만성 신부전 환자에서 관상동맥질환의 비침습적 검사 = Diagnostic Noninvasive Tests for Coronary Artery Disease in Chronic Renal Failure Patients

다국어 초록 (Multilingual Abstract)

Background:As ischemic heart disease is the major cause of death in chronic renal failure patients, screening tests are clinically important. Although coronary angiography is considered the gold standard for the diagnosis of coronary artery disease, other noninvasive tests are usually used to avoid this potentially dangerous and costly procedure.
Methods:We retrospectively determined the sensitivity, specificity, and positive and negative predictive values for electrocardiography, echocardiography, cardiac enzyme determination, and Technetium 99m tetrofosmin (TF) single photon emission computed tomography (SPECT) in 61 chronic renal failure patients who underwent coronary angiography.
Results:Nineteen patients (31.1%) were undergoing chronic hemodialysis, seven patients (11.4%) were undergoing peritoneal dialysis, and thirty five patients (57.3%) were undergoing conservative treatment. 99mTc SPECT had a sensitivity of 96% and specificity of 19%. Although echocardiography and tronponin-T had a relatively lower sensitivity of 69 % and 56% than 99mTc SPECT, they had a higher specificity of 63% and 63%, respectively. 99mTc SPECT had the highest sensitivity of 88% and echocardiography had the highest specificity of 78% in renal replacement group. 99mTc SPECT had the highest sensitivity of 100% and Troponin T had the highest specificity of 71% in conservative treatment group.
Conclusion:Noninvasive test for coronary artery disease in patients with chronic renal failure, especially 99mTc SPECT is of limited value because of their low specificity, so echocardiography and troponin T may helpful for diagnosing coronary artery disease. (Korean J Nephrol 2005;24(3):407-413)

국문 초록 (Abstract)

배 경:허혈성 심질환은 만성 신부전 환자에서 주요 사망원인으로 관상동맥질환의 조기진단이 임상적으로 중요한데 관상동맥 조영술은 가장 정확하나 일차적으로 시행하기 어려운 단점이 있어 심전도, 심장초음파 등과 같은 비침습적 검사법이 이용되고 있으나 민감도와 특이도가 다양한 것으로 알려져 있다. 저자들은 만성 신부전 환자에서 위험성이 적고 정확성이 높은 비침습적인 검사법이 무엇인지 알아보기 위하여 본 연구를 시행하였다.
방 법:만성 신부전 환자 중 1997년부터 2003년까지 허혈성 심질환이 의심되는 환자에서 관상동맥조영술을 시행한 총 61명을 대상으로 하였으며 이 환자들의 심전도, 심초음파, 심근표지자, 심근 SPECT의 결과를 기록하여 관상동맥조영술 결과와 일치성 등을 조사하였다.
결 과:대상 환자 중 혈액투석 환자가 19명, 복막투석 환자가 7명, 보존적 치료환자가 35명이였다. 심근 SPECT는 민감도가 96%로 높았으나 특이도가 19%로 낮은 소견을 보였다. 심초음파와 TnT는 민감도는 각각 69%, 56%으로 상대적으로 낮았으나 특이도가 63%, 63%로 높은 소견을 보였다. 신대체 요법을 받는 환자군에서는 심근 SPECT와 심초음파가 각각 민감도 88%, 특이도 78%로 가장 높은 소견을 보였다. 보존적 요법을 받는 군에서는 심근 SPECT와 TnT가 각각 민감도 100%, 특이도 71%로 가장 높은 소견을 보였다.
결 론:만성 신부전 환자에서 관상동맥질환을 진단시 비침습적검사, 특히 심근 SPECT는 특이도가 낮아 심초음파, TnT를 함께 측정시 진단적 가치가 높을 것으로 사료된다.

참고문헌 (Reference)

1 "and creatine kinase MB in dialysis patients without ischemic heart disease evidence of cardiac troponin T expression in skeletal muscle" 43 : 976-982, 1997

2 "The predictive value of resting electrocardiograms for 12-year incidence of coronary heart disease in the Honolulu Heart Program" 41 : 293-302, 1998

3 "The epidemiology of coronary artery disease in patients on maintenance hemodialysis implications for management The Heart in End-Stage Renal Failure" 34-41, 1986

4 "The clinical epidemiology of cardiac disease in chronic renal failure" 10 : 1606-1615, 1999

5 "Predictive value of cardiac troponin I & T for subsequent death in end-stage renal disease" 106 : 2941-2945, 2002

6 "Prediction of coronary artery disease and cardiac events using electrocardiographic changes during hemodialysis" 36 : 592-599, 2000

7 "Perfusion thallium imaging of type I diabetes patients with end stage renal disease:comparison of oral and intravenous dipyridamole administration" 175 : 103-105, 1990

8 "Outcome and risk factors of ischemic heart disease in chronic uremia" 49 : 1428-1434, 1996

9 "Onset of coronary artery disease prior to initiation of haemodialysis in patients with end-stage renal disease" 12 : 718-723, 1997

10 "Kidney disease as a risk factor for development of cardiovascular disease a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease" 42 : 1050-1065, 2003

11 "Informational contribution of noninvasive screening tests for coronary artery disease in patients on chronic renal replacement therapy" 37 : 56-63, 2001

12 "Informational contribution of noninvasive screening tests for coronary arterty disease in patients on chronic renal replacement therapy" 37 : 56-63, 2001

13 "Ineffectiveness of dipyridamole SPECT thallium imaging as a screening technique for coronary artery disease in patients with end-stage renal failure" 49 : 100-103, 1990

14 "How to manage the renal patient with coronary heart disease:The agony and the ecstasy of opinion-based medicine" 14 : 2556-2572, 2003

15 "Homocysteinemia and vascular disease in end-stage renal disease" 57 : 11-17, 1996

16 "Highly specific immunoassay for cardiac troponin I assessed in noninfarct patients with chronic renal failure or severe polytrauma" 41 : 1675-1676, 1995

17 "Clinical epidemiology of cardiovascular disease in chronic renal disease" 32 : -119, 1998

18 "Clinical aspects of cardiomyopathy in dialysis patients" 12 : 267-276, 1994

19 "Cardiac troponins in renal insufficiency:review and clinical implications" 40 : 2065-2071, 2002

20 "Cardiac troponin elevations in patients without acute coronary sy ndrome" 106 : 2871-2872, 2002

21 "Cardiac troponin I.A marker with high specificity for cardiac injury" 88 : 101-106, 1993

22 "A prospective comparison of methods for determining if cardiovascular disease is a predictor of mortality in dialysis patients" 23 : 382-388, 1994