급성 심근경색증에 대한 일차 관상동맥 중재술 후 심근조직 재관류 평가에 있어 TIMI 화면계수법과 TIMI 심근관류등급법의 비교

김범준,정해억,고윤석,임상현,윤호중,강동헌,승기배,김재형,홍순조,최규보 대한순환기학회 2003 Korean Circulation Journal Vol.33 No.10

심근경색과 비만 패러독스

한숙원 대한임상건강증진학회 2012 Korean Journal of Health Promotion Vol.12 No.2

Background: Despite the adverse impact that being overweight or obese has on cardiovascular disorders, numerous studies have addressed the ‘obesity paradox’, which suggests that obese persons seem to have a better prognosis with these conditions than those with a normal body mass index (BMI). In addition, the effect of BMI on outcomes after percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) remains controversial. Methods: Our subjects included 457 patients who had undergone PCI for AMI between January 1, 2009 and September 30, 2011. They were classified into 3 groups according to baseline BMI - normal weight (BMI<23kg/m2), overweight (BMI 23-25 kg/m2), obesity (BMI>25 kg/m2). Clinical characteristic and cardiovascular risk factors and major adverse cardiac events (MACE), including death after PCI, were compared among the groups. Results: Overweight or obese subjects were younger (P<0.001) and associated with higher left ventricle ejection fraction (LVEF) (P=0.012) and less frequency of MACE (P=0.003). Multiple logistic regression analysis showed that independent predictors for death and MACE were not obesity but age (P=0.006, P=0.017),high-density lipoprotein cholesterol (P=0.002, P=0.005) and LVEF (P=0.001, P<0.001). Conclusions: In our study, BMI had no effect on MACE in patients undergoing primary PCI for AMI. The phenomenon,'obesity paradox', may be explained by the possibility that AMI was diagnosed at a younger age in obese patients and that these younger patients had higher LVEFs than the other groups in this study. 연구배경: 비만은 심근경색의 위험요인이며 그 부정적인 영향에도 불구하고 여러 연구에서 정상체중보다 좋은예후를 초래하는 것으로 보고되어 이를 비만 패러독스라고 부른다. 일차적 관상동맥중재술 후 심근경색 환자들의예후와 관련하여 체질량지수의 영향에 관하여는 많은 논란이 있다. 방법: 연구 대상자는 2009년 1월에서 2011년 9월 사이에일차적 관상동맥중재술을 실시한 457명이다. 이들은 체질량지수에 따라 정상체중군(<23 kg/m2), 과체중군(23-25kg/m2), 비만군(>25 kg/m2)으로 분류되었다. 세 군의 임상적 특성, 심혈관계 위험요인, 그리고 주요심장사건에 관하여 비교하였고 다변량분석을 통해 주요심장사건의 예측인자를 분석하였다. 결과: 본 연구 대상자들에서는 체질량지수가 정상인 환자는 과체중 또는 비만인 환자에 비해 심근경색의 발병연령이 낮았고(P<0.001) 좌심실 박출률이 높았으며(P=0.012)사망을 비롯한 주요심장사건의 발생이 적게(P=0.003) 나타났다. 다변량로지스틱회귀분석 결과 사망률 및 주요심장사건의 유의한 예측인자는 체질량지수가 아니라 연령(P=0.006, P=0.017)과 고밀도콜레스테롤(P=0.002, P=0.005),좌심실 박출률(P=0.001, P<0.001)로 나타났다. 결론: 체질량지수는 심근경색 환자에서 사망 및 주요심장사건 발생에 의미있는 예측인자가 아니며 비만한 환자가 보다 젊은 나이에 심근경색이 발생했기 때문에 나타난현상으로 볼 수 있다.

선천성 심장기형의 수술 후 Histidine-tryptophan-ketoglutarate 심정지액과 혈성 심정지액의 전자현미경적 심근 구조의 비교 관찰

김시호,이영석,우종수,서시찬,최필조,조광조,방정희,노미숙 대한흉부외과학회 2007 Journal of Chest Surgery Vol.40 No.1

배경: 선천성 심장기형의 수술적 교정 시, Histidine-Tryptophan-Ketoglutarate (HTK) 심정지액과 혈성 심정지액의 심근 보호에 관한 비교를 위해 술 후 심근에 대한 전자현미경적 고찰을 시행하였다. 대상 및 방법: 개심술을 계획하고 있는 선천성 심기형 환아 22명의 환자를 대상으로 하였고 이들은 무작위로 두 집단으로 나누어 전향적으로 연구를 진행하였다. 22명 중 11명(HTK 집단)은 개심술 시 HTK 심정지액을, 다른 11명(혈성 심정지액 집단)은 혈성 심정지액을 사용하였다. 술 중 재관류 30분 후 우심실에서 작은 조직을 채취하여 전자현미경적 관찰을 시행하였다. 전자현미경에 의한 심근 초미세구조에 대한 평가는 무작위 체계적 표본 추출법에 의한 반정량적 평가법을 사용하였다. 1명의 병리조직학자에 의해 사전정보의 제공 없이 시행되었다. 결과: 미토콘드리아의 보존 형태에 대한 반정량적 평가는 혈성 심정지액 집단이 19.65 4.75 그리고 HTK 집단이 25.25 5.85 (p=0.03)였다. 혈성 심정지액 집단 중 6명의(54.5%) 환아에서 그리고 HTK 집단 중 3명(27.3%)에서 3도 이상의 사이질의 부종을 보였다. 결론: 전자현미경적 초미세구조의 보존은 HTK 심정지액이 더 우수한 결과를 보였다. 그러나 임상적 그리고 수술 중의 다양한 요인을 고려한 술 중 심근 보호에 대한 우월성에 대한 비교는 계속적인 관찰과 연구를 요한다.

2017 유럽심장학회 ST분절 상승형 심근경색증 진료지침의 새로운 점

배장환 대한내과학회 2018 대한내과학회지 Vol.93 No.1

The 2017 Clinical Guidelines for ST‐segment elevation myocardial infarction of the European Society of Cardiology updated many important aspects of the pre‐hospital phase, the selection of a reperfusion strategy, interventional and pharmacological treatment, and patient quality assessment. The principal changes are a clear definition of the first medical contact, elimination of the door‐to‐balloon time from consideration, recommended radial access intervention, a recommendation that drug‐eluting stents should be preferred to bare metal stents, recommended complete revascularization during hospitalization, and early discharge of selected patients. Routine manual thrombus aspiration and oxygen supplementation for patients who are not hypoxemic are now discouraged.

Mitochondrial Permeability Transition Pore와 허혈-재관류 손상으로부터의 심근보호작용

이종화,심연희 대한의사협회 2009 대한의사협회지 Vol.52 No.10

Opening of mitochondrial permeability transition pore (mPTP) was found to have a critical role in cell death from ischemia/reperfusion (I/R) injury experimentally in the late 1980’s. Thereafter, tremendous efforts have been made to define the molecular composition of mPTP and underlying mechanisms of its opening. mPTP opening, so far, has been demonstrated with the conformational changes of the mitochondrial protein components including cyclophilin-D, adenine nucleotide translocase, and voltage-dependent anion channel, which were induced by the modification of the levels of Ca2+, phosphate, mitochondrial membrane potential, intracellular pH and adenine nucleotide. At present, genetic modulation of the expression of protein components are being used in the investigation of its properties, presenting novel mechanisms of mPTP opening, including phosphate carrier. For therapeutic intervention, cyclosporin A and its analogues were first to be demonstrated to inhibit the opening of mPTP, affecting cyclophilin-D. There are numerous pharmacological substances that have direct or indirect effects on mPTP opening, including bongkrekic acid, reactive oxygen species scavengers, calcium channel blockers, and Na+/H+ exchanger-1 inhibitors, but only cyclosporin A was clinically tried to limit the myocardial infarction. Conditioning interventions, ischemic or anesthetic, have also been shown to be effective in limiting the detrimental effects of I/R injury. These interventions are commonly related to specific receptors on cell membrane and then signal transduction pathway consisting of many protein kinases, which eventually lead to mitochondria. And being presented are experimental evidences that inhibition of mPTP opening is a primary mechanism of these conditioning interventions. In conclusion, mPTP opening is now presented as primary mechanism and therapeutic target of I/R injury, but precise mechanism and standardized treatment method are needed to be clarified.

특집/급성 ST분절 상승 심근경색증의 재관류 전략

김영조 대한의사협회 2010 대한의사협회지 Vol.53 No.3

At the most severe end of the spectrum of acute coronary syndromes is ST-segment elevation myocardial infarction(STEMI), which usually occurs when a fibrin-rich thrombus completely occludes an epicardial coronary artery. Timely reperfusion therapy is the best and the most important component of the treatment for STEMI. Several randomized trials and metaanalysis have shown that primary percutaneous coronary intervention(PPCI) is superior to thrombolysis in STEMI therapy. However, PPCI should be regarded as preferred strategy only within a reasonable time delay from onset to treatment, in contrast to thrombolysis. There is a continuing controversy about the acceptable time-window for PPCI in patients with STEMI. Recent American and European guidelines recommend PPCI if the delay in performing PPCI instead of administering fibrinolysis (PCI-related delay) is 60 minutes and the presentation delay is more than 3 hours. Based on a review of the literature, the evidence supports an acceptable PCI-related delay of 80-120 min and PPCI as a better reperfusion strategy also in the high-,medium- risk patients and early incomers. Furthermore, To maximize the number of patients with STEMI eligible for PPCI, the optimal logistic strategy could be the confirmation of the diagnosis in the prehospital phase, to bypass local hospitals, and to re-route patients directly to facilities that can administer catheterization. To obtain the maximal benefit for survival, the optimal antithrombotics and adjuvant drug therapy is necessary.

심실 제세동 직후 ST 분절 상승이 소실된 급성심근경색

조성균 ( Sung Kyun Cho ),강윤정 ( Yoon Jung Kang ),김태훈 ( Tae Hoon Kim ),이혜영 ( Hye Young Lee ),조성우 ( Sung Woo Cho ),황미원 ( Mee Won Hwang ),변영섭 ( Young Sup Byun ) 대한내과학회 2011 대한내과학회지 Vol.80 No.6

A 38-year-old man presented with typical squeezing-type anterior chest pain. An initial electrocardiogram (ECG) showed prominent ST-segment elevation (V1-V4 lead, 3 mm). Suddenly, the patient fell unconscious and had no pulse. At that time, the ECG showed polymorphic ventricular fibrillation (VT). After direct current (DC) cardioversion, the patient regained vital signs and defibrillation converted the VT into an accelerated idioventricular rhythm with resolution of the ST-segment elevation. The patient was referred to our hospital for close observation and further evaluation. At our hospital, an ECG showed normal sinus rhythms and cardiac enzymes were within normal limits. We diagnosed the patient with variant angina rather than ST elevation myocardial infarction (STEMI), because his clinical manifestations were quite distinct; ST-segment elevations disappeared slowly at the reperfusion stage. However, the patient`s final diagnosis was STEMI because coronary angiography showed severe eccentric tubular stenosis (85%) with remnant thrombus in the middle left anterior descending artery. Defibrillation likely removed thethrombus, which led to STEMI. (Korean J Med 2011;80:708-711)

논평 : 재관류 치료 시 발생하는 Slow/No-reflow는 예측이 가능한가?

이상훈 ( Sang Hoon Lee ) 대한내과학회 2008 대한내과학회지 Vol.74 No.1

Impact of Door-to-Balloon time in patients with ST-elevation Myocardial infarction by use of helicopter

조현영,최한주 대한응급의학회 2018 대한응급의학회 학술대회초록집 Vol.2018 No.2

안정적인 돼지 심근 경색 모델 제작을 위한 3차원 바이오 프린팅 이식체 개발

정승만(Seungman Jung),김한별(Han Byul Kim),홍영준(Young Joon Hong),장진아(Jinah Jang) 대한기계학회 2020 대한기계학회 춘추학술대회 Vol.2020 No.12