관동맥연축의 비침습적 진단에 있어 Ergonovine Echocardiogrpahy의 유용성

송재관,박성욱,김재중,두영철,김원호,박승정,이종구 울산대학교 의과대학 1992 울산의대학술지 Vol.1 No.1

관동맥연축의 비침습적인 진단방법의 확립은 침습적인 관동맥조영술 및 연축유발검사에 비해 반복적용이 가능한 이론적인 장점이 있어 선별검사(screening test)로서의 기능뿐만 아니라 치료로 이용되는 약물의 효과비교 및 추적검사를 통한 관동맥연축의 임상ㄹ활동도 평가등에 손쉽게 이용될 수 있으라라 예상된다. 이에 저자들은 ergonovine 투여시 기록된 좌심실벽운동장애 유무가 갖는 관동맥연축에 의한 심근허혈의 진단적 가치를 평가하기 위해 Beside Ergonovine Echocardiography Test를 시행하였다. 관동맥조영술 및 연축유발검사에서 변이형협심증으로 증명된 30명(남자 27명, 평균연령 54세)과 비특이적인 흉통질환군 20명(여자 12명, 평균연령 55세)을 대상으로 관동맥조영술 다음날 ergonovine test를 시행하였다. 운동부하검사가 음성인 환자들을 대상으로 6시간 공복시킨 뒤 앙와위에서 상지정맥을 통하여 25-50microgram(이하 mcg)을 5뷴 간격으로 투여하여 흉통의 유무, 심전도 및 이면성심초음파를 5분마다 기록하였으며 총투여량이 350mcg에 도달하거나 양성반응을 보이는 경우 nitroglycerin 250mcg 정주 및 설하투여로 종료하였다. 좌심실벽운동의 분석은 side-by-side continuous cine-loop display가 가능한 QUAD screen 방법으로 판별하였다. 가역적인 심전도 변화나 국소적인 심실벽운동장애가 유발되는 경우를 양성으로 판정하였다. Ergonovine Echocardiography의 전체 민감도는 90%, 특이도는 100%로 동시에 기록된 심전도 변화의 민감도(73%)보다 높았으며 특히 흉통이 있으나 심전도 변화가 전혀 없었던 5례 모두에서 좌심실벽운동장애가 관찰되어 본 검사법의 우월성을 확인할 수 있었다. 양성반응을 보인 ergonovine 평균 투여량이 173±95mcg 이었으며 흉통발작의 빈도를 기준으로한 임상활동도가 높은 경우 활동도가 낮은 군에 비해 양성반응을 의한 총 ergonovine 투여량이 적었으며(123±86 vs 213±83mcg, p<0.01) 관동맥협착이 연축에 동반되어 있는 경우 정상 관동맥에 연축이 있는 경우보다 민감도가 더 높았다(100% va 60%, P=0.02). Ergonovine 투여로 혈압은 기저치 보다 약 17%정도 증가되었으나 맥박수는 큰 변화를 나타내지 않아 안전하게 시행될수 있었으며 오심, 두통, 견갑부통증, 심실기외수축, 방실차단 등이 소수례에서 관찰되었으나 검사로 인한 사망례는 없었다. Ergonovine 주입후 기록된 좌심실벽운동동장애는 심전도 변화보다 더 민감하게 관동맥연축에 의한 심근허혈을 진단할 수 있었으며 Ergonovine Echocardiography는 운동부하검사 등으로 심한 관동맥협착이 배제된 선별된 흉통환자들에서 관동맥연축의 진단에 안전하게 시행될 수 있는 민감하고 특이도가 높은 검사방법이며 변이형협심증의 임상활동도와 관동맥협착의 동반유무가 본 검사법의 결과에 영향을 미칠 수 있으리라 사료된다. The purpose of this study was to evaluate the clinical feasibility of bedside intravenous ergonovine test with echocardiography as a noninvasive diagnostic method for coronary vasospasm. Bedside ergonovine test was performed in 50 patients with chest pain one day after coronary angiography with spasm provocation test;30 patients showed positive results of provocation test while in 20 patients there was no evidence of coronary vasospasm. A bolus of ergonovine maleate(.025 or .05mg) was injected at 5 min intervals up to total cumulative dosage of 0.35mg, and 12-leads ECG and 2-D Echo were recorded every 3min after each injection. Left ventricular wall motion was analyzed with a commercially available ' QUAD' system. The positive criteria of beside ergonovine test included reversible ST segment elevation or depression, T wave changes in ECG(ECG criteria) and reversible regional wall motion abnormalities(RWMA) in Echo(Echo criteria). The overall sensitivity and specificity of ECG criteria were 73%(22/30) and 100% respectively ; The sensitivity of Echo criteria increased up to 90%(27/30) without the change of the specificity. Among 22 patients with reversible ECG changes only 73%(16/22) showed typical ST segment elevation while ST depression was recorded in 2 patients(9%) and minor T wave peaking or flattening without ST segment displacement in 4 patients(18%). Concomitant fixed coronary lesion does increase the sensitivity of the test compared to pure coronary vasospasm with ECG criteria(100% vs 60%, p<0.05). Mean does of ergonovine with positive results was 173±95 microgram(mcg) and the amount of does of ergonovine for positive result was significantly larger in patients with low disease activity (chest pain <5times/자) than those with high disease activity(213±83 vs 123±86mcg, p<0.01). There was no procedure related mortality or fatal arrhythmias. Ergonovine echocardiography is a highly sensitive and specific test for coronary vasospasm and is safe in selected patients in whom the exercise test is negative and severe fixed coronary artery disease has been excluded. Presence of concomitant fixed coronary artery disease and the degree of clinical activity of coronary vasospasm may influence the results of this test.

관동맥연축의 진단을 위한 Ergonovine Echocardiography의 안전성 및 임상적 유용성

송재관,박성욱,강덕현,조구영,나득영,이내희,이철환,홍명기,김재중,박승정 대한순환기학회 2000 Korean Circulation Journal Vol.30 No.8

관동맥연축에서 서방형 칼슘길항제인 Diltiazem 과 Verapamil 의 치료효과 : Ergonovine Echocardiography 를 이용한 무작위 비교 연구

송재관(Jae Kwan Song),박성욱(Seong Wook Park),제수정(Soo Jung Je),김재중(Jae Joong Kim),두영철(Young Cheoul Doo),김원호(Won Ho Kim),진재용(Jae Yong Chin),김형호(Hyeong Ho Kim),정상식(Sang Sig Cheong),박승정(Seung Jung Park),이종구(Jo 대한내과학회 1994 대한내과학회지 Vol.46 No.3

N/A Background: Detection of left ventricular regional wall motion abnormality with two dimensional echocardiography during ergonovine injection (Ergonovine Echocardiography: Erg Echo) is a useful noninvasive diagnostic method of coronary vasospasm, and as it can be used repeatedly, comparison of the therapeutic efficacy of the prescribed drugs for the patients with variant angina may be possible with this method. The purpose of this study were to compare the antispasmotic action of short-term medication of two currently available sustained-releasing (SR) calcium antagonists (Diltiazem vs Verapamil) with Erg Echo, to investigate the factors determining the drug efficacy and to determine if the results of repeated tests of Erg Echo after shortterm medication correlate with the clinical response. Methods: Forty patients with angiographicallyproven coronary vasospam and positive Erg Echo without medication were randomly assigned into group I and II. Diltiazem SR 90mg b.i,d. was prescribed in the patients of group l and Verapamil SR 120 mg b.i.d. in group II. Isosorbide-5-mononitrate (ISMN, Elantan 20 mg b.i.d.) was commonly given in both groups. After medication of 4 days Erg Echo was repeated, and if follow up results were positive doubling of the dosage of prescribed calcium channel antagonists (i.e. Diltiazem SR 180 mg or Verapamil SR 240 mg b.i.d.) was done and the second follow up test of Erg Echo was performed after another 4 days. Clinical follow-up was done with the dosage of negative Erg Echo, and during 9 (±3) month follow-up period one patient of group I and two of group II were lost and final analysis was done with total 37 patients (19 in group I and 18 in group II). Results: Among 37 patients with variant angina, 32 were male and the mean age was 53 (±8). Sex ratio, mean age, body weight, clinical activity of variant angina assessed by the frquency of chest pain attack, number of spasm-documented coronary vessels, dosage of ergonovine for positive response in baseline Erg Echo and number of the patients with concomitant fixed coronary stenosis were not significantly different between both groups. After 4 day medication coronary vasospasm was not provoked with ergonovine injection in 13 patients of group I, and the positive rate of Erg Echo after medication was 32% (6/19) in group I, which was not significantly different from that (50%, 9/18) of group II (p=0.66). In 15 patients coronary vasospasm was provoked with ergonovine injection despite the medication, and ergonovine dose for positive response rose from 146±84 microgram (mcg) to 218±75 mcg with medication. Patients with 'mixed disease' (coronary vasospasm and concomitant fixed disease) showed higher positive result of Erg Echo after medication than the patients with pure spasm (p=0.001). During open label follow-up of 9±3 months, there was neither case of acute myocardial infarction nor that of sudden cardiac death. Recurrent chest pain with medication was observed in 6 patients of group I and 7 of group II (p=0.90), and recurrent chest pain during follow-up was more frequently observed in patients with positive Erg Echo after 4 day medication than those with negative test (p=0.01). In group II medication was modified to control the high activity of variant angina (chest pain attacks more than 5 per week) in 3 patients and verapamil SR was withdrawned in 4 patients due to side effects (2 cases of impotence, each case of constipation and peripheral edema), while there was no case of drug modification or withdrawl of diltiazem SR (p<0.05) in group I. Conclusion: Although there was no significant difference of short term medication on prevention of coronary vasospasm provoked by ergonovine injection, during long term follow-up of variant angina, diltizem SR with ISMN was superior to verapamil SR with ISMN in control of chest pain and absence of side effects. Erg Echo after short term medication was useful in comparison of drug efficacy, investication of the fact

Ergonovine Stress Echocardiography for the Diagnosis of Vasospastic Angina and Its Prognostic Implications in 3,094 Consecutive Patients

Yeo-Jeong Song,Sang Jin Ha,Dong Seok Lee,Woo-Dae Bang,신동금,Yeongmin Woo,Sangsig Cheong,Sang-Yong Yoo 대한심장학회 2018 Korean Circulation Journal Vol.48 No.10

Background and Objectives Ergonovine stress echocardiography (ErgECHO) has been proposed as a noninvasive tool for the diagnosis of coronary vasospasm. However, concern over the safety of ErgECHO remains. This study was undertaken to investigate the safety and prognostic value of ErgECHO in a large population. Methods We studied 3,094 consecutive patients from a single-center registry who underwent ErgECHO from November 2002 to June 2009. Medical records, echocardiographic data, and laboratory findings obtained from follow-up periods were analyzed. Results The overall positive rate of ErgECHO was 8.6%. No procedure-related mortality or myocardial infarction (MI) occurred. Nineteen patients (0.6%) had transient symptomatic complications during ErgECHO including one who was successfully resuscitated. Cumulative major adverse cardiac events (MACEs) occurred in 14.0% and 5.1% of the patients with positive and negative ErgECHO results, respectively (p<0.001) at a median follow-up of 10.5 years. Cox regression survival analyses revealed that male sex, age, presence of diabetes, total cholesterol level of >220 mg/dL, and positive ErgECHO result itself were independent factors associated with MACEs. Conclusions ErgECHO can be performed safely by experienced physicians and its positive result may be an independent risk factor for long-term adverse outcomes. It may also be an alternative tool to invasive ergonovine-provoked coronary angiography for the diagnosis of vasospastic angina.

급성관동맥증후군 환자와 변이형 협심증 의증 환자에서 Ergonovine 부하 심초음파 검사의 유용성

박태호,김무현,박은희,강기태,김성근,장세준,이수훈,차광수,김영대,김종성 대한순환기학회 2001 Korean Circulation Journal Vol.31 No.4

에르고노빈 심초음파로 확진된 승모판 폐쇄부전을 유발한 혈관연축 1예

차정준,경찬희,조장호,김용훈,김혜원,이성주,임세중,최의영 영남대학교 의과대학 2013 Yeungnam University Journal of Medicine Vol.30 No.2

The common causes of organic mitral regurgitation (MR) include mitral valve prolapse (MVP) syndrome, rheumatic heart disease, and endocarditis. MR also occurs secondary to dilated cardiomyopathy and coronary artery disease. In acute severe MR, the hemodynamic overload often cannot be tolerated, and mitral valve repair or replacement must be performed immediately. We report herein a case of severe MR due to coronary vasospasm that was confirmed via ergonovine echocardiography in a 70-year-old man. He was scheduled to undergo mitral valve surgery, but it did not push through and he was put on medical therapy.