흉통과 ST 분절상승을 보이는 환자에서 급성심근경색증과 비심근경색증의 심전도 분석

김용권(Yong Kweon Kim),류진호(Jin Ho Ryoo),허탁(Tag Heo),민용일(Yong Il Min),소정일(Jung Il So) 대한응급의학회 2000 대한응급의학회지 Vol.11 No.4

Background: ST segment elevation in patient with chest pain was seen in acute myocardial infarction and in numerous other non-infarction syndromes. The causes of non-infarction syndrome were left ventricular hypertrophy, BER(benign early repolarization), and left bundle branch block in cardiac origin and were hyperkalemia and hyperventilation syndrome in metabolic origin and were others. Furthermore, the differentiation of electrocardiogram between acute myocardial infarction and non-infarction syndrome was very difficult. So, we compared and analysed characteristics of ST segment elevation of acute myocardial infarction and non-infarction syndrome that suggested the clue of early diagnosis of coronary artery disease. Method and Materials: We retrospectively reviewed the electrocardiogram of 961 patients with chest pain who visited the emergency center from January 1999 to December 1999. Acute myocardial infarction was diagnosed by clinical finding, electrocardiogram, cardiac enzyme, echocardiogram, and myocardial spect. Left ventricular hypertrophy, BER, and left bundle branch block in cardiac origin of non-infarction syndrome were diagnosed by electrocardiographic criteria suggested by William J. Brady. Acute myocarditis, acute pericarditis, and hyperventilation syndrome were diagnosed by clinical finding. Results: Among 961 patients with chest pain, 236(24.6%) patients manifested ST segment elevation who were diagnosed acute myocardial infarction in 162(68.6%) patients and non-infarction syndrome in 74(31.4%) patients. The causes of non-infarction syndrome in 74 patients were left ventricular hypertrophy(32:13.6%), BER(28:11.9%), left bundle branch block(11:4.7%), and others(3:1.3%). Three others were acute myocarditis, acute pericarditis, and hyperventilation syndrome. Electrocardiographic characteristics of ST segment elevation of non-infarction syndrome manifested almost same finding compared to William J. Brady` criteria. Conclusion: ST segment elevation in patient with chest pain visited emergency department was seen in acute myocardial infarction(68.6%) and the other non-infarction syndromes(31.4%). Significant number of patients were not associated with acute myocardial infarction. Therefore, we must completely understand characteristics of ST segment elevation in acute myocardial infarction and the other non-infarction syndromes to diagnose fatal early coronary artery disease and to avoid unnecessary thrombolytic therapy.

관동맥 질환에서 혈청 Troponin T 의 임상적 의의

이병권(Byoung Kwon Lee),권혁문(Hyuck Moon Kwon),박현영(Hyun Young Park),박광주(Kwang Joo Park),김현승(Hyun Seung Kim),최종락(Jong Rak Choi),송경순(Kyung Soon Song) 대한내과학회 1996 대한내과학회지 Vol.50 No.1

Objectives: Although the diagnosis of coronary heart disease is usually straight forward, conventional diagnostic tests, such as CK, CK-MR, LDH, and AST have several drawbacks. The diagnostic efficiency of these conventional thests is disappointingly low, especially in minimal myocardial damage. l herefore, there has be necessity of more sensitive and specific diagnostic thest. Recently, cardiac TnT (TnT) was introduced with better sensitivity, specificity, and more wide diagnostic window. So we analyzed distribution of TnT in control, release kinetics, diagnositic significance of TnT in coronary heart disease including unstable angina and acute myocardial infarction, and efficiency of TnT as a marker of reperfusion in acute myocardial infarction. Methods: We tested cardiac TnT in 40 normal healthy subjects and 25 extracardiac traumatic patients as control group. We also tested cardiac TnT in 34 patients with acute myocardial infarction and 27 patients with unstable angina. We evaluated the distribution and serial change of cardiac TnT with other cardiac enxzymes after chest pain onset, the discriminant power of Tnl in discriminating of reperfusion after thrombolytic therapy in patients with acute myocardial infarction with conventional coronary angiography and the correlation between release kinetics of TnT and left ventricular ejection fraction with echocaroliography. Results: 1) In control group, all 65 cases serum TnT value were less than 0.2㎍/L. And its specificity (100%) and sensitivity in diagnosis of coronary heart disease including untable angina(acute myocardial infarction: 100%, unstable angina 70.4%) was better than those of other cardiac enzymes, such as CK, CK-MB. 2) In patient group, the release pattern of cardiac TnT was in bimodal curve pattern, while the pattern of other cardiac enzymes was in unimodal pattern. 3) In acute myocardial infarction, the first peak value of cardiac TnT appeared siginificantly earlier (9.53±2.36 hr in stable-reperfused group, 13.40±1.92 hr in non-reperfused group of acute MI than that of caridac enzymes; CK(17.65±6.48 hr in stable-reperfused group 27.53±10.26 hr in non-reperfused group), and CK-MH (16.84±7.93hr in stable-reperfused group, 24.33±10.36 hr in non-reperfused group of acute MI)(p<0.01). And troponin T was continuously increased above the cut-off value during the test period, so the diagnostic window of TnT was longer than other cardiac enzyme. 4) In acute myocardial infarction, cardiac TnT showed better discriminant power above 80% for reperfusion than those of CK(67.65%) and CK-MB (58.82%) In stable reperfused group of acute MI, cardiac TnT showed significant correlation with left ventri- cular ejection fraction(absolute value of r >0.6, p< 0.001). Conclusion: Cardiac troponin T was a good diagnostic marker for coronary heart disease including unstable angina and acute myocardial infarction with better sensitivity and specificity, for discriminating of reperfusion after thrombolytic therapy, and for the prognosis of remnant left ventricular global systolic function

급성 심근경색후 좌심실 기능과 용적의 변화

심완주(Wan Joo Shim),안태훈(Tae Hoon Ahn),김영훈(Young Hoon Kim),노영무(Young Moo Ro) 대한내과학회 1991 대한내과학회지 Vol.41 No.6

To assess changes of left ventricular size and function after acute myocardial infarction, 15 patients with acute myocardial infarction were studied by 2-D echocardiogram. The left ventricular volume and extent of regional wall motion abnormality were calculated using measurements from the 2-D echocardiogram at entry and at 7 days and 2 months after acute myocardial infarction. The left ventricular volume increased from 124+40ml at entry to 143+24ml at 2 months after acute myocardial infarction in 5 patients (33.3%). The location of the infarction was the anterior wall in all of these 5 patients, who had a greater infarct area than those who had normal left ventricular volume at 2 months (p=0.07). The timing of the left ventricular dilatation after acute myocardial infarction was different in each of these 5 patients. The rest of the 10 patients (66.7%) exhibited either no change of a decrease in left ventricular volume. The wall motion score decreased from 6.2+2.9 at entry to 5.2+2.8 at 2 months (p<0.05) with no con-comitent improvement of gloval left ventricular function. No relation was demonstrated between the ejection fraction at entry and the left ventricular dilation at 2 months, Thus, left ventricular dilation after acute myocardial infarction occurs mainly in anterior wall infarction and is related to the extent of the infarct area at entry. Initial left ventricular function (ejection fraction) does not predict left ventricular dilatation 2 months after acute myocardial infarction.

급성심근경색증 환자에서 발생초기의 지단백질 변화

이혜진,신길자,조홍근,박시훈 梨花女子大學校 醫科大學 醫科學硏究所 2000 EMJ (Ewha medical journal) Vol.23 No.3

연구배경 : 저자등은 한국인 급성심근경색증 환자에서 첫째, 급성 흉통이후 발병초기에서 지질치의 변화를 관찰하고 둘째, 기존의 고지혈증 유무와 성별등이 지질 변동치에 영향을 주는지를 규명하며 셋째, 급성흉통 이후의 어느 시기에 측정하는 것이 기저지질치와 가장 유사하여 치료의 기준으로 삼을 수 있는가를 알아보기 위하여 본 연구를 시행하였다. 방법 : 급성흉통으로 응급실을 내원한 환자중, 28명의급성 심근경색증 환자를 대상으로 응급실 내원당시와 입원 다음날 공복시 총콜레스테롤, 저밀도 콜레스테롤, 고밀도 콜레스테롤, 중성지방을 측정하여 다음과 같은 결과를 얻었다. 결과 : 1) 급성심근경색증 환자에서 총콜레스테롤, 저밀도 콜레스테롤은 의의있는 감소를 보였다. 2) 지질변동치는 응급실 내원당시 지질수치와 양의 상관관계를 보였다. 3) 남성군에서 여성군에 비해 저밀도 콜레스테롤의 더 큰 감소폭을 보였다. 결론 : 급성심근경색증으로 응급실을 내원한 환자에서 입원 다음날 측정한 콜레스테롤치는 응급실 내원당시에 비해 의의있게 감소된 수치를 보였다. 이는 내원 다음날 측정한 지질치가 고지혈증의 진단과 치료 시작에 잘못된 판단기준으로 작용할 수 있다는 점을 시사한다. 결론적으로 급성흉통으로 응급실을 내원하는 환자에서 초기 지질측정이 필수적이며, 초기에 검사가 이루어지지 못한 경우는 지질치가 기저치에 비해 낮게 측정됐음을 고려하여 고지혈증의 치료여부를 결정해야 할 것이다. 본 논문에서는 급성흉통으로 응급실을 내원한 급성 심근경색증 환자에서 내원 당시의 수치와 비교해 볼 때 내원 다음날의 총콜레스테롤은 11.5%, 저밀도 콜레스테롤은 9.5% 감소하였다. Objectives : Hyperlipidemia is an important risk factor of coronary atherosclerosis. Serum lipids, especially cholesterol level is closely related to coronary artery and early identification and treatment of hypercholesterolemia reduced the risk of ischemic heart disease. In secondary prevention studies, lipid regulation has been demonstrated to result in a reduced incidence of myocardial infarction and mortality. But during the acute phase of a myocardial infarction, the serum lipid pattern is known to be rapidly changed and consequently dose not reflect the baseline level of the patient. Total serum cholesterol concentrations measured within 24 hours after acute myocardial infarction are likely to reflect basal levels, thus they must be used as the reference for the diagnosis and treatment of hyperlipidemia. If serum lipid levels were not measured within 24 hours of acute chest pain, it is essential to correct the lipid level to the baseline level. So we investigated the following. First, serum lipid alteration during the acute phase of acute myocardial infarction, second, the factors that are related to lipid change, third, the time to check the baseline value of lipid level during the acute phase of myocardial infarction. Methods : We have measured the total cholesterol, LDL cholesterol, HDL cholesterol and triglyceride at admission time and the next day in a group of 51 acute myocardial infarction patients who had acute chest pain. Results : First, total cholesterol, LDL cholesterol at the next day were significantly reduced. Second, positive correlation was noted between lipid alteration and the lipid level that was checked at admission time. Last, male groups had more significant reduction of LDL cholesterol than female groups. Conclusion : Cholesterol levels thats were checked the next day were significantly reduced in comparison with the cholesterol value registered at hopital admission. Consequently, it is essential to check the lipid level at the time of hospital admission. But if it was not done, corrected values are a useful guide to patients basal lipid state and treatment references.

급성심근경색에서 Troponin T 와 경색의 크기와의 상관관계

서창희(Chang Hee Suh),김한수(Han Soo Kim),강한걸(Han Geol Kang),신준한(Joon Han Shin),탁승제(Seung Jae Tahk),이승호(Seong Ho Lee),최병일(Byung Il William Choi) 대한내과학회 1997 대한내과학회지 Vol.52 No.1

Objectives: The estimation of infarct size has been important in evaluation of prognosis of the patients who had acute myocardial infarction. The infarct size estimated by the thallium-201 SPECT has been known to correlate with the prognosis of patient. The enzymatic estimation by the total release of creatine kinase isoenzyme MB(CK-MB) has been widely used in estimating infarct size clinically, but inconvienent and not cardiospecific. Recently, serum troponin T, cardiospecific myofibrillar protein, has been used in the diagnosis of acute myocardial infarction, and used in the estimation of reperfusion following myocardial infarction. To assess the role of the late troponin T peak concentration on the estimation of infarct size, this prospective study was carried out. Methods: The patients with acute myocardial infarction who were admitted, within 48hours after the onset of chest pain, to Ajou University Hospital between April 1995 and August 1995 were evaluated. All patients were divided into anterior and inferior infarct and checked serum troponin T and CK-MB serially, and underwent stress Thallium-201 SPECT 1 week after infarction, In each group, we assessed the correlation of the late toponin T peak concentration, the total release of CK-MB, and the infarct size estimated by thallium-201 single photon emission computed tomography(SPECT). Results: 1) The eligible subjects consisted of 22 patients (17 men and 5 women), and age ranged from 29 to 77 years(mean 57.8±12.5 years). 2) The mean arrival time to the hospital after the onset of chest pain was 15.5±13.2 hours. The 19 patients had at least one risk factor for coronaryartery disease. 3) The late troponin T peak concentration and the total release of CK-MB in patients with anterior infarction were not different from those with inferior infarction. The infarct size estimated by the thallium-201 SPECT in patients with anterior infarction was larger than patients with inferior infarction The left ventricular ejection fraction in anterio infarction was lower than inferior infarction. 4) The late troponin T peak concentration ha: positive correlation with the infarct size estimated by the thallium-201 SPECT in the total patients, and both patients with anterior infarction and inferio infarction. 5) The total release of CK-MB correlated with the infarct size estimated by the thallium-20 SPECT in the total patients, and the patients of inferior infarction. Conclusion: The late troponin T peak concentration was more accurate than the total release o CK-MB in the estimation of infarct size. Therefore, when the patient arrived to the hospital less than 48hr after the onset of chest pain, the late troponin T peak concentration is useful in the decision and evaluation of therapeutic intervention and in the prediction of prognosis.

급성 하벽 심근경색증의 임상양상을 보인 복부 대동맥류 파열 1예

이준엽,남지형,김승민,김준섭,김강,성낙일,박정배,천우정,배준호,나득영 동국대학교 의학연구소 2006 東國醫學 Vol.13 No.2

대부분의 복부 대동맥류 파열은 저혈압, 복통을 동반하거나, 복부의 박동성 종괴가 촉지된다. 하지만 급성 심근경색의 임상양상을 나타낸 증례는 세계적으로 1예만이 보고되어 드문 것으로 알려져 있다. 그러나 수술적 치료가 요구되는 복부 대동맥류 파열과 혈전 용해제, 관상동맥성형술 등의 내과적 치료가 우선시 되는 급성 심근경색은 질환의 특성상 증상발현과 동시에 치명적인 결과를 초래할 수 있어, 신속하고 정확한 진단과 동시에 적절한 치료가 요구된다. 특히 복부 대동맥류를 가진 환자 중 22%에서 심혈관질환을 동반한 경우가 있고, 복부 대동맥류 파열로 인한 저혈압은 관상동맥의 혈류량을 감소시켜 급성 심근경색의 임상양상을 나타낼 수 있다. 따라서 급성 심근경색의 전형적인 흉통을 호소하는 환자도 이전의 병력이 없더라도 급성 대동맥 증후군의 위험인자를 가지고 있을 경우 급성 대동맥 증후군을 염두에 두어, 좀 더 세심한 이학적 검사, 전산화단층촬영 등의 대동맥에 대한 검사를 고려 해야 한다. 이에 저자들은 전형적인 급성 하벽 경색의 증상과 심전도 소견을 나타내었으나, 대동맥 조영술과 복부전산화단층촬영을 통해 복부 대동맥류 파열을 진단하였던 예를 문헌고찰과 함께 보고하는 바이다. The majority of acute aortic aneurysmal rupture presents the symptoms of hypotension, abdominal pain, and/or palpable pulsating abdominal mass. Acute aortic aneurysmal rupture with symptoms of acute myocardial infarction was rarely reported. The treatment of ruptured abdominal aortic aneurysm needs surgery, but acute myocardial infarction needs thrombolytc agents and/or coronary interventions. Hence these diseases need prompt and accurate differential diagnosis. Especially, the 22% of patients with aortic aneurysm have coronary heart disease, and the hypotension due to aortic aneurysmal rupture decreases the flow of coronary artery and causes mimic symptoms of acute myocardial infarction. Therefore, the patients with typical symptoms of acute myocardial infarction without pervious history of aortic aneurysm need more careful examination such as chest/abdominal CT for differential diagnosis of aortic aneurysmal rupture. We reported a 74-year-old female developed typical symptoms of acute myocardial infarction, but was diagnosed as ruptured abdominal aortic aneurysm by aortogram and computed tomography.

급성심근경색 해당 여부에 대한 판단 기준 연구

최병규 한국경영법률학회 2024 경영법률 Vol.35 No.1

Private insurance supplements state-run social insurance and performs the function of providing economic stability to the people. However, disputes are constantly occurring in the insurance field. From the perspective of insurance companies, there is a conflict between focusing on sales and expecting policyholders to receive sufficient coverage. One of the causes of disputes is the extent to which data must be provided to prove acute myocardial infarction or ischemic heart disease. In the case in question, the insured person suffered a sudden seizure after going to the bathroom, lost consciousness, and eventually died. An autopsy was not performed on the body after the death of the insured, and the doctor who examined the body diagnosed the death as due to cardiopulmonary arrest due to suspected acute myocardial infarction. Acute myocardial infarction is a disease in which the coronary arteries that feed the heart muscle are suddenly completely blocked, causing the heart muscle to die. It occurs when a blood clot called a ‘thrombus’ suddenly blocks the coronary artery that supplies blood to the heart, preventing blood from being supplied to the heart muscle. This is different from angina. When myocardial infarction occurs, one third of people die before reaching the hospital. In order to meet the requirements of the terms and conditions stipulating whether it is an acute myocardial infarction, it is not enough for the optometrist who simply examined the patient to have a myocardial infarction. What is needed is clearer evidence. As a way to improve the system, insurance payments are made even when the cause of death is confirmed or presumed to be acute myocardial infarction according to the autopsy report to prevent disputes and add some additional clarity requirements, meaning that cases without accurate grounds will be excluded from insurance payment payments. This means that even if the requirements that meet the standards of the terms and conditions are not met, the judgment of the autopsy doctor will be additionally considered. Otherwise, if you simply rely on the post-mortem optometrist's opinion, the criteria for insurance payment will be too unclear, increasing the possibility of causing disputes in the future. Ultimately, from this point of view, in this case, it is difficult to pay the diagnosis fee for acute myocardial infarction. In the future, we will continue to make efforts to explore clear standards for resolving disputes and find ways to meet the requirements of the terms and conditions and protect insurance consumers.

급성 심근경색 환자에서 예후 예측인자로 혈청 감마-글루타밀 트랜스퍼라제가 유용한가?

이장훈 ( Jang Hoon Lee ),채성철 ( Shung Chull Chae ),이현상 ( Hyun Sang Lee ),박용휘 ( Yong Whi Park ),류현민 ( Hyeon Min Ryu ),이순학 ( Soon Hak Lee ),배명환 ( Myung Hwan Bae ),양동헌 ( Dong Heon Yang ),박헌식 ( Hun Sik Park ) 대한내과학회 2007 대한내과학회지 Vol.72 No.3

Background: Serum gamma-glutamyl transferase activity (GGT) is able to catalyse low-density lipoprotein oxidation in coronary atherosclerotic plaques and has a role in the pathogenesis of atherosclerosis. GGT has been shown to be an independent risk factor for cardiac mortality in patients with a previous myocardial infarction. The purpose of this study is to determine the prognostic value of GGT within its normal range at an acute stage in patients with acute myocardial infarction. Methods: In a retrospective study, GGT and other cardiac risk factors were evaluated in 192 patients (M/F=143/49; mean age: 60.8±11.8 years) who were diagnosed with an acute myocardial infarction at the emergency room. We compared the serum GGT values for each patient with or without a cardiac event, including cardiac death, non-fetal myocardial infarction and unstable angina, after an acute myocardial infarction for a mean follow-up of 16.5±10.8 months. Results: During the follow-up period, 17 patients underwent cardiac death and experienced an acute myocardial infarction and 23 patients had unstable angina. Although the mean GGT values were significantly different from patients with cardiac events (29.5±10.0 U/L vs 25.0±11.2 U/L, p=0.024), serum GGT was not an independent cardiac risk factor for a cardiac event based on multivariate analysis adjusted for age, sex, alcohol and known cardiovascular risk factors. Conclusions: Serum GGT within its normal range at an acute stage in patients that experienced an acute myocardial infarction is not an independent prognostic marker. (Korean J Med 72:281-289, 2007)

급성 심근경색증에서 심근경색증 발생 직전에 발병한 협심증으로 유도된 허혈전조치 효과에 관한 연구

유규형,이영,김철홍 대한순환기학회 1998 Korean Circulation Journal Vol.28 No.10

당뇨병 환자에서 급성 심근경색증의 관상동맥 중재술시 혈당이 No-reflow현상에 미치는 영향

홍택종 부산대학교 병원 암연구소 2008 부산대병원학술지 Vol.- No.24

Background : Diabetes mellitus is associated with endothelial dysfunction and platelet activation that may contribute to the occurrence of coronary no-reflew, But the precise mechanism of coronary no-reflow in diabetes is not well known until now. Even more there are many debates in its role of acute and chronic hyperglycemia. It was evaluated whether hyperglycemia at admission might or not be associated with the occurrence of coronary no-reflow in diabetic patients undergoing coronary angioplasty for acute myocardial infarction. Subjects and Methods: Of the 475 acute myocardial infarction patients who had underwent coronary angioplasty between February 2003 to June 2005, angiographic and clinical characteristics were investigated in 117 diabetic patients to know the impact of hyperglycemia on the occurrence of coronary no-reflew in diabetic patients with acute myocardial infarction. Results : Of the 117 diabetic patients, 22 patients(19.5%) showed coronary no-reflow. Glucose level on admission was not different regardless of reflow disturbance(199.4 ± 88.8 vs. 212.7 ± 88.9, p = 0.568). But glycosylated hemoglobin (HbA1c) suggesting chronic hyperglycemia is higher in diabetic patients with no-reflow than in those with normal flow(7.8 ± 1.5 vs. 7.0 ± 1.2, p = 0.05). Conclusion : Intensive glucose control may improve coronary flow disturbance in diabetic patients with acute myocardial infarction undergoing coronary angioplasty. 배경 및 목적 당뇨환자는 미세혈관의 기능 장애와 혈소판의 활성으로 인해 관상동맥 혈류가 감소될 수 있는데, 그 기전은 아직 정확히 알려져 있지 않다. 더구나 급성 및 만성 고혈당이 관상동맥 no-reflow 발생에 미치는 역할에 대해 이론이 아직도 많은 실정이다. 본 연구에서는 당뇨병을 동반한 급성 심근경색증 환자에서 스텐트를 이용한 관상동맥 중재술시 행시 급성 또는 만성 고혈당이 no-reflow 현상의 발생에 미치는 영향을 알아보고자 하였다. 대상 및 방법 2003년 2월 부터 2005년 6월까지 급성 심근경색증으로 부산대학교 병원을 방문하여 관상동맥 중재술을 시행 받은 475명의 환자 중 당뇨병으로 진단받은 117명 (24.6%) 의 의무기록을 바탕으로 입원 중 시행한 당화혈색소 및 시술 전 혈당 그리고 관상동맥조영술 소견을 후향적으로 분석하였다. 결과 117명의 대상 환자 중 80.5 %인 95명에서 정상적인 혈류가 관찰되었으며 (normal flow 군) 19.5 % 인 22명에서 no-reflow 현상이 관찰되었다(no-reflow 군). 내원 당시 혈당치 (199.4±88.8 vs 212.7±88.9, p = 0.568) 는 양군 사이에 통계학적인 유의성은 없었으나 당화혈색소(7. 0 ±1.5 vs 7.8±1.2, p = 0.05)는 normal flow 군에서 no-reflow 군에 비해 낮았다. 당뇨조절은 no-reflow 군에서 인슐린 치료를 필요로 하는 빈도가 normal flow 군에 비해 높은 경향을 보였다(33. 3 % vs 14.7% p = 0.058). 결론 당뇨환자에서 적절한 혈당조절은 급성심근경색으로 인한 관상동맥 중재시술시 관상 동맥 혈류장애를 개선시킬 수 있을 것이다.