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)

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.

흡연을 하는 급성 심근경색증 환자에서 일년 후 사망 예측인자

설수영 ( Soo Young Seol ),정명호 ( Myung Ho Jeong ),이승헌 ( Seung Hun Lee ),손석준 ( Seok-joon Sohn ),김민철 ( Min Chul Kim ),심두선 ( Doo Sun Sim ),홍영준 ( Young Joon Hong ),김주한 ( Ju Han Kim ),안영근 ( Youngkeun Ahn ),조명찬 대한내과학회 2018 대한내과학회지 Vol.93 No.4

목적: 흡연은 관상동맥 질환의 위험인자로 잘 알려져 있으며, 흡연을 하는 급성 심근경색증 환자에서 임상적 특성을 파악하고 일년 후 사망 예측인자를 파악하고자 하였다. 방법: 2011년 11월부터 2015년 12월까지 KAMIR-NIH에 등록된 13,104예 중 흡연을 하는 5,110예(57.1 ± 11.6세, 남성95%)를 대상으로 하였다. 그중 흡연자 중에서 생존한 급성심근경색증 환자를 I군 4,844예(56.5 ± 11.3세, 남자 95.3%), 사망한 급성 심근경색증 환자를 II군 266예(68.9 ± 12.5세, 남자 88.3%)로 분류하여, 각 군 간의 임상적 특징과 관상동맥 조영술 소견 및 1년 사망률과 관련된 사망 예측인자를 분석하였다. 결과: 사망한 흡연자 그룹은 65세 이상의 고령자가 많았으며, 고혈압, 당뇨병의 유병률이 유의하게 높았다. II군은 흡연기간과 흡연 갑년에서 I군에 비하여 유의하게 많았다. 다변량분석 결과 1년 추적 관찰 기간 중 사망사건 발생의 독립적인 인자는 creatine 2 mg/dL 이상, 좌심실구혈률 40% 미만, Killip class II 이상의 높은 Killip class, 65세 이상 고령, 관상동맥중재술 후 TIMI flow II 이하의 낮은 TIMI flow였다. 결론: 흡연을 하는 급성 심근경색증 환자에서 1년 후 유의한 사망 예측인자는 65세 이상의 고령, 신장 기능 장애, 좌심실구혈률 저하, 높은 Killip class, 관상동맥중재술 후 TIMI flow 2 이하였다. Background/Aims: It is well known that smoking is associated with clinical outcomes in patients with acute myocardial infarction (AMI). In this study, we aimed to predict the one-year mortality in AMI patients that smoked. Methods: Of the AMI patients who were enrolled in the Korean Acute Myocardial Infarction Registry-National Institutes of Health study, 5,110 were current smokers (57.1 ± 11.6 years, male 95%), and these patients were included in the present study. Patients were divided into two groups; group I (survival group, n = 4,844, 56.5 ± 11.3 years, male 95%) and group II (deceased group, n = 266, male 88%). Clinical characteristics, coronary angiographic findings, procedural characteristics, and independent factors related to one-year mortality were analyzed. Results: In group II, the incidence of hypertension and diabetes were significantly higher than in group I, and the patients were significantly older. Patients with history of angina pectoris, myocardial infarction, and heart failure were significantly more common in group II than in group I. Smoking duration and pack-years of smoking were also significantly longer in group II than in group I. Multivariate analysis revealed that creatine > 2 mg/dL, left ventricular ejection fraction < 40%, Killip class ≥ II, age ≥ 65 years, and post-percutaneous coronary intervention thrombolysis in myocardial infarction (post-PCI TIMI) flow ≤ II were independent factors of mortality during the one-year follow-up. Conclusions: The predictors of one-year mortality in AMI patients with smoking were renal and left ventricular dysfunction, high Killip class, old age, and low post-PCI TIMI flow. (Korean J Med 2018;93:369-378)

고령의 급성 심근경색증 환자에서 성별에 따른 영향

설수영 ( Soo Young Seol ),정명호 ( Myung Ho Jeong ),이승헌 ( Seung Hun Lee ),손석준 ( Seok-joon Sohn ),조재영 ( Jae Yeong Cho ),김민철 ( Min Chul Kim ),심두선 ( Doo Sun Sim ),홍영준 ( Young Joon Hong ),박형욱 ( Hyung Wook Park 대한내과학회 2019 대한내과학회지 Vol.94 No.1

목적: 급성 심근경색증 환자에서 성별의 차이가 임상 경과에 미치는 영향은 잘 알려져 있다. 이전의 연구들은 여성 심근경색증 환자의 임상 경과가 남성에 비하여 비슷하거나 더 좋지 않았다고 보고되었으나, 급성 심근경색증을 가진 고령 환자에서 성별에 따른 예후의 차이에 대한 보고는 많지 않다. 방법: 2011년 11월부터 2015년 6월까지 한국인 급성 심근경색증 등록 연구 사업에 등록된 75세 이상의 고령인 환자 2,953예(80.2 ± 4.2세, 남자: 48.2%)를 대상으로 하였다. 결과: 여성 환자는 1,529 (51.8%)였으며, 평균 나이는 남성 보다 유의하게 많았다(80.7 ± 4.4 years vs. 79.6 ± 4.0 years, p < 0.001). 심혈관질환의 위험인자인 고혈압은 고령 여성에서 남성에 비하여 유의하게 많았다(74.8 vs. 60.3%, p < 0.001). 흡연과 협심증, 심근경색증, 뇌졸중 등 과거력은 고령의 남성에서 여성과 비교하여 유의하게 많았다. 고령의 여성 환자는 남성에 비하여 응급 의료 서비스 이용 빈도가 유의하게 낮았다(11.5 vs. 15.4%, p < 0.001). 고령 여성의 PRU 값이 남성보다 유의하게 높았으나, 항 혈소판 제제 사용에는 유의한 차이가 없었다. 관상동맥중재술의 성공률은 고령 여성이 남성에 비하여 낮았다(p = 0.049). 병원내 사망률은 성별 간에 유사하였으며(7.1 vs. 8.4%), 단변량 콕스 회귀분석 결과 1년 추적 관찰 기간 동안 주요 심장 사건은 고령의 여성에서 고령의 남성보다 유의하게 낮았다(HR 1.19, 95% CI 1.00-1.41, p = 0.045). 주요 심장 사건에 영향을 주는 독립적인 인자는 나이, 흉통, 호흡곤란, Killip class, 심부전증 등이었다. 다변량 분석 결과 1년 추적 관찰 기간 중 주요 심장 사건 발생의 독립적인 인자는 고령의 남성(HR 1.37, 95% CI 1.14-1.65, p < 0.001), 연령, Killip class, 당뇨병 및 심부전증이었다. 결론: 심근경색증을 가진 고령의 환자에서 성별 간에 병원내 사망률과 시술 주위 합병에서는 유의한 차이가 없었다. 그러나 1년 추적 관찰 기간 동안 고령의 여성에서 남성보다 더 양호한 예후를 보였다. Background/Aims: It is well known that gender differences are associated with clinical outcomes in patients with acute myocardial infarction (AMI). However, it is not clear whether gender differences affect the prognosis of elderly patients with AMI. Methods: We analyzed the incidence of in-hospital complications and mortality in the Korea Acute Myocardial Infarction Registry-National Institutes of Health from November 2011 to June 2015. This study included elderly patients (≥ 75 years) diagnosed with AMI. Results: A total of 2,953 patients were eligible for this study. Among them, 1,529 (51.8%) patients were female, and the mean age of the female group was older than that of the male group (80.7 ± 4.4 vs. 79.6 ± 4.0 years, respectively, p < 0.001). Elderly females utilized emergency medical services less frequently compared with elderly males (11.5 vs. 15.4%, respectively, p < 0.001). Elderly female AMI patients had a similar rate of in-hospital mortality compared with elderly males (7.1 vs. 8.4%, respectively, p = 0.196). The rate of major cardiac adverse events (MACEs) was lower in elderly females than males during a 12-month follow-up (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.00-1.41, p = 0.045). According to multivariate analysis, the male gender is an independent factor for predicting 1-year MACEs (HR 1.37, 95% CI 1.14-1.65, p < 0.001). Conclusions: No significant differences in peri-procedural complications or in-hospital mortality were observed between male and female elderly patients with AMI. However, elderly female patients had a more favorable prognosis than male patients during a 1-year clinical follow-up. (Korean J Med 2019;94:96-106)

인공 심박동기 환자에서 심실동기이상의 관련인자

김성수 ( Sung Soo Kim ),조정관 ( Jeong Gwan Cho ),김현국 ( Hyun Kuk Kim ),장수영 ( Soo Young Jang ),심두선 ( Doo Sun Sim ),윤남식 ( Nam Sik Yoon ),윤현주 ( Hyun Ju Yoon ),홍영준 ( Young Joon Hong ),박형욱 ( Hyung Wook Park ),김주 대한내과학회 2010 대한내과학회지 Vol.78 No.1

Background/Aims: Chronic right ventricular pacing (RVP) can lead to increased risks of ventricular dyssynchrony (VD), heart failure, and mortality. This study examined the factors influencing VD in patients treated with a permanent pacemaker (PPM). Methods: The study enrolled 139 patients (M:F=1:1.35, 66.8±1.0 years) who had permanent pacemaker implanted [AAI (R): 11, VVI (R): 39, VDD (R): 50, DDD: 39]. Their clinical characteristics, 12-lead electrocardiogram (ECG), echocardiography, and laboratory parameters were evaluated. The patients were divided into two groups according to the presence of VD. Results: VD was seen in 71.9% of the patients with a PPM. No significant difference was observed in the clinical characteristics, except for the indications and current action mode of the PPM. VD was more frequently associated with patients with AV block and ventricular pacing. The QRS duration and QTc interval were significantly wider in patients with VD (159.9±3.2 vs. 129.4±6.3 ms, p<0.001; 487.7±4.0 vs. 470.9±8.0 ms, p<0.05, respectively). On echocardiography, tricuspid regurgitation was more common in patients with VD. The N-terminal B-type natriuretic peptide (NT-proBNP) level was higher in the dyssynchrony group (431.4±66.1 vs. 202.8±40.8, p<0.05). Conclusions: Patients with AV block and ventricular pacing developed VD more frequently. A higher serum NT-proBNP level and prolonged QRS duration, QTc, and tricuspid regurgitation might be associated with VD. (Korean J Med 78:59-67, 2010)

고중성지방혈증과 복부비만이 관상동맥 중재술을 시술받은 급성 심근경색증 환자의 임상경과에 미치는 영향

박종춘 ( Jong Chun Park ),강정채 ( Jung Chaee Kang ),한수경 ( Soo Gyoung Han ),정명호 ( Myung Ho Jeong ),이정애 ( Jung Ae Rhee ),최진수 ( Jin Su Choi ),이기홍 ( Kee Hong Lee ),박근호 ( Keun Ho Park ),심두선 ( Doo Sun Sim ),홍영준 대한내과학회 2014 대한내과학회지 Vol.86 No.2

Background/Aims: Dyslipidemia and obesity are risk factors for the development of acute myocardial infarction (AMI) that affect the clinical outcomes in patients. Methods: We analyzed 2,751 consecutive AMI patients who underwent percutaneous coronary intervention (PCI) (mean age, 63.7 ± 12.1 years). The patients were divided into four groups based on serum triglyceride levels and central obesity [Group Ia: triglycerides < 200 mg/dL and (-) central obesity; Group Ib: triglyceride < 200 mg/dL and (+) central obesity; Group IIa: triglyceride ≥ 200 mg/dL and (-) central obesity; Group IIb: triglyceride ≥ 200 mg/dL and (+) central obesity]. In-hospital outcome was defined as in-hospital mortality and complications. One-year clinical outcome was compared and defined as the composite of 1-year major adverse cardiac events (MACE), including death, recurrent MI, and target vessel revascularization. Results: Total MACE developed in 502 patients (18.2%), while 303 patients (11.0%) died prior to the 1-year follow-up visit. In-hospital complications and in-hospital mortality were not different among the four groups. One-year clinical outcomes based on triglyceride levels (Group I vs. Group II) were not different. In addition, there were no differences in clinical outcomes in patients with a triglyceride level < 200 mg/dL, regardless of central obesity. One-year MACE rates were not significantly different among the four groups. Conclusions: There was no significant difference in the 1-year MACE rate based on the triglyceride level and presence of central obesity in patients with AMI who underwent PCI. (Korean J Med 2014;86:169-178)

대동맥 탄성도와 동맥경화증의 혈액학적 인자의 관계

김현국 ( Hyun Kuk Kim ),박종춘 ( Jong Chun Park ),김성수 ( Sung Soo Kim ),최홍상 ( Hong Sang Choi ),심두선 ( Doo Sun Sim ),윤남식 ( Nam Sik Yoon ),윤현주 ( Hyun Ju Yoon ),홍영준 ( Young Joon Hong ),박형욱 ( Hyung Wook Park ),김주 대한내과학회 2009 대한내과학회지 Vol.77 No.1

Background/Aims: The elasticity of the aorta modulates the entire cardiovascular system. Increasing arterial stiffness with the loss of aortic elasticity is not only a surrogate marker for early atherosclerosis, but also a predictor of cardiovascular events. Methods: This study included 203 patients (57.6±14.7 years, 117 male) who underwent diagnostic transesophageal echocardiography. We investigated the correlation between the arterial stiffness index (β stiffness index), which is calculated from the distensibility of the descending thoracic aorta and blood pressure, and known serologic markers of atherosclerosis and cardiovascular events. Results: The β stiffness index correlated significantly with the brachial-ankle pulse wave velocity (R2=0.243, p<0.001) and in-tima-media thickness of the descending thoracic aorta (R2=0.470, p<0.001). It also correlated with age (r=0.465, p<0.001) and the presence of diabetes mellitus (r=0.250, p<0.001). The β stiffness index was significantly positively correlated with the levels of N-terminal pro-brain natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein (hsCRP), glucose, HbA1c, apolipoprotein (Apo) A-I, and erythrocyte sediment rate. A multivariate regression analysis demonstrated that the β stiffness index was associated with the levels of NT-proBNP, hsCRP, HbA1c, and Apo A-I. Conclusions: The β stiffness index for the distensibility of the descending thoracic aorta significantly correlates with other parameters of arterial stiffness and serologic markers for atherosclerosis. Therefore, the β stiffness index can be used as a parameter of cardiovascular events in diseases requiring transesophageal echocardiography, such as atrial fibrillation and mitral stenosis. (Korean J Med 77:68-75, 2009)

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)