만성 신질환: 심방 세동 환자에서 혈전 색전증의 독립적 위험인자
Chronic Kidney Disease as an Independent Risk Factor for Thromboembolism in Patients with Atrial Fibrillation
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목적: 심방세동 환자의 혈전 색전증의 위험도를 평가하기 위하여 CHADS_2 점수체계가 사용되었다. 만성 신질환은 심방 세동 관련 뇌졸중의 발생에 연관이 있음이 밝혀져 있음에도 불구하고 점수체계에 포함되어 있지 않다. 중등도의 뇌졸중 위험도를 가진 심방 세동 환자에서 만성 신질환의 유무에 따라 혈전 색전증의 발생을 비교하였다. 방법: 서울대학교병원 부정맥 클리닉에서 심방 세동을 진단받은 1,952명의 환자 중 CHADS_2 1점인 451명의 환자를 대상으로 만성 신질환의 유무에 따른 혈전 색전증을 분석하였다. 결과: 451명의 환자 중 94명의 만성 신질환 환자에서 유의하게 혈전 색전증의 발생이 증가하였다(HR 3.630, 95% CI 1.565-8.422, p = 0.003). 만성 신질환 환자들에서 아스피린을 사용할 경우 와파린 군에 비하여 유의하게 혈전 색전증 발생의 빈도가 높았으나, 만성 신질환이 없는 환자들에서는 아스피린과 와파린의 사용에 따라 혈전 색전증의 발생 빈도에 유의한 차이를 보이지 않았다. 결론: 중등도의 뇌졸중 위험도를 가진 한국인 심방 세동 환자에서 만성 신질환은 혈전 색전증의 독립적인 위험인자가 될 수 있다. 만성 신질환 환자에서는 아스피린보다는 와파린이 혈전 색전증 예방에 효과적일 것으로 기대된다.
Abstract
Background/Aims:The CHADS_2 scoring system has been widely used to stratify thromboembolic risk associated with atrial fibrillation. Chronic kidney disease (CKD) is associated with increased risk of stroke in patients with atrial fibrillation (AF) but has not yet been included in risk-scoring systems. We analyzed the difference in thromboembolic risk of patients with AF and a moderate risk of stroke according to the presence of CKD. Methods:Of 1,952 patients with AF, 451 with a CHADS_2 score of 1 were divided into two groups according to the presence of CKD, and thromboembolic events were analyzed. Each group was further classified by the antithrombotic regimen used: warfarin or aspirin. Results:Of the 451 patients, 94 with CKD had a significantly higher risk for thromboembolic complications than the 357 patients without CKD (hazard ratio [HR], 3.630; 95% confidence interval [CI], 1.565-8.422; p = 0.003). Patients with CKD who were on aspirin had a higher risk for thromboembolic events than those on warfarin (HR, 5.203; 95% CI, 1.056-25.633, p = 0.043). However, in patients without CKD, the aspirin group did not have a higher risk of thromboembolic events than the warfarin group (HR, 0.803; 95% CI, 0.225-2.867, p = 0.735). Conclusions:In Korean patients with AF and a CHADS2 score of 1, CKD may be an independent thromboembolic risk factor. In patients with CKD, warfarin may be superior to aspirin for lowering thromboembolic risk. (Korean J Med 2011;81:464-469)
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