123.2 📚 國考版醫垫國考 / PGY OSCE

123.2.0.1 📌 Cram Sheet

123.2.0.1.1 🔥 高 yield 12
  1. Aspirin = irreversible COX-1 acetylation75-100 mg daily 預防platelet 終生10 day
  2. P2Y12 inhibitors: clopidogrel (CYP2C19 prodrug), prasugrel (avoid > 75 / < 60 kg / prior stroke), ticagrelor (reversible, dyspnea/brady AE)
  3. DAPT post-PCI: 12 mo standardTWILIGHT 3 mo DAPT → ticagrelor alone for high bleed
  4. UFH (aPTT 1.5-2.5x, protamine 1 mg : 100 unit)LMWH (no monitor, partial protamine reversal)fondaparinux (anti-Xa only, no reversal)
  5. Warfarin = VKOR inhibitor; INR 2-3 (most), 2.5-3.5 (mech mitral, recurrent VTE)vit K + 4F-PCC reversal
  6. DOAC: dabigatran (IIa) + rivaroxaban/apixaban/edoxaban (Xa)idarucizumab (dabi reversal), andexanet (Xa reversal)
  7. DOAC contraindicated: mech valve (RE-ALIGN), triple-positive APS (TRAPS), pregnancy, severe renal
  8. Factor XI inhibitors 22E: abelacimab/milvexian/asundexian — 抗血栓 䞍增 bleed
  9. tPA stroke: ≀ 4.5 hr; 0.9 mg/kg, max 90 mg; 10% bolus + 90% over 1 hr
  10. STEMI tPA: if PCI > 120 min delay; 100 mg accelerated 1.5 hr
  11. Massive PE tPA: 100 mg over 2 hr
  12. Warfarin teratogenic in pregnancy → LMWH preferred
123.2.0.1.2 🔢 必背敞字
項目 æ•žå­—
Aspirin daily prevention 75-100 mg
Aspirin loading ACS 300 mg
Clopidogrel loading 600 mg
Ticagrelor loading 180 mg
Ticagrelor maintenance 90 mg bid
Prasugrel maintenance 10 mg qd
LMWH (enoxaparin) 1 mg/kg bid (treatment)
UFH bolus VTE 80 IU/kg + 18 IU/kg/hr
Fondaparinux dose 7.5 mg SC qd (50-100 kg)
Warfarin INR (most) 2-3
Warfarin INR (mech mitral, recurrent VTE) 2.5-3.5
Apixaban for VTE 10 bid × 7d → 5 bid
Apixaban for AF 5 bid (or 2.5 if criteria)
Rivaroxaban for VTE 15 bid × 21 d → 20 qd
Rivaroxaban for AF 20 qd
Dabigatran for AF 150 bid (110 if old/renal)
Idarucizumab dose 5 g IV
Andexanet bolus 400/800 mg + infusion
4F-PCC dose 25-50 IU/kg
Protamine 1 mg per 100 unit heparin
tPA stroke window ≀ 4.5 hr (extended 9 hr selected)

123.2.0.2 ⭐ 高 yield è¡š

123.2.0.2.1 Antiplatelet 比范
藥 Class Onset 每日 反蜉
Aspirin COX-1 irreversible 30 min 75-100 mg Platelet transfusion
Clopidogrel P2Y12 irreversible 6 hr 75 mg Platelet transfusion (loading 600 mg)
Prasugrel P2Y12 irreversible 30 min 10 mg (avoid > 75 / < 60 kg / prior stroke)
Ticagrelor P2Y12 reversible 30 min 90 mg bid dyspnea, brady
Cangrelor P2Y12 IV reversible mins IV PCI bridging reversal short
123.2.0.2.2 Anticoagulant 比范
藥 Target Route Monitor Reversal
UFH IIa + Xa (1:1) IV aPTT Protamine
LMWH (enoxaparin) Xa > IIa SC None (anti-Xa if needed) Protamine partial
Fondaparinux Xa only SC None rFVIIa or 4F-PCC
Argatroban IIa direct IV aPTT (HIT only)
Warfarin Vit K (II/VII/IX/X + PC/PS) PO INR Vit K + 4F-PCC
Dabigatran IIa direct PO None Idarucizumab
Rivaroxaban Xa direct PO None Andexanet alfa or 4F-PCC
Apixaban Xa direct PO None Andexanet or 4F-PCC
Edoxaban Xa direct PO None Andexanet or 4F-PCC
123.2.0.2.3 DOAC vs Warfarin 遞擇
情境 遞
Non-valvular AF DOAC > warfarin (apixaban most balanced)
VTE acute / extended DOAC (apixaban/rivaroxaban no lead-in; dabigatran/edoxaban LMWH lead-in)
Cancer-associated thrombosis DOAC (CARAVAGGIO) > LMWH (most cancers); LMWH for GI/GU
Mechanical valve Warfarin (DOAC contraindicated)
Triple-positive APS Warfarin (DOAC contraindicated)
Pregnancy LMWH (DOAC + warfarin contraindicated)
Severe renal failure (CrCl < 15) Warfarin (or low-dose apixaban if criteria)
Bridging for surgery LMWH replace DOAC (depending on bleed risk + procedure timing)
123.2.0.2.4 tPA Indications + Contraindications
Indication 時間窗 Dose
Acute ischemic stroke ≀ 4.5 hr (extended 9 hr selected) 0.9 mg/kg, max 90 mg
STEMI (no PCI access) < 12 hr (best < 3 hr) 100 mg accelerated
Massive PE < 14 day 100 mg / 2 hr
Catheter clot — 局郚
Absolute Contraindications
Active bleeding
Recent (3 mo) hemorrhagic stroke / brain surgery / trauma
Suspected aortic dissection
Brain tumor / aneurysm
BP > 185/110 (stroke), > 180/100 (others)
Bleeding disorder / 嚎重 thrombocytopenia
123.2.0.2.5 22E Trials 重芁
Trial 結論
TWILIGHT Ticagrelor alone after 3 mo DAPT for high-bleed PCI
COMPASS Rivaroxaban 2.5 bid + aspirin > aspirin alone in CAD/PAD
CARAVAGGIO Apixaban ≥ dalteparin for CAT
SELECT-D Rivaroxaban ≥ dalteparin
TRAPS DOAC inferior in triple-positive APS
RE-ALIGN Dabigatran inferior in mech valve
AZALEA-TIMI 71 Abelacimab (Factor XI i) ↓ bleed vs rivaroxaban in AF

123.2.0.3 🎯 自我檢枬 12 題

  1. Aspirin 機制 → COX-1 irreversible acetylation
  2. P2Y12 inhibitor reversible 䞀個 → Ticagrelor
  3. Prasugrel 犁忌 → > 75 æ­² / < 60 kg / prior stroke
  4. UFH reversal? → Protamine 1 mg : 100 unit
  5. Warfarin INR target for mech mitral? → 2.5-3.5
  6. Dabigatran reversal? → Idarucizumab (Praxbind) 5 g IV
  7. Xa inhibitor reversal? → Andexanet alfa or 4F-PCC
  8. DOAC contraindicated 䞉倧情境? → Mech valve, triple-positive APS, pregnancy
  9. tPA stroke time window? → ≀ 4.5 hr (extended 9 hr selected)
  10. tPA STEMI indication? → PCI > 120 min delay
  11. Factor XI inhibitor 22E example? → Abelacimab, milvexian, asundexian
  12. Pregnancy 抗凝銖遞? → LMWH (enoxaparin)

123.2.0.4 🩺 PGY OSCE 堎景

123.2.0.4.1 Scenario 165 æ­² STEMI + PCI 芏劃
  • ASA 300 mg loading + 81 mg daily
    • Ticagrelor 180 mg loading + 90 mg bid
  • IV UFH bolus pre-PCI
  • DAPT × 12 mo
123.2.0.4.2 Scenario 270 æ­² AF + CHA2DS2-VASc 4 + bleed risk moderate
  • Apixaban 5 mg bidadjust if criteria → 2.5 bid
  • 芏埋 follow renal + bleed signs
  • 衛教 dose timing + adherence
123.2.0.4.3 Scenario 3dabigatran-treated AF + 急性 ICH
  • Stop dabigatran
  • Idarucizumab 5 g IV
  • ICU + neurosurgery consult + supportive
  • 埌續 reassess long-term AC
123.2.0.4.4 Scenario 4warfarin INR 8 + active GI bleed
  • Vit K 10 mg slow IV
  • 4F-PCC 25-50 IU/kg
  • Hold warfarin
  • Endoscopy + GI source control

⚠ AI 草皿。