심전도상 흉부유도에서 지속적 T파 역위를 보이는 협심증 환자의 임상 및 관동맥조영소견과 치료후의 변화

Abstract

[한글]

임상에서 기본적으로 시행하는 안정시 표면 심전도검사는 허혈성 심질환의 진단과 예추정에 도움이 되는 경우가 많다. 안정시 심전도상 흉부유도에서 대칭적 T파의 역위물 보이는 협심증 환자들은 대부분 좌전하행관동맥의 심한 협착을 동반하며 예후도 불량한 것으로 몇몇 외국 문헌에 보고되었으나 국내에서는 이어대한 연구가 보고된 바 없다.

이에 저자는 1980년 1월부터 1989년 12월까지 연세대학교 의과대학 부속 세브란스 병원에 입원한 협심증 환자중 관동맥조영소견에서 주요 내경이 50%이상 협착되어 있으면서 안정시 표면심전도상 지속적으로 흉부유도에 대칭적 T파 역위를 보이는 89예(T봐 음성군)와 정상 심전도소견을 나타낸 132예(T파 양성군)의 임상 및 관동맥과 좌심실조영소견을 비교 관찰하고, T파 역위가 있는 환자들에서 경피적 관동맥 풍선확장성형술과 약물치료에 따른 T파의 변화를 관찰하여 다음과 같은 결과를 얻었다.

1. T파 음성군의 평균연령은 56.4±12.9세, 남녀비는 2.3:1 이었고, T파 양성군의 평균연령은 54.4±8.8세, 남녀비 3.1:1로 T파 음성군에서 여자의 비율이 높았으나 통계적 의의는 없었으며, 협심증의 기간은 T파 음성군이 5.7±11.2개월, T파 양성군이 9.0±13.8개월로서 T파 음성군에서 통계적 의의는 없었으나 다소 짧은 양상을 보였다. 위험인자들 중 T파 양성군에서 혈청 콜레스테롤치가 약간 높은 것(187.4±35.5mg/dl v.s. 199.9±49.2mg/dl, p<0.05)을 제외하고는 양군간에 의의있는 차이는 없었다.

2. 관동맥질환의 범위는 T파 음성군에서 좌주간관동맥질환 3예(3.3%), 단일혈관질환 54예(60.7%), 두혈관질환 20예(22.5%), 세혈관질환이 12예(13.5%)였고, T파 양성군에서는 좌주간관동맥질환이 10예(7.5%), 단일혈관질환 71예(53.8%), 두혈관질환 29예(22.0%), 세

혈관질환이 22예(16.7%)로서 양군간에 의의있는 차이는 없었다.

3. 좌전하행동맥과 대각지에 협착이 있는 경우는 T파 음성군이 87.9%, T파 양성군이 76.5%로서 T파 음성군에서 의의있게 많았다(p<0.05). 좌전하행동맥 주간의 근위부 협착은 T파 음성군에서 53.2%, 양성군 54.1%로서 양군사이에 의의있는 차이는 없었다. 좌전하행동맥의 평균협착정도는 T파 음성군 79.5±17.0%, T파 양성군 77.0±16.2%로서 양군간에 의의있는 차이는 없었으나 95%이상의 심한 협착은 T파 음성군에서 32.9%, 양성군은 14.3%로서 음성군이 양성군보다 의의있게 많았다(p＜0.05).

4. 좌심실조영술을 시행하였던 환자에서 좌전하행동맥 지배부위의 심실벽 운동이상은 T파 음성군에서 25.3%, 양성군 11.9%로 음성군에서 심실벽의 운동이상이 의의있게 많았다(p＜0.05). 그러나 좌심실 구혈율(68.8±12.8% v.s. 71.9±11.4%)과 좌심실 말기확장기압( 11.6±5.4mmHg v.s. 12.9±4.9mmHg)은 양군간에 의의있는 차이가 없었다.

5. T파 양성군에서 관동맥우회로술 시행후 사망한 2예를 제외하고는, 입원중 사망하거나 급성심근경색증이 발생한 경우는 양군 모두 1예도 없었다.

6. T파 음성군에서 경피적 관동맥 풍선확장성형술을 시행하여 성공한 군과 약물치료만을 시행한 군의 T파의 변화를 비교한 결과 경피적 관동맥 풍선확장성형술을 시행한 군에서 좌전하행동맥 협착의 정도가 약물치료만 시행한 군에서 보다 심함에도 불구하고(86.6

±10.9% v.s. 70.8±21.4%, p＜0.05), T파의 역위가 정상화되는 비율이 의의있게 높았다(70.8% v.s. 37.0%, p<0.05).

이상의 결과로서 협심증 환자에서 안정시 표면심전도상 흉부유도의 대칭적 T파의 역위는 좌전하행동맥의 심한 협착 및 심벽의 운동이상과 관련이 깊은 것으로 보이며, 경피적 관동맥 풍선확장성형술과 같은 적절한 치료를 시행하는 경우에는 심근허혈의 개선과 함께

T파의 역위가 정상화될 수 있고 예후가 반드시 불량하지만은 않은 것으로 사료된다.

Clinical and coronary angiographic findings of patients with angina pectoris

showing persistent I wave inversion in the precordial leads on the resting

electrocardiogram and T wave changes after treatments

Jin Hyuk Choi

Department of Medical Science The Graduate School Yonsei University

(Directed by Associated Professor Seung Yun Cho. M.D.)

The resting electrocardiography performed routinely in the clinical field is a

useful method for the diagnosis of ischemic heart disease and for predicting its

prognosis. There have been reports about angina patients with symmetric T wave

inversion in the precordial leads on the resting electrocardiogram(ECG) who usually

showed stenotic lesions of left anterior descending coronary artery and with poor

prognosis. However, we have had no studies on this subject in Korea .

The author conducted retrospectively a comparative study on the patients uith

angina pectoris in the Yonsei University Severance Hospital from Jan. 1980 to Dec.

1989. We set two groups for comparison: one group consisted of 89 patients who had

more than 50% stenosis in luminal diameter of coronary artery on coronary angiogram

and persistent symmetric T wave inversion in the precordial leads (T negative

group): the other group included 132 patients who had normal ECG but significant

stenosis of the coronary arteries (T positive group). We compared theme two groups

in clinical and coronary angiographic findings and evaluated the changes of T wave

after percutaneous transluminal coronary angioplasty(PTCA) and medical treatment in

the T negative group.

1. The mean age of the T negative group was 56.4±12.9 years, and the male to

female ratio was 2.3:1; in the T positive group. the mean age was 54.4±8.8 years,

and the male to female ratio was 3.1:1. There was a relatively high occurrence rate

in females in the T negative group, but this was not statistically significant. The

duration of angina was 5.7±11.2 months in the T negative group, and 9.0±13.8

months in the T positive group, and relatively short in the T negative group. There

was no difference in the risk factors between these trio groups except for a

slightly higher level of serum cholesterol in the T positive group than the T

negative group (187.4±35.5mg/dl v.s. 199.9±49.2mg/dl, p<0.05).

2. The extent of coronary artery disease in the T negative group was 3 cases of

left main coronary artery disease(3.3%), 54 cases of one vessel disease(60.7%), 20

cases of trio vessel disease(22.5%), 12 cartes of three vessel disease (13.5%): in

the T positive group, left main coronary artery disease was found in 10

cases(7.5%), one vessel disease in 71 cases(53.8%), two vessel disease in 25

cases(22.0%), three vessel disease in 22 cases(16.7%). There was no difference in

the extent of coronary artery disease between these two groups.

3. The occurrence rate of involvement of left anterior descending artery (LAD)

and its branches was 87.9% in the T negative group, and 76.5% in the T positive

group, which indicated more frequent involvement of LAD in the T negative

group(p<0.05). The mean degree of stenosis of LAD was 79.5±17.0% in the T negative

group, and 77.0±16.2% in the T positive group, but there was no significant

difference between the two groups. Those patients with more than 95% stenosis of

LAD were 32.9% of the T negative group, 14.3% of the T positive group, and the T

negative group showed a significantly higher rate than the T positive

group(p<0.05).

4. The wall motion abnormalities in the LAD territory were more frequently noted

in the T negative group than the T positive group(25.3% v.s. 11.9%, p<0.05).

However, upon determining the ejection fraction(68.8±12.8% v.s. 71.9±11.4%) and

left ventricular end diastolic pressure(11.6±5.4mmHg v.s. 12.9±4.9mmHg), no

difference was found.

5. There were no episodes of acute myocardial infarction or hospital death during

the admission in either group except for 2 cases of death after coronary artery

bypass graft in the I positive group.

6. Although the patients who underwent PTCA showed more severe stenosis of LAD

than those who had radical treatment only in the T negative group (86.0±10.9% v.s.

70.8±21.4%, p<0.05), there was a higher rate of normalization of T wave inversion

in the PTCA group compared with that in the medical treatment group(70.8% v.s.

37.0%, p＜0.05).

The above results suggest that T wave inversion in the precordial leads on the

resting ECG in patients with angina pectoris was associated with severe stenosis of

LAD and ventricular wall motion abnormalities, and the T wave inversion could be

normalized with improvement of myocardial ischemia and the prognosis for such

patients was relatively good if appropriate treatments such as PTCA were performed.

[영문]

The resting electrocardiography performed routinely in the clinical field is a useful method for the diagnosis of ischemic heart disease and for predicting its prognosis. There have been reports about angina patients with symmetric T wave inversion in the precordial leads on the resting electrocardiogram(ECG) who usually showed stenotic lesions of left anterior descending coronary artery and with poor prognosis. However, we have had no studies on this subject in Korea .

The author conducted retrospectively a comparative study on the patients uith angina pectoris in the Yonsei University Severance Hospital from Jan. 1980 to Dec. 1989. We set two groups for comparison: one group consisted of 89 patients who had more than 50% stenosis in luminal diameter of coronary artery on coronary angiogram and persistent symmetric T wave inversion in the precordial leads (T negative group): the other group included 132 patients who had normal ECG but significant stenosis of the coronary arteries (T positive group). We compared theme two groups in clinical and coronary angiographic findings and evaluated the changes of T wave after percutaneous transluminal coronary angioplasty(PTCA) and medical treatment in the T negative group.

1. The mean age of the T negative group was 56.4±12.9 years, and the male to female ratio was 2.3:1; in the T positive group. the mean age was 54.4±8.8 years, and the male to female ratio was 3.1:1. There was a relatively high occurrence rate in females in the T negative group, but this was not statistically significant. The duration of angina was 5.7±11.2 months in the T negative group, and 9.0±13.8 months in the T positive group, and relatively short in the T negative group. There was no difference in the risk factors between these trio groups except for a slightly higher level of serum cholesterol in the T positive group than the T negative group (187.4±35.5mg/dl v.s. 199.9±49.2mg/dl, p<0.05).

2. The extent of coronary artery disease in the T negative group was 3 cases of left main coronary artery disease(3.3%), 54 cases of one vessel disease(60.7%), 20 cases of trio vessel disease(22.5%), 12 cartes of three vessel disease (13.5%): in

the T positive group, left main coronary artery disease was found in 10 cases(7.5%), one vessel disease in 71 cases(53.8%), two vessel disease in 25 cases(22.0%), three vessel disease in 22 cases(16.7%). There was no difference in the extent of coronary artery disease between these two groups.

3. The occurrence rate of involvement of left anterior descending artery (LAD) and its branches was 87.9% in the T negative group, and 76.5% in the T positive group, which indicated more frequent involvement of LAD in the T negative

group(p<0.05). The mean degree of stenosis of LAD was 79.5±17.0% in the T negative group, and 77.0±16.2% in the T positive group, but there was no significant difference between the two groups. Those patients with more than 95% stenosis of LAD were 32.9% of the T negative group, 14.3% of the T positive group, and the T

negative group showed a significantly higher rate than the T positive group(p<0.05).

4. The wall motion abnormalities in the LAD territory were more frequently noted in the T negative group than the T positive group(25.3% v.s. 11.9%, p<0.05). However, upon determining the ejection fraction(68.8±12.8% v.s. 71.9±11.4%) and left ventricular end diastolic pressure(11.6±5.4mmHg v.s. 12.9±4.9mmHg), no difference was found.

5. There were no episodes of acute myocardial infarction or hospital death during the admission in either group except for 2 cases of death after coronary artery bypass graft in the I positive group.

6. Although the patients who underwent PTCA showed more severe stenosis of LAD than those who had radical treatment only in the T negative group (86.0±10.9% v.s. 70.8±21.4%, p<0.05), there was a higher rate of normalization of T wave inversion in the PTCA group compared with that in the medical treatment group(70.8% v.s. 37.0%, p＜0.05).

The above results suggest that T wave inversion in the precordial leads on the resting ECG in patients with angina pectoris was associated with severe stenosis of LAD and ventricular wall motion abnormalities, and the T wave inversion could be normalized with improvement of myocardial ischemia and the prognosis for such patients was relatively good if appropriate treatments such as PTCA were performed.