급성 심근경색증에 의한 심인성 쇼크 환자의 장기적 예후 예측인자
Long-term predictive factors of major adverse cardiac events in patients with acute myocardial infarction complicated by cardiogenic shock
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목적 : 급성 심근경색증 후 5～10%에서 심인성 쇼크가 발생하며, 사망률이 감소하고 있으나 여전히 60%에 이르는 것으로 알려져 있다. 본 연구는 심인성 쇼크가 발생한 환자들의 임상적 특징 및 시술 관련요인을 비교하고, 이들이 주요 심장사건에 어떠한 영향을 줄 수 있는지 알아보아 사망률을 감소시킬 수 있는 인자를 찾고자 하였다. 방법 : 2000년 7월부터 2002년 6월까지 24개월간 전남대학교 병원 광주전남 광역 응급의료센터에 내원한 환자 중 급성 심근경색증으로 확진되었던 환자 1,268명에서 심인성 쇼크가 발생한 환자 255예(연령 66.0±11.0세, 남:여=156:99)를 대상으로, 1년 무사고 생존군 129예(I군)과 사망 및 주요 심장사건 발생군 126예(Ⅱ군)로 나누어 임상적 특징 및 시술 관련요인을 분석하였다. 결과 : I군에 비하여 Ⅱ군이 평균연령이 높았고(64.2±10.6 vs. 68.1±10.0, p=0.004), 진구성 심근경색증의 과거력이 많았다(0% vs 17.4%, p<0.001). 좌심실 구혈률은 Ⅱ군에서 유의하게 낮았다(49.1±13.0% vs. 39.1±12.9%, p<0.001). 검사실 소견에서 양군에서 CK, CK-MB 및 혈중 지질수치의 유의한 차이는 보이지 않았으나, troponin (Tn)과 CRP가 Ⅱ군에서 유의하게 높았다(Tn-I:29.2±7.7 ng/dL vs. 50.8±5.2 ng/dL, p=0.017, CRP:3.8±0.5 mg/dL vs. 9.9±1.2 mg/dL, p<0.001). 관상동맥 조영술에서 좌주간지의 병변이 Ⅱ군에서 유의하게 높았으며(0.7% vs. 22.0%, p=0.004), I군 108예(83.7%)과 Ⅱ군 31예(24.6%)에서 재관류술을 실시하였다. 재관류술을 시행한 환자들의 사망률이 재관류술을 시행하지 않고 내과적 치료만 시행한 환자들에 비해 유의하게 낮았으며(22.3% vs 81.8%, p=0.001), 관상동맥 중재술 후 경색 관련 혈관의 TIMI 3 혈류의 도달율이 Ⅱ군에서 유의하게 낮았다. 결론 : 고령, 심근경색의 과거 병력, 높은 트로포닌과 CRP 수치, 낮은 좌심실 구혈율 및 좌주간지 병변 등이 급성 심근 경색으로 인한 심인성 쇼크 환자들의 주요 심장사건과 관련이 있었다. 재관류술 후 TIMI 3 혈류에 도달하였을 때 병원 내 사망률을 줄일 수 있었다.
Abstract
Background : Cardiogenic shock (CS) after acute myocardial infarction (AMI) is developed in 5～10% of patients and associated with high mortality. The aim of this study is to assess the predictive factors of major adverse cardiac events (MACE) in patients with AMI and CS. Methods : Two hundred fifty five AMI patients with CS (66.0±11.0 years, M:F=156:99) out of 1,268 AMI patients, who admitted at Chonnam National University Hospital between July 2000 and June 2002, were analyzed according to clinical characteristics, coronary angiographic findings and MACE during admission and 1-year clinical follow-up. Results : Among the enrolled patients, 129 patients survived without MACE (Group Ⅰ, 64.2±10.6 years, M:F=76:53) and 126 patients had MACE (Group Ⅱ, 68.1±10.0 years, M:F=80:46) during admission and 1-year follow-up period. There were significant differences in age (64.2±10.6 vs. 68.1±11.0 years, p=0.004) and previous MI history (0 vs. 17.4%, p<0.001). Left ventricular ejection fraction (EF) was lower in Group Ⅱ (Group I vs. II: 49.1±13.0 vs. 39.1±12.9%, p<0.001). The levels of troponin (Tn) I and C-reactive protein (CRP) were higher in Group Ⅱ (Group I vs. II: 29.2±7.72 vs. 50.8±5.17 ng/dL, p=0.017, 3.8±0.48 vs. 9.9±1.21 mg/dL, p<0.001 respectively). Left main stem lesion (LMSL) was more common in Group II than in Group I (0.7% vs. 22.0%, p=0.004). In-hospital death was associated with low Thrombolysis In Myocardial Infarction (TIMI) flow after coronary revascularization. Conclusion : Old age, previous MI history, high Tn and CRP, low EF and LMSL are associated with higher MACE in patients with AMI and CS. Coronary revascularization with TIMI 3 flow lowers in-hospital mortality.
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