에서 19예 (4.5%), II군에서 13예 (7.5%) 로양군에서차이는없었다. 급성심근경색의재발이 I군에서 4예 (1.0%) 보였으며, 재관류중재술이 I군에서 39예 (9.6%), II군에서 13예 (7.8%) 에서시행되었으며양군에서차이는없었다 ( 표 6). 1년추적관찰결과에서 I군에서 7예, II군에서 7예가추가로탈락하였으며, 사 - 586 -
- Min Chul Kim, et al. Prognosis in patients with acute myocardial infarction - Table 4. Procedural characteristics in the STEMI and NSTEMI groups Variable STEMI (n=447) NSTEMI (n=186) p Door to balloon time (minutes) 323.9±863.0 2354.2±2883.9 <0.001 Before 90 (minutes) 71.85±13.16 81.00±4.53 0.127 After 90 (minutes) 710.43±1282.69 2429.96±2901.27 <0.001 Stent length (mm) 25.4±5.2 24.0±6.4 0.010 Stent diameter (mm) 3.2±0.4 3.2±0.6 0.001 Numbers of stents implanted per patients 1.6±0.9 1.6±1.1 0.007 Final TIMI flow grade, n (%) 0 7 (1.7) 5 (4.7) 0.363 1 4 (0.9) 1 (0.5) 0.614 2 13 (3.1) 5 (4.7) 0.812 3 399 (94.3) 154 (90.1) 0.049 Procedural success, n (%) 403 (94.4) 150 (81.5) <0.001 Revascularization, n (%) Total revascularization 333 (78.0) 117 (63.6) <0.001 Revascularization of single IRA 223 (52.2) 95 (51.6) 0.930 Revascularization of only IRA in multi-vessel 72 (16.9) 32 (17.4) 0.907 Multi-vessel revascularization 115 (26.9) 26 (14.1) 0.001 No revascularization of IRA 14 (3.3) 18 (9.8) 0.002 STEMI, ST-segment elevation myocardial infarction; NSTEMI, non-st-segment elevation myocardial infarction; TIMI, thrombolysis in myocardial infarction; IRA, infarct related artery. Table 5. In-hospital outcomes in the STEMI and NSTEMI groups In-hospital outcome, n (%) STEMI (n=447) NSTEMI (n=186) p Ventricular fibrillation 6 (1.3) 0 (0) 0.187 Ventricular tachycardia 21 (4.7) 3 (1.6) 0.070 Cardiogenic shock 49 (11.0) 13 (7.2) 0.143 IABP insertion 40 (8.9) 9 (4.8) 0.078 Coronary artery bypass graft 9 (2.0) 5 (2.7) 0.599 Atrioventricular block 35 (7.8) 2 (1.1) <0.001 Bradycardia 2 (0.4) 1 (0.5) 0.145 Atrial fibrillation 3 (0.7) 0 (0) 0.559 Death 17 (3.8) 6 (3.2) 0.819 Cardiogenic 16 (3.6) 5 (2.7) 0.568 Non-cardiogenic 1 (0.2) 1 (0.5) 0.521 Others 10 (2.2) 2 (1.1) 0.524 STEMI, ST-segment elevation myocardial infarction; NSTEMI, non-st-segment elevation myocardial infarction. 망률 (4.8% vs. 8.1%), 재관류중재술시행 (12.3% vs. 10.1%) 의비율에있어서양군에서차이는없었다. CABG의경우 1년추적관찰에서 II군에서 1예 (0.6%) 시행하였다 ( 표 6). 양군의 1년생존과주요심장사건발생의 Kaplan-Meier curve 에유 의한차이는없었다 ( 그림 1). 4. 다변량회귀분석을이용한예후인자 다변량회귀분석결과에서 1 년추적기간동안의주요심 - 587 -
- 대한내과학회지 : 제 77 권제 5 호통권제 591 호 2009 - Table 6. Clinical outcomes at 6 months and 1 year follow-up in the STEMI and NSTEMI groups Follow-up at 6 months STEMI (n=406) NSTEMI (n=166) p Composite, n (%) 76 (18.7) 28 (16.8) 0.488 Death 33 (8.1) 15 (9.0) 0.366 Myocardial infarction 4 (1.0) 0 (0) 0.328 Re-percutaneous coronary intervention 39 (9.6) 13 (7.8) 0.631 Target vessel revascularization 5 (1.2) 1 (0.6) 0.677 Non-target vessel revascularization 16 (4.0) 4 (2.4) 0.458 Target lesion revascularization 18 (4.4) 8 (4.8) 0.827 Coronary artery bypass graft 0 (0) 0 (0) Follow-up at one years STEMI (n=399) NSTEMI (n=159) p Composite, n (%) 92 (23.0) 37 (23.2) 0.674 Death 38 (9.5) 20 (12.5) 0.567 Myocardial infarction 5 (1.3) 0 (0) 0.328 Re-percutaneous coronary intervention 49 (12.3) 16 (10.1) 0.559 Target vessel revascularization 7 (1.8) 1 (0.6) 0.450 Non-target vessel revascularization 18 (4.5) 4 (2.5) 0.341 Target lesion revascularization 22 (5.5) 7 (4.4) 0.677 Coronary artery bypass graft 0 (0) 1 (0.6) 0.285 STEMI, ST-segment elevation myocardial infarction; NSTEMI, non-st-segment elevation myocardial infarction; MACE, major adverse cardiac event. Figure 1. One-year Kaplan- Meier survival curves according to the type of myocardial infarction. MACE, major adverse cardiac events. 장사건에영향을미치는인자는 I군에서당뇨, 흡연, 내원시좌심실기능부전 (EF<0.4) 및 troponin I level이었으며 ( 표 7), II군에서당뇨, 흡연, 내원시좌심실기능부전 (EF<0.4) 이었다 ( 표 8). 고찰최근한국에서급성심근경색증등의급성관동맥증후군 (acute coronary syndrome, ACS) 은증가하고있으며성인에서주요사망원인이되고있다. 임상적으로 STEMI의경우내원시활력징후가불안정한경우가많고, NSTEMI에비해조기에치명적인결과를낳는경우가많은것으로알려져있다 9). 현재까지 STEMI와 NSTEMI의입원중사망률, 장기추적관찰에대해분석된자료는부족한실정이다. Steg 등 10) 은 3개월간의관찰에서 NSTEMI, 불안정성협심증 (unstable angina pectoris, UAP) 에비해 STEMI의높은사망률을보고하 - 588 -
- 김민철외 19 인. 급성심근경색증환자의예후 - Table 7. Multivariate predictors of 12-month MACE in STEMI p 95% confidence interval Lower Upper Odds ratio Hypertension 0.135 0.738 2.024 1.223 Diabetes 0.044 1.485 3.464 1.843 Smoking 0.041 1.629 2.196 2.063 Hyperlipidemia 0.151 0.417 1.145 0.691 Prior CAD 0.096 0.303 1.438 1.438 Familial history of CAD 0.863 0.235 3.364 1.890 Cardiogenic shock 0.995 0.114 8.649 0.994 IABP insertion 0.075 0.012 1.231 0.124 Door to balloon time (> 90 minutes) 0.304 0.455 1.278 0.763 Low left ventricular EF (< 40%) 0.002 1.468 5.283 2.785 TnI (at admission) 0.047 1.001 1.113 1.683 CK-MB (at admission) 0.137 0.995 1.001 0.998 MACE, major adverse cardiac events; MI, myocardial infarction; CAD, coronary artery disease; IABP, intra-aortic balloon counter pulsation; EF, ejection fraction; TnI, troponin-i; CK-MB, Creatine kinase-mb. Table 8. Multivariate predictors of 12-month MACE of NSTEMI p 95% confidence interval Lower Upper Odds ratio Aging 0.277 0.965 1.035 0.999. Prior CAD 0.142 0.235 1.441 0.582 Hypertension 0.460 0.456 1.287 1.521 Diabetes 0.041 1.259 2.270 1.882 Hyperlipidemia 0.639 0.356 1.885 0.819 Smoking 0.042 1.390 2.954 2.874 Familial history of CAD 0.084 0.883 13.283 1.559 Cardiogenic shock 0.156 0.029 1.759 0.227 IABP insertion 0.055 0.979 8.015 2.801 TnI (at admission) 0.139 0.997 1.021 1.009 Low left ventricular EF (< 40%) 0.033 1.096 8.524 3.057 MACE, major adverse cardiac events; MI, myocardial infarction; CAD, coronary artery disease; IABP, intra aortic balloon counter pulsation; TnI, troponin-i; EF, ejection fraction. 였고, Rogers 등 11) 은 ACS의 90일사망률은다르지않다고하였다. Rosengren 등 12) 은 9개월간의연구에서고령의 ACS 환자군에서 STEMI 발현율이적은반면, 사망률은높은것으로설명하고있으며, Goldberg 등 13) 은 6개월동안시행된연구에서 UAP에대한 STEMI, NSTEMI의불량한예후를보고하였다. 최근몇몇연구에서두질환군의추적관찰후예후에대해분석하여사망률등에있어유사한것으로보고하고있다. Montalescot 등 4) 은 1년간관찰한연구에서 STEMI와 NSTEMI의비슷한예후를보고하였고, Abbott 등 5) 은 5년간의후향적연구에서비록 STEMI가높은원내사망률을보이지만, 장기예후는심근경색의종류에관계없다고보고하였다. Cox 등 6) 의연구에서도경피적관동맥중재술후 STEMI, NSTEMI의 1년예후는비슷하다고하였다. 본연구에서는두집단에대해 1년추적관찰을통해주요심장사건의발현에대한비교와더불어이에영향을미치는예후인자에대해조사하였다. - 589 -
- The Korean Journal of Medicine: Vol. 77, No. 5, 2009 - Rasoul 등 14) 은급성심근경색증환자의예후에관한연구에서 NSTEMI의경우 STEMI에비해고령환자의비율이높고, 동반질환비율이유의하게높으나관상동맥조영술이시행된비율이적고, 1년사망률이높음을보고하였다. 관상동맥조영술을시행한급성심근경색증환자에서 statin을투여한경우 restenosis, target lesion revascularization rate, MACE 감소를보였다 15). 본연구에서는 NSTEMI 환자군의경우 statin 처방률에있어서 STEMI군에비해유의하게적고, 조기에관상동맥조영술을시행하는침습적치료군에서의비율에있어서도 STEMI군에비해적어양군의예후에영향을미칠수있어추후보완이필요하다. 위험인자로는 STEMI, NSTEMI 모두흡연 (45% vs. 30%), 고혈압 (38% vs. 44%), 고지혈증 (31% vs. 37%), 당뇨 (14% vs. 16%), 심근경색과거력 (14% vs. 19%) 등으로흡연이가장흔한위험인자였다. NSTEMI에서내원시의심근효소치는증상발현시부터내원시까지의시간에상관없이높을수록장기사망률과비례하다는보고가있다 16-19). 본연구에서는내원시양군에서측정된 CK-MB, troponin-i 수치가 STEMI에서유의하게높았으나 1년장기추적결과상예후에차이가없었다. STEMI군의경우조기에재혈관화가시행된비율이높아이로인한경색크기의감소가영향을끼쳤을가능성이있으나다른요인들의영향도배재하기어려우므로장기추적관찰이필요하다. 일반적으로조기에관동맥성형술등의재관류술을시행할경우장기예후가개선되는것으로보고되었으나 20-23), 중간위험군, 저위험군으로분류된경우조기관동맥성형술에도불구하고퇴원후 10개월사망률에차이가없다는보고도있다 24). 본연구에서는 STEMI의경우 85.0% 에서일차성경피성관동맥성형술이시행되었으며, NSTEMI 경우조기침습적치료가시행된비율은 66.7% 의비율이었으나예후에는큰영향을미치지않았다. 혈전용해술이나관동맥성형술을시행하지않은경우는전신상태악화로인한경우가많았으며, 그외 CABG를시행한경우가 14예, 관동맥조영술상유의한협착병변이없는경우, 환자나보호자가거절한경우, coronary artery spasm을보였던경우들이다. 내원시부터풍선확장시까지의시간은급성심근경색의치료결과에중요한영향을미치는인자이다 25,26). 본연구에서내원시부터풍선확장시까지의시간은 STEMI에서유의하게적었으며 STEMI의예후에주요예측인자였다. 고위험관상동맥중재술시에 glycoprotein IIb/IIIa receptor blocker를사용한경우 MACE 를추적관찰한연구에서주요 예측인자는병변혈관수와중재술후낮은 TIMI 혈류등급이었다 27). 본연구에서 STEMI의경우중재술후 TIMI 혈류등급 3을보인경우가더많았으나 (p=0.049) 장기간의추적관찰을통한보다정확한예측이필요하다. STEMI의경우 NSTEMI 에비해입원기간내합병증발생비율이더높은것으로보고있다. 본연구에서는입원기간내사망률을비교해보았을때각각 17예 (3.8%), 6예 (3.2%) 로차이가없었다. 내원당시심인성쇼크를보였던경우와 IABP 삽입이필요하였던경우는양군에서유의한차이는없었으나 STEMI군에서심인성쇼크환자에서주요심장사건과관련된인자라고알려진 C-반응성단백, 높은 troponin-i 수치를보여 1년이상의추적관찰이필요하다 28). 급성관상동맥증후군환자를평균 10개월간추적관찰한 Nikus 등 29) 의연구에서는 NSTEMI의경우가사망률이더높았으며, Allen 등 30) 의연구에서는 1년간급성심근경색환자를추적관찰한결과동반질환이많을수록가이드라인에서제시한기본치료의빈도가감소할수록 NSTEMI 의장기예후가좋지않았으며, 치료의강도를동일시했을때에 STEMI 의사망률이높은것으로나타났다. 1년간의추적관찰기간을가진본연구에서는주요심장사건의발생에유의한차이가없었으며, 흡연, 고혈압, 당뇨가예후인자였다. 본연구의제한점으로는단일기관에서시행한후향적인연구로서 1년의추적기간으로서다른연구에비해장기추적기간이연장되지못하였다는점이다. 보다대규모, 장기간동안의전향적연구가필요하며이로인해여러인자들의예후에대한영향과양군의예후에대한예측의정확도를높일수있을것이다. 본연구에서는급성심근경색증환자에서치료후 1년간추적관찰을통해주요심장사건의발생과임상예후에미치는인자를비교분석하였으며, 그결과주요심장사건의발생에는양군에서차이가없었으며, 예후에영향을미치는인자로는흡연, 당뇨, 내원시낮은좌심실구혈률이었으며 troponin I는 STEMI에서만예후인자였다. 요약목적 : 급성 ST분절상승심근경색증 (ST-segment elevation myocardial infarction, STEMI) 이 ST분절비상승심근경색증 (non-st-segment elevation myocardial infarction, NSTEMI) 에비해상대적으로좋지않은예후를보일것으로예상되나다양한임상연구결과가보고되고있다. 본연구에서는 ST - 590 -
- Min Chul Kim, et al. Prognosis in patients with acute myocardial infarction - 분절상승여부에따른임상적특징과치료내용및예후를비교하고각각의질환의예후에미치는인자를비교분석하였다. 방법 : 2005년 11월부터 2006년 12월까지급성심근경색증으로내원한환자 633예 (I군: STEMI 447예, II군 : NSTEMI 186예 ) 를 1년간추적관찰하여주요심장사건발생을조사하고, 이에영향을미치는인자를조사하였다. 주요심장사건으로는사망, 심근경색의재발, 재관류술, 관상동맥우회술을기준으로하였다. 퇴원후 1개월, 6개월, 1년째외래에서추적관찰하였고, 6개월째추적관상동맥조영술을시행하였다. 결과 : 관상동맥질환의주요위험인자로는흡연 (I군: 66.4%, II군 : 59.1%), 고혈압 (I군: 46.1%, II군 : 49.5%), 당뇨 (I군: 26.8%, II군 : 33.3%) 순으로빈도가높았으나양군에유의한차이는없었다. I군의 85.0% 가일차적경피적관동맥중재술을시행받았으며, 7.2% 에서혈전용해술을시행하였다. II군에서는 66.7% 의대상환자에서입원 48시간이내에관상동맥조영술을시행하였다. 내원시부터풍선확장시까지걸린평균시간은 I군에서 323.9분, II군에서 2,354.2분으로 I군에서더짧았다. 입원기간동안의사망률은양군에서유의한차이가없었으며치료후추적관찰에서 6개월및 1년후주요심장사건의발생률은양군에서차이가없었다. 주요심장사건에미치는인자들은 I군에서흡연, 당뇨여부, 내원시좌심실기능저하, troponin I이었고, II군에서는흡연, 당뇨여부, 내원시좌심실기능저하였다. 결론 : I군과 II군간의병원내사망률및 1년동안의주요심장사건의발생률에차이를보이지않았다. 예후인자중 troponin I level은 I군에서만예후인자였다. 중심단어 : ST 분절비상승심근경색증 ; ST 분절상승심근경색증 ; 예후 REFERENCES 1) Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, Hochman JS, Krumholz HM, Lamas GA, Mullany CJ, Pearle DL, Sloan MA, Smith SC Jr. 2007 Focued update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 117:296-329, 2007 2) Anderson JL, Antman EM, Adams CD, Bridges CR, Califf RM, Casey DE Jr, Chavey WE 2nd, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wegner NK, Wright RS, Smith SC Jr, Jacobs AK, 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 myocaridal infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 116:e148-e304, 2007 3) Maddox TM, Reid KJ, Rumsfeld JS, Spertus JA. One-year health status outcomes of unstable angina versus myocardial infarction: a prodpective, observational cohort study of ACS survivors. BMC Cardiovasc Disord 7:28, 2007 4) Montalescot G, Dallongeville J, Van Belle E, Rouanet S, Baulac C, Degrandsart A, Vicaut E. STEMI and NSTEMI: are they so different?: 1 year outcomes in acute myocardial infarction as defined by the ESC/ACC definition (the OPERA registry). Eur Heart J 28:1409-1417, 2007 5) Abbott JD, Ahmed HN, Vlachos HA, Selzer F, Williams DO. Comparison of outcome in patients with ST-elevation versus non-st-elevation acute myocardial infarctiontreated with percutaneous coronary intervention (from the National Heart, Lung, and Blood Institute Dynamic Registry). Am J Cardiol 100:190-195, 2007 6) Cox DA, Stone GW, Grines CL, Stuckey T, Zimetbaum PJ, Tcheng JE, Turco M, Garcia E, Guagliumi G, Iwaoka RS, Mehran R, O Neill WW, Lansky AJ, Griffin JJ. Comparative early and late outcomes after primary percutaneous coronary intervention in ST-segment elevation and non-st-segment elevation acute myocardial infarction (from the CADILLAC trial). Am J Cardiol 98:331-337, 2006 7) Mukherjee D, Fang J, Chetcuti S, Moscucci M, Kline-Rogers E, Eagle KA. Impact of combination evidence-based medical therapy on mortality in patients with acute coronary syndromes. Circulation 109:745-749, 2004 8) Allen LA, O Donnell CJ, Guigliano RP, Camargo CA Jr, Lloyd-Jones DM. Care concordant with guidelines predicts decreased long-term mortality in patients with unstable angina pectoris and non-st-elevation myocardial infarction. Am J Cardiol 93:1218-1222, 2004 9) Roe MT, Ohman EM, Pollack CV Jr, Peterson ED, Brindis RG, Harrington RA, Christenson RH, Smith SC Jr, Califf RM, Gibler WB. Changing the model of care for patients with acute coronary syndromes. Am Heart J 146:605-612, 2003 10) Gabriel Steg P, Iung B, Feldman LJ, Maggioni AP, Keil U, Deckers J, Cokkinos D, Fox KA. Determinants of use and outcomes of invasive coronary procedures in acute coronary syndromes: results from ENACT. Eur Heart J 24:613-622, 2003 11) Rogers WJ, Canto JG, Barron HV, Boscarino JA, Shoultz DA, Every NR. Treatment and outcome of myocardial infarction in - 591 -
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