심방세동에서의 항응고요법

고점석 ( Jum Suk Ko ),김남호 ( Nam Ho Kim ) 대한내과학회 2011 대한내과학회지 Vol.81 No.4

Atrial fibrillation (AF) is the most commonly occurring arrhythmia. An antithrombotic agent is considered mandatory as part of the management in most patients with AF. It has been conclusively demonstrated that long-term anticoagulation therapy can significantly reduce the risk of stroke in patients with non-valvular AF. While vitamin K antagonists (VKAs) such as warfarin are highly effective, they possess numerous limitations that curtail their use, or make their use challenging for clinicians and patients. A new generation of anticoagulants are being investigated in clinical trials in patients with AF. One or more of these agents have the potential to either replace or act as alternatives to VKA therapy in AF. This review summarizes the recent accumulated evidence on anticoagulation to prevent the thromboembolism in patients with non-valvular AF. (Korean J Med 2011;81:434-443)

심방세동 환자에서 혈전색전성 합병증의 새로운 위험인자

조천영 ( Cheon Yeong Cho ),정대호 ( Dae Ho Jung ),고점석 ( Jum Suk Ko ),윤남식 ( Nam Sik Yoon ),이상록 ( Sang Rok Lee ),임상엽 ( Sang Yup Lim ),박형욱 ( Hyung Wook Park ),손일석 ( Il Suk Sohn ),김계훈 ( Kye Hun Kim ),홍영준 ( Youn 대한내과학회 2006 대한내과학회지 Vol.71 No.4

목적: 심방세동은 가장 흔한 지속성 부정맥이며 전신 혈전색전증의 가장 흔한 원인이다. 심방세동에서 혈전색전증은 사망률이 높고 심각한 불구를 초래하므로 예방이 무엇보다도 중요하며 이를 위해서는 위험인자의 정확한 규명이 필수적이다. 본 연구는 심혈관 질환 치료에 안지오텐신 전환효소 억제제, 안지오텐신-II 수용체 차단제, 스타틴 등이 활발히 사용된 이후에 심방세동의 혈전색전 위험인자에 새로운 변화가 있는지 조사하고 심방세동에서 혈전색전 위험의 증가 기전을 규명하기 위해 시행되었다. 방법: 혈전색전의 위험인자를 파악하기 위해 심방세동으로 치료받고 있는 환자 192명(61±11세, 남자 137)을 색전성 뇌경색증이 합병한 색전군(n=95명)과 합병하지 않은 비색전군(n=97명)으로 나누어 인구학적 특성, 동반 질환, 심전도 소견, 심초음파도 소견 및 치료 약제 등을 비교하였다. 혈전색전의 위험을 증가시키는 기전을 규명하기 위해서는 심장 율동이 정상인 25명과 심방세동 환자 71명[발작성: 21명(46±18세), 지속성: 19명(59±10세), 영속성: 31명(51±12세)]을 대상으로 내피세포기능을 반영하는 von Willebrand factor (vWF; factor 8 related antigen), 전신 염증 상태를 나타내는 백혈구 수, 적혈구 침강속도, 고예민성 C-reactive protein (hsCRP), 혈액 응고계 상태를 반영하는 fibrinogen, fibrinogen degradation product, fibrin d-dimer 등을 측정하여 비교하였다. 결과: 1. 심방세동에서 혈전색전의 위험인자 심방세동 환자 중 색전군이 비색전군에 비해 의미있게 나이가 많았고(p<0.05), 동반 질환으로 고혈압, 당뇨병, 이상지질혈증, 흡연이 색전군에서 의미있게 더 많았다(각각 p<0.05). 심전도에서는 심방세동파의 크기가 1mm 미만인 경우가 색전군에서 의미있게 많았고(p<0.05), 심초음파도에서는 좌심실기능부전(좌심실 구혈률 <40%), 판막질환, 심근증의 빈도가 색전군에서 의미있게 높았고(각각, p<0.05), 좌심방 직경도 색전군에서 의미있게 컸다(p<0.05). 색전군에서 비색전군에 비해 항응고제(p<0.01), 안지오텐신-II 수용체 차단제(p<0.05), 스타틴(p<0.05)을 복용한 경우가 의미게 적었다. 2. 심방세동에서 혈전색전 위험 증가의 기전 심방세동 환자에서 vWF-factor 8 related antigen의 농도는 좌심실부전(EF<40%), 고혈압, 고령(>65세), 당뇨병, 승모판협착증이 동반된 경우에 의미있게 증가하였다(각각, 165±53% vs. 116±49%, p<0.05; 135±22% vs. 119±24%, p<0.05; 136±55% vs. 113±51%, p<0.05; 138±59% vs. 120±52%, p<0.05; 151±34% vs. 120±33%, p<0.05). 또한 vWF-factor 8 related antigen의 농도는 나이(r=0.392, p<0.001), 좌심방 크기(r=0.375, p<0.01), 좌심실 수축기말 직경(r=0.283, p<0.05), 좌심실 확장기말 직경(r=0.234, p<0.05), 좌심실구혈률(r=0.255, p<0.05), 심방세동의 유병 기간(r=0.341, p<0.01) 등과 의미있는 상관관계가 있었다. 전신 염증 표지자는 혈전색전 위험인자 동반 유무에 따른 차이가 없었다. 혈중 fibrinogen 농도는 나이(r=0.368, p<0.001), NYHA class (r=0.314, p<0.01)와 의미있는 상관관계가 있었고 d-dimer는 NYHA class와 의미있는 상관관계가 있었다(r=0.505, p<0.001). 결론: 본 연구 결과로 기존의 혈전색전 위험인자에 더하여 흡연, 심전도에서 미세 심방세동파(<1 mm), 안지오텐신-II 수용체 차단제나 스타틴의 무복용 등이 심방세동의 새로운 혈전색전 위험인자가 될 수 있음을 알 수 있었다. 심방세동에서 혈전색전의 증가는 주로 심내막과 동맥의 내피세포 기능 저하에 의해 일어남을 알 수 있었다. Background: Atrial fibrillation (AF) is the most common cause of embolic cerebral infarction. This study was performed to determine new risk factors and the mechanism underlying thromboembolism (TE) in patients with AF. Methods: 192 patients (M:F=137:55, 61±11 years) with AF were randomly selected and divided into a TE (n=95) and non-TE group (n=97). Another 71 patients with AF (M:F=38:33, 55±14) were studied for endothelial function by measuring the level of von Willebrand factor (vWF; factor 8 related antigen), inflammation by WBC, ESR, and high sensitive CRP and coagulation system by fibrinogen, fibrinogen degradation product and fibrin d-dimer; the results were compared with 25 patients with normal sinus rhythm. Results: The TE group was older than non-TE group. Hypertension (HTN), diabetes mellitus (DM), hypercholesterolemia, smoking and fine AF (AF wave amplitude <1 mm) were more frequent in the TE group. Mitral valvular disease, an ejection fraction <40% and dilated cardiomyopathy were more frequent in the TE group and the left atrial (LA) dimension was greater in the TE group. The use of anticoagulants, an angiotensin-II receptor blocker and statins were less frequently observed in the TE group. The vWF-factor 8 related antigen was higher in patients with advanced age, LV dysfunction, HTN, DM, mitral stenosis and positively correlated with age, LA dimension, LV end-diastolic and end-systolic dimension, ejection fraction, NYHA class and AF duration. The fibrinogen level was positively correlated with age, NYHA class, LA dimension and d-dimer with NYHA class. Markers for inflammation or coagulation were not significantly different in the atrial fibrillation and the sinus rhythm group. Conclusions: No use of an angiotensin-II receptor blocker or statin and fine AF may be new risk factors for TE in patients with AF. The TE risk factors are thought to increase TE by impairing endothelial function.(Korean J Med 71:371-380, 2006)

관상동맥 중재술을 받은 급성 심근경색증 환자의 저밀도 지단백 콜레스테롤 수치와 임상경과

조경훈 ( Kyung Hoon Cho ),정명호 ( Myung Ho Jeong ),박근호 ( Keun Ho Park ),이민구 ( Min Goo Lee ),고점석 ( Jum Suk Ko ),이신은 ( Shin Eun Lee ),강원유 ( Won Yu Kang ),김수현 ( Soo Hyun Kim ),심두선 ( Doo Sun Sim ),윤남식 ( Nam Si 대한내과학회 2009 대한내과학회지 Vol.76 No.6

목적: 최근에 인구의 고령화 및 생활습관의 변화로 심근경색증, 협심증 등의 관상동맥 질환은 최근 10여 년간 한국성인에서 급증하여 주요 사망원인이 되고 있다. 관상동맥 질환의 위험인자로는 흡연, 고혈압, 당뇨병, 고지혈증 등이 잘 알려져 있으며, 이러한 위험인자를 조절하는 것이 관상동맥질환의 예방과 치료에 필수적이다. 또한, 관상동맥 질환의 치료로써 경피적 관상동맥 풍선 확장술과 스텐트 삽입술과 같은 경피적 관상동맥 중재술(percutaneous coronary intervention: PCI)이 많이 시행되고 있다. 그러므로 이러한 위험인자들과 PCI 후 임상경과에 대한 연구는 급성심근 경색증환자의 예방 및 치료에 중요하다. 본 연구에서는 LDL-C이 높을수록 관상동맥 중재술 후 임상경과에 어떠한 영향을 미치는지 파악하고자 하였다. 방법: 2006년 1월부터 2007년 12월까지 전남대학교병원에 내원하여 급성 심근경색증으로 PCI 후 1년간 추적관찰 하였던 867명(62.6±12.0세, 남자; 70%)을 LDL-C 수치에 따라 다섯 군으로 나누어서 각 군 간에 관상동맥 중재술 후 임상경과와 그에 대해 영향을 끼칠 수 있는 요인들을 분석 검토하였다. 결과: 대상 환자의 위험인자는 흡연(63%), 고혈압(46%), 당뇨병(28%) 순이었다. LDL-C 수치가 높을수록 허혈성 심장질환의 과거력이 적었고(p=0.036), 크레아티닌 청소율은 증가하는 추세(p=0.039)였으며, hsCRP는 감소추세(p=0.000)였다. 160 mg/dL 미만에서 LDL-C이 증가할수록 NT-proBNP는 감소하였으며(p=0.002), LDL-C이 70 mg/dL 미만에서 관상동맥 중재술 시술 후 TIMI flow grade III가 유의하게 적었다(p=0.001). LDL-C 수치가 160 mg/dL 이상인 그룹을 제외하면, LDL-C이 높아질수록 PCI 후 병원 내 합병증 발생이 적었다(linear p=0.010). 1개월간 추적관찰하였을 때 LDL-C각 군 간에 임상경과에 차이는 없었다. 1년 동안 추적관찰하였을 때 LDL-C이 100~129 mg/dL인 군에 비해 130~159 mg/dL인 군에서 주요 심장 사건 발생률은 낮았으나(p=0.033), 사망률에는 유의한 차이는 없었다. 1년 간 사망률에 독립적인 예측인자로는 좌심실 구혈률(p<0.000), hsCRP (p=0.011), 나이(p=0.047), 크레아티닌 청소율(p=0.039) 등이었다. 결론: 관상동맥 중재술 시술을 받은 급성 심근경색증 환자에서 낮은 저밀도 지단백 콜레스테롤 수치를 보인 환자에서 병원 내 합병증 발생률이 높았으며, 장기적 임상경과와 무관하였다. Background/Aims: This study examined the relationship between the low-density lipoprotein cholesterol (LDL-C) level and clinical outcome after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). Methods: Between January 2006 and December 2007, 867 patients (age, 62.6±12.5 years; males, 71%) undergoing a 1-year follow-up after PCI for AMI were divided into five groups according to the LDL-C level: <70, 70-100, 100-130, 130-160, and ≥160 mg/dL. Results: Smoking (63%), hypertension (46%), and diabetes mellitus (28%) were common risk factors. The history of ischemic heart disease decreased as the LDL-C level increased (p=0.036). Patients with lower LDL-C levels had lower creatinine clearance and higher high-sensitivity C-reactive protein (hsCRP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels. The rate of in-hospital complications after PCI declined with increases in the LDL-C level, except in patients with LDL-C >160 mg/dL (linear p=0.010). There was no correlation between the LDL-C level and the 30-day or 1-year clinical outcome after PCI. After multivariate adjustment, independent predictors of the 1-year mortality after PCI were left ventricular ejection fraction, hsCRP, age, and creatinine clearance. Conclusions: Higher LDL-C levels were related to fewer in-hospital complications, but there was no correlation between the LDL-C level and long-term clinical outcome after PCI in Korean patients with AMI. (Korean J Med 76:692-700, 2009)

증례 : 순환기; 흉선종이 동반된 중증 근육무력증 환자에서 발생한 완전 방실 전도 차단

김송이 ( Song I Kim ),김남호 ( Nam Ho Kim ),조훈길 ( Hoon Gil Jo ),김은경 ( Eun Kyoung Kim ),고점석 ( Jum Suk Ko ),이상재 ( Sang Jae Rhee ),윤경호 ( Kyeong Ho Yun ) 대한내과학회 2013 대한내과학회지 Vol.85 No.6

중증 근육무력증은 그 기전은 명확하지 않으나 드물게는 심장을 침범하여 심근염, 심부전증, 부정맥 등 다양한 임상양상을 나타낼 수 있다. 이 중 전도장애도 나타날 수 있는데, 완전 방실전도차단은 매우 드문 현상이다. 저자들은 안검하수 및 어지러움을 주소로 내원한 69세 남자 환자에서 흉선종을 동반한 중증 근육무력증과 완전 방실전도차단을 경험하였기에 문헌고찰과 함께 보고하는 바이다. Myasthenia gravis is an autoimmune disorder characterized by antibodies against acetylcholine receptors in skeletal muscle. Myocardial involvement can present as myocarditis, ventricular tachycardia, heart failure and sudden death. However, advanced heart block is a very rare symptom. We report the case of a 69-year-old male who experienced dizziness and ptosis for one-month prior. He was diagnosed with myasthenia gravis and thymoma accompanied by complete atrioventricular block. The dizziness disappeared after implantation of a permanent pacemaker and the advanced heart block was resolved after surgical removal of the thymoma. (Korean J Med 2013;85:619-622)

전북지역 급성 ST 분절 상승 심근경색증 환자의 119 이용 실태

우선호 ( Sun Ho Woo ),윤경호 ( Kyeong Ho Yun ),이미림 ( Mi Rim Lee ),김은경 ( Eun Kyoung Kim ),고점석 ( Jum Suk Ko ),이상재 ( Sang Jae Rhee ),이정미 ( Jeong Mi Lee ),김남호 ( Nam-ho Kim ),오석규 ( Seok Kyu Oh ) 대한내과학회 2016 대한내과학회지 Vol.90 No.6

목적: 급성 ST 분절 상승 심근경색증 환자에서 최초 의료접촉 방식 및 이에 따른 특성과 시간과의 관계를 조사했다. 방법: 전북 권역심혈관센터 데이터베이스에 등록된 527명의 일차적 관상동맥 중재시술을 받았던 급성 ST 분절 상승심근경색증 환자를 대상으로 의료 접촉 방식에 따른 일반적특징, 사회적 요인 및 시간 지연에 대한 예측 인자에 대해 조사했다. 결과: 전체 환자 중에서 28.8%만이 119를 이용했으며, 이들은 심부전, 심인성 쇼크 등의 임상 양상이 더 좋지 않았다. 최초 119를 이용하였어도 36.2%의 환자가 중재시술이 불가능한 병원으로 이송되었고 이들은 유의하게 증상 발생 후 관상동맥 중재술 시행까지 시간이 지연되었다(211.3 ± 358.0분vs. 320.2 ± 374.6분, p = 0.034). 증상 발생 후 관상동맥 중재술 시행까지 시간 단축의 독립적인 요인으로는 119를 이용(OR = 0.4, p < 0.001)하는 것과 이전 관상동맥 중재술 기왕력(OR = 0.4, p = 0.033)이었으며, 시간 지연의 독립적인 요인으로는 65세 이상의 고령(OR = 1.9, p = 0.003)과 중재술이 불가능한 병원을 먼저 내원한 경우(OR = 2.0, p < 0.001)였다. 결론: 전북 권역 심근경색증 환자들은 낮은 119 이용률을 보이며, 상당수가 중재시술이 불가능한 병원으로 이송되고 있다. 심근경색증에 대한 증상 인지율을 높이고 증상이 시작되면 즉시 119 구급차를 이용하여 중재시술이 가능한 병원으로 방문하도록 하는 홍보 및 교육이 필요할 것으로 생각된다. Background/Aims: The use of emergency medical services (EMSs) at the onset of pain, and the relationship between transport type and the treatment delay for acute ST-segment elevation myocardial infarction (STEMI) were evaluated using the Jeonbuk Regional Cardiovascular Center database. Methods: In total, 527 STEMI patients who underwent primary percutaneous coronary intervention (PCI) were enrolled in this study. Basic characteristics, socioeconomic variables, and delay factors were compared between patients that contacted an EMS as first medical contact (FMC) and patients that used other forms of FMC. Results: Only 28.8% of patients used EMS as their FMC. The patients that used EMS showed significantly shorter onset-to-balloon time than those who did not (250.7 ± 366.6 min vs. 405.9 ± 649.8 min, p = 0.001). However, 36.2% of patients that used EMS as FMC were transported to non-PCI-capable centers, which led to significantly prolonged onset-to-balloon time. Multivariate analysis revealed that transfer via another hospital (odds ratio [OR] 2.0, p < 0.001), EMS as FMC (OR 0.4, p < 0.001), age > 65 years (OR 1.9, p = 0.003), and previous history of PCI (OR 0.4, p = 0.033) were independent predictors of pre-hospital delay. Conclusions: EMS used as FMC at the onset of chest pain was an important factor for decreasing treatment delay in patients with STEMI. However, a small number of patients used EMS as FMC, and some patients that used EMS were transported to non-PCI-capable centers. Public campaigns and education are needed to raise the public awareness of STEMI and the use of EMSs. (Korean J Med 2016;90:507-513)

관상동맥 중재술을 받은 급성 심근경색증 환자에서 흡연 유무에 따른 임상경과

설수영 ( Soo Young Seol ),이숙자 ( Sook Ja Lee ),정명호 ( Myung Ho Jeong ),이정애 ( Jung Ae Rhee ),최진수 ( Jin Su Choi ),황승환 ( Seung Hwan Hwang ),고점석 ( Jum Suk Ko ),이민구 ( Min Goo Lee ),심두선 ( Doo Sun Sim ),박근호 ( Keu 대한내과학회 2011 대한내과학회지 Vol.80 No.5

Background/Aims: To analyze the clinical effects of continuing to smoke in patients with acute myocardial infarction (AMI), clinical outcomes of those continuing or ceasing smoking were compared. Methods: In total, 498 patients with AMI who underwent percutaneous coronary intervention (PCI) from January to December 2007 were enrolled. Of these patients, 407 (63.9±11.9 years, males 70%) with 1-year follow-ups were analyzed. Based on risk factors for smoking, patients were divided into two groups: group I (smokers, n=164, 57.9±11.2 years) and group II (nonsmokers, n=243, 68.0±10.6 years). Additionally, group I patients were subdivided by cessation of smoking after discharge: group IA (current smokers, n=95, 56.8±10.5 years) and IB (past smokers, n=69, 59.4±12.0 years). Clinical characteristics, coronary angiographic and procedural findings, and 1year major adverse cardiac events (MACE) were analyzed. Results: During the 1-year follow-up period, MACE developed in 112 patients (27.6%) and death in 42 patients (10.3%). In terms of smoking habits at admission, there was no significant difference in the 1-year MACE between current smokers (Group I) and nonsmokers (Group II). In the subgroup analysis, there were no significant difference in clinical characteristics between groups I Α and IΒ. Mortality was significantly higher in group IA than in group IB during the 1-year clinical follow-up (11% vs. 0%; p=0.005). Conclusions: Of the AMI patients who underwent PCI, mortality was significantly higher in current smokers than in past smokers after PCI.

관상동맥 중재술을 시술 받은 고령 환자들의 최근 10년간 임상 양상의 변화

박종춘 ( Jong Chun Park ),조정관 ( Jeong Gwan Cho ),안영근 ( Young Keun Ahn ),강정채 ( Jung Chaee Kang ),김주환 ( Ju Han Kim ),김민석 ( Min Suk Kim ),정명호 ( Myung Ho Jeong ),황슨환 ( Seung Hwan Hwang ),고점석 ( Jum Suk Ko ),이 대한내과학회 2010 대한내과학회지 Vol.79 No.6

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)

심방세동 환자에서 주요 항부정맥제의 전기생리 작용의 차이

장수영 ( Su Young Jang ),조정관 ( Jeong Gwan Cho ),정형기 ( Hyung Ki Jung ),기원주 ( Won Ju Ki ),이경진 ( Kyoung Jin Lee ),고점석 ( Jum Suk Ko ),이민구 ( Min Goo Lee ),박근호 ( Keun Ho Park ),심두선 ( Doo Sun Sim ),윤남식 ( Nam Si 대한내과학회 2011 대한내과학회지 Vol.80 No.6

Background/Aims: Drug-eluting stents (DES) are superior to bare metal stents (BMS) in reducing restenosis rates across a wide range of patients and lesion subsets.This study compared the clinical outcomes of DES versus BMS in patients with large coronary Methods: The study compared 134 patients (59.9±10.6 years, 90 men, 44 women) who underwent single vessel angioplasty with DESimplantation in large vessels with 115 patients (60.3±8.9 years, 82 men, 33 women) who received BMS. The clinical outcomes at 12 months were compared between groups. The study end points were major adverse cardiac events (MACE), including cardiac death, nonfatal myocardial infarction, and the need for target vessel and target lesion revascularization. Results: The baseline clinical coronary angiography and procedural characteristics were similar in both groups. The duration of dual antiplatelet therapy was longer in the DES group than in the BMS group (240±2.7 vs. 348±1.7 days, p=0.042). During the 12-month clinical follow-up, MACE were observed in 13 patients (11.3%) with BMS and 12 patients (9.0%) with DES (p=0.486). Conclusions: For coronary stents implanted in large coronary arteries, DES seems to be more favorable, although no significant differences were observed in the clinical outcomes between DES and BMS during a 1-year clinical follow-up. (Korean J Med2011;80:664-671)

ST분절 비상승 심근경색증 환자에서 증상발생 후 병원 도착 시간이 일년 후 사망률에 미치는 임상적 영향

이선옥 ( Sun Ok Lee ),오상은 ( Sang Eun Oh ),정명호 ( Myung Ho Jeong ),김현국 ( Hyun Kuk KIM ),전해정 ( Hae Jung Jeon ),최영자 ( Young Ja Choi ),김성수 ( Sung Soo Kim ),고점석 ( Jum Suk Ko ),이민구 ( Min Goo Lee ),심두선 ( Soo Sun 대한내과학회 2010 대한내과학회지 Vol.78 No.6

Background/Aims: Symptom-to-door time is associated with the prognosis for ST-segment elevation myocardial infarction. However, this value has not been a concern in patients with non-ST segment elevation myocardial infarction (NSTEMI). The aim of this study was to assess the relationship between symptom-to-door time and clinical outcomes in patients with NSTEMI. Methods: In total, 1,971 patients with NSTEMI (64.8±12.1 years, 23.6% women) were enrolled between Nov. 2005 and Jan. 2008. The patients were divided into two groups according to the time difference between the presentation of symptoms and first medical contact: group I (<12 hours, n=1433) and group II (>12 hours, n=538). One-year mortality rates were compared between the groups. Thrombolysis In Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) risk scores were calculated in all study patients. Results: The mean age was 64.4±12.2 years in group I and 65.6±12.0 years in group II (p=0.046). No significant differences existed between the two groups, except for the prevalence of hypertension, diabetes mellitus, initial systolic blood pressure, and initial serum creatinine levels. One-year mortality rates decreased significantly in group I patients [hazard ratio (HR)=1.35, 95% CI (confidential interval): 1.03~1.75, p=0.028] based on a multivariate Cox proportional analysis, which was adjusted by GRACE score, baseline characteristic variables, and predictors of a 1-year mortality in a univariate analysis. In intermediate-to high-risk patients (n=1,184, defined as having a TIMI risk score above 3 points), significant differences were observed in mortality rates between the two groups (HR=1.35, 95% CI: 1.02~1.80, p=0.037); the low-risk patients (n=787, HR=1.57, 95% CI: 0.80~3.05, p=0.188), however, showed no such differences. Conclusions: Symptom-to-door time was an independent long-term clinical predictor in patients with NSTEMI, especially in intermediate-to high-risk groups. (Korean J Med 78:717-724, 2010)