The Korean Journal of Medicine

  • 제79권1호
  • /
  • Pages.23-31
  • /
  • 2010
  • /
  • 1738-9364(pISSN)
  • /
  • 2289-0769(eISSN)
대한내과학회 (The Korean Association of Internal Medicine)
권호 표지

급성 심근경색증 환자의 예후인자로서 내원 시 혈당의 유용성

Admission Glucose Is a Useful Prognostic Factor in Patients with Acute Myocardial Infarction

  • 투고 : 2009.12.03
  • 심사 : 2010.05.11
  • 발행 : 2010.07.01
⟨ 이전 논문 다음 논문 ⟩

초록

목적: 급성 심근경색증 환자에서 내원 당시 고혈당은 당뇨병의 유무와 관계없이 병원내 사망률을 증가시키고 예후가 나쁘다고 알려져 있으나 국내에서는 당뇨병을 동반하지 않은 급성 심근경색증 환자를 대상으로 내원 시 고혈당과 장단기 예후를 관찰한 연구가 미흡한 실정이다. 이에 본 연구에서는 급성 심근경색증 환자에서 내원 시 고혈당과 병원내 주요 임상 사건 및 사망률 그리고 1년 동안의 추적관찰을 통한 사망률을 알아보고자 하였다. 방법: 2005년 11월부터 2008년 1월까지 KAMIR에 등록된 14,870명의 급성 심근경색증 환자 중에서 당뇨병의 병력이 없고, 1년 동안의 추적관찰이 완료되어 분석 가능한 6,030명의 환자를 대상으로 하였다. 혈당 수치에 따라서 140 mg/dL 미만을 I군 3,307명($64.3{\pm}13.3$세, 여성 23.9%), 140 mg/dL 이상 200 mg/dL 미만을 II군 1,946명($65.9{\pm}12.7$세, 여성 29.5%), 200 mg/dL 이상을 III군 777명($67.7{\pm}13.0$세, 여성 35%)으로 분류하여 병원 내 주요 임상사건 및 1년 후 사망률과의 관계를 비교하였다. 결과: 위험인자에서 고혈압(p=0.001)과 흡연력(p=0.001), 현동반질환에서 심부전증(p=0.001)이 III군으로 갈수록 많았으며, 병원내 주요임상 사건에서는 심인성 쇼크(p=0.001), 심실성 빈맥증(p=0.001), 방실전도차단(p=0.001) 등과 입원 중 사망률(p=0.001)이 III군으로 갈수록 많았다. 위험인자를 보정한 Cox proportional anaylsis에서는 I군에 비해 II군에서 사망률이 유의하게 높았으며[Hazard ratio (HR)=1.19, 95% Cl(confidential interval) 1.02~1.40, p=0.032], I군에 비해 III군에서 사망률이 유의하게 높았다(HR=1.91, 95% Cl 1.59~2.30, p=0.001). II군과 III군 간의 비교에서도 II군에 비해 III군에서 사망률이 유의하게 높았다(HR=1.55, 95% Cl 1.27~1.88, p=0.001). 결론: 급성 심근경색증 환자의 내원 시 혈당이 높은 군으로 갈수록 입원 중 사망률 및 1년 후 사망률이 증가하였다.

Background/Aims: It has been suggested that admission hyperglycemia is associated with poor clinical outcomes in patients with acute myocardial infarction (AMI). The aim of this study was to assess the relationship between admission hyperglycemia and short-long term prognosis in patients with AMI. Methods: A total of 6,030 AMI patients without a previous history of diabetes were enrolled between Nov. 2005 and Jan. 2008. The patients were divided into three groups according to the levels of admission glucose levels: group I (<140 mg/dL, n=3,307), group II (140~199 mg/dL, n=1,946), and group III (${\geq}$200 mg/dL, n=777). In-hospital and one-year mortality were compared among three the groups. Results: The mean age was $64.3{\pm}13.3$, $65.9{\pm}12.7$, and $67.7{\pm}13.0$ years in group I, II and III, respectively. The proportion of female gender (23.9%, 29.5%, 35.0%; p<0.001), Killip class III-IV (8.9%, 12.3%, 28.3%; p<0.001), ST-segment elevation myocardial infarction (54.6%, 71.5%, 71.7%; p<0.001), and in-hospital mortality (3.5%, 7.5%, 19.7%; p<0.001) increased with higher tertiles of elevated values of initial serum glucose. Hazard ratio (HR) for mortality rate were significantly increased in group II [HR=1.19, 95% confidential interval (Cl) 1.02~1.40, p=0.032], and in group III [HR=1.91, 95% Cl 1.59~2.30, p=0.001], compared with group I. And also significant differences were existed between group II and group III [HR =1.55, 95% Cl 1.27~1.88, p=0.001]. Conclusions: Admission glucose in patients with AMI provides incremental prognostic value, and significantly correlates with in-hospital and one-year mortalities.

키워드

참고문헌

  1. Kim HS. Management of STEMI (ST Elevation Myocardial Infarction). Korean J Med 70:608-616, 2006
  2. Lee KH, Jeong MH, Ahn YK, Kim JH, Chae SC, Kim YJ, Hur SH, Seong IW, Hong TJ, Choi DH, Cho MC, Kim CJ, Seung KB, Chung WS, Jang YS, Cho JG, Park SJ. Sex differences of the clinical characteristics and early management in the Korea Acute Myocardial Infarction Registry. Korean Circ J 37:64-71, 2007 https://doi.org/10.4070/kcj.2007.37.2.64
  3. Bae EH, Lim SY, Jeong MH, Park HW, Lim JH, Hong YJ, Kim W, Kim JH, Cho JG, Ahn YK, Park JC, Suh SP, Ahn BH. Long-term predictive factors of major adverse cardiac events in patients with acute myocardial infarction complicated by cardiogenic shock. Korean J Intern Med 20:8-15, 2005 https://doi.org/10.3904/kjim.2005.20.1.8
  4. Lee WJ, Ko KS, Rhee BD. Intensive glucose and cardiovascular outcomes: focused on recent clinical trials. J Kor Endocr Soc 23:289-297, 2008 https://doi.org/10.3803/jkes.2008.23.5.289
  5. Mellbin LG, Malmberg K, Norhammar A, Wedel H, Ryden L. DIGAMI 2 Investigators. The impact of glucose lowering treatment on long-term prognosis in patients with type 2 diabetes and myocardial infarction: a report from the DIGAMI 2 trial. Eur Heart J 29:166-176, 2008
  6. Lee SL, Chang CH, Shim YH, Han DW, Kim CS, Hin CS. Admission hyperglycemia aggravates the prognosis of critically ill patients. Korean J Crit Care Med 19:121-125, 2004
  7. Kim CM, Yu KD, Moon KW, Paek SH, Park YG, Rho TH, Kim JH, Choi KB, Hong SJ. Glucose-insulin-potassium as an adjunctive therapy in acute myocardial infarction. Korean Circ J 35:779-786, 2005
  8. Capes, SE, Hunt, D, Malmberg, K, Gerstein, HC. Stress hyperglycemia and increased risk of death after myocardial infarction in patients with and without diabetes : a systematic overview. Lancet 355:773-778, 2000 https://doi.org/10.1016/S0140-6736(99)08415-9
  9. Stranders, I, Diamant, M, van Gelder, RE, Spruijt, HJ, Twisk, JW, Heine RJ, Visser FC. Admission blood glucose level as risk indicator of death after myocardial infarction in patients with and without diabetes mellitus. Arch Intern Med 164:982-988, 2004 https://doi.org/10.1001/archinte.164.9.982
  10. Ishihara M, Kagawa E, Inoue I, Kawagoe T, Shimatani Y, Kurisu S, Nakama Y, Maruhashi T, Ookawa K, Dai K, Aokage Y. Impact of admission hyperglycemia and diabetes mellitus on short- and long-term mortality after acute myocardial infarction in the coronary intervention era. Am J Cardiol 99:1674-1679, 2007 https://doi.org/10.1016/j.amjcard.2007.01.044
  11. Latchamsetty R, Fang J, Kline-Rogers E, Mukherjee D, Otten RF, LaBounty TM, Emery MS, Eagle KA, Froehlich JB. Prognostic value of transient and sustained increase in in-hospital creatinine on outcomes of patients admitted with acute coronary syndrome. Am J Cardiol 99:939-942, 2007 https://doi.org/10.1016/j.amjcard.2006.10.058
  12. Wahab NN, Cowden EA, Pearce NJ, Gardner MJ, Merry H, Cox JL. ICONS Investigators. Is blood glucose an independent predictor of mortality in acute myocardial infarction in the thrombolytic era?. J Am Coll Cardiol 40:1748-1754, 2002 https://doi.org/10.1016/S0735-1097(02)02483-X
  13. Suleiman M, Hammerman H, Boulos M, Kapeliovich MR, Suleiman A, Agmon Y, Markiewicz W, Aronson D. Fasting glucose is an important independent risk factor for 30-day mortality in patients with acute myocardial infarction: a prospective study. Circulation 1116:754-760, 2005
  14. Thygesen K, Alpert JS, White HD. Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J 28:2525-2538, 2007 https://doi.org/10.1093/eurheartj/ehm355
  15. Ryan TJ, Bauman WB, Kennedy JW, Kereiakes DJ, King SB 3rd, McCallister BD, Smith SC Jr, Ullyot DJ. Guidelines for percutaneous transluminal coronary angioplasty. A report of the American Heart Association/American College of Cardiology Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Percutaneous Transluminal Coronary Angioplasty). Circulation 88:2987-3007,1993 https://doi.org/10.1161/01.CIR.88.6.2987
  16. Scanlon PJ, Faxon DP, Audet AM, Carabello B, Dehmer GJ, Eagle KA, Legako RD, Leon DF, Murray JA, Nissen SE, Pepine CJ, Watson RM, Ritchie JL, Gibbons RJ, Cheitlin MD, Gardner TJ, Garson A Jr, Russell RO Jr, Ryan TJ, Smith SC Jr. ACC/AHA guidelines for coronary angiography. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Coronary Angiography). Developed in collaboration with the Society for Cardiac Angiography and Interventions. J Am Coll Cardiol 33:1756-1824,1999 https://doi.org/10.1016/S0735-1097(99)00126-6
  17. McCowen, KC, Malhotra, A, Bistrian, BR. Stress induced hyperglycemia. Crit Care Clin 17:107-124, 2001 https://doi.org/10.1016/S0749-0704(05)70154-8
  18. Dennis KE, Braunwald E, Anthony SF, Stephen LH, Dan LL, Jameson JL. Harrion's Principle of internal Medicine. 17th ed. P.2152-2180 New York, McGraw-Hill, 2008
  19. Hirsch IB. In patient hyperglycemia are we ready to treat it yet?. J Clin Endocrinal Metab 87:975-977, 2002 https://doi.org/10.1210/jc.87.3.975
  20. Kolman L, Hu YC, Montgomery DG, Gordon K, Eagle KA, Jackson EA. Prognostic value of admission fasting glucose levels in patients with acute coronary syndrome. Am J Cardiol 104:470-474, 2009 https://doi.org/10.1016/j.amjcard.2009.04.006
  21. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 87:978-982, 2002 https://doi.org/10.1210/jc.87.3.978
  22. Lee SH. Could we predict the development of slow/no-reflow phenomenon after reperfusion therapy? Korean J Med 74:1-3, 2008
  23. Roe MT, Ohman EM, Maas AC, Christenson RH, Mahaffey KW, Granger CB, Harrington RA, Califf RM, Krucoff MW. Shifting the open-artery-hypothesis downstream: the quest for optimal referfusion. J Am Coll Cardiol 37:9-18, 2001 https://doi.org/10.1016/S0735-1097(00)01101-3
  24. Choi DS, Baik SH. Inflammation, insulin resistance, and glucose intolerance in acute myocardial infarction patients without a previous diagnosis of diabetes mellitus. J Clin Endocrinal Metab 90:175-178, 2005