257.1 🎓 醫孞生版

257.1.0.1 📌 䞀頁重點

257.1.0.1.1 Epidemiology
  • CVD ~ 18 million deaths/yr globally (32% of all deaths — leading cause)
  • CAD #1 within CVD (8M deaths); stroke #2 (6M)
  • Shift to LMICs: 80% of CVD deaths now in low / middle-income countries
  • Risk factor transition: developing countries — tobacco + sedentary + diet + urbanization
  • Aging populations + survival of acute MI → HF + arrhythmia burden
257.1.0.1.2 Major Categories of Cardiovascular Disease
  1. Coronary / Atherosclerotic — angina, MI, peripheral arterial disease, stroke
  2. Heart Failure — HFrEF, HFpEF, HFmrEF, advanced
  3. Arrhythmias — bradycardia (sinus node, AV blocks), supraventricular (AF/flutter/AVNRT/AVRT), ventricular (VT/VF), sudden cardiac death
  4. Structural / Valvular — congenital, valvular (AS, MR, AR, MS), pericardial, cardiomyopathies (DCM, HCM, RCM, ARVC, takotsubo)
  5. Vascular — aortic (aneurysm, dissection), peripheral, venous, pulmonary HTN
257.1.0.1.3 Functional + Symptomatic Approach (4 Symptoms)
  • Chest pain / discomfort: angina, MI, pericarditis, aortic dissection, PE, GERD, MSK
  • Dyspnea: HF, ischemia, arrhythmia, pulmonary embolism, valvular, pulm causes
  • Palpitations: arrhythmia, ectopy, anxiety, hyperthyroid, anemia
  • Syncope: arrhythmia, structural, vasovagal, orthostatic, neurologic
257.1.0.1.4 Biomarkers (Modern)
  • High-sensitivity troponin (hs-cTn) — MI diagnosis; 1-3 hr algorithms (rule-in/rule-out)
  • BNP / NT-proBNP — HF diagnosis + prognosis + monitoring
  • D-dimer — PE, dissection (exclude with low pretest probability)
  • LDL, ApoB, Lp(a) — risk stratification + lipid management
257.1.0.1.5 Risk Stratification
  • ASCVD risk calculator (USA ACC/AHA — 10-year CVD risk)
  • SCORE2 (Europe)
  • Risk enhancers: family history, ethnicity, chronic kidney disease, inflammatory disease, metabolic syndrome
  • Coronary artery calcium (CAC) score for intermediate risk
  • Imaging risk markers (CT angio, carotid IMT)
257.1.0.1.6 2024 CKM Syndrome (Cardiac-Kidney-Metabolic, AHA 2023+)
  • New framework integrating cardiovascular + renal + metabolic disease
  • Stages 0-4 continuum
  • Stage 0: no risk factors
  • Stage 1: excess adiposity / dysfunctional adipose / pre-diabetes
  • Stage 2: metabolic risk factors / CKD
  • Stage 3: subclinical CVD or high-risk equivalents
  • Stage 4: clinical CVD
  • Implications: integrated prevention + management
  • SGLT2i + GLP-1 RA + finerenone era
257.1.0.1.7 Prevention Paradigm Shift (2024)
  • Primary prevention focus
  • Secondary prevention with SGLT2i + GLP-1 RA + statins + anti-platelets (Ch 267-270)
  • Polypill approaches (combinations)
  • Population-based interventions (salt reduction, smoking, sugar tax)
  • Personalized risk (genetics, biomarkers, imaging)

257.1.0.2 1⃣ Functional Categories

257.1.0.2.1 Coronary / Atherosclerotic Cardiovascular Disease (ASCVD)
  • Coronary artery disease (CAD) → angina + MI
  • Stroke (mostly ischemic from atherosclerosis)
  • Peripheral arterial disease (PAD)
  • Aortic atherosclerosis
  • All share atherosclerosis pathophysiology
257.1.0.2.2 Heart Failure (HF)
  • HFrEF: reduced EF ≀ 40% (formerly “systolic HF”)
  • HFpEF: preserved EF ≥ 50% (formerly “diastolic HF”)
  • HFmrEF: mid-range EF 41-49% (newer category)
  • Advanced HF: refractory, end-stage
  • Acute decompensated HF (ADHF): emergent presentation
257.1.0.2.3 Arrhythmias
  • Bradycardia: sinus node dysfunction, AV blocks (1°, 2° Mobitz I/II, 3° complete heart block)
  • Supraventricular: AF, atrial flutter, AVNRT, AVRT, ectopic atrial tachycardia
  • Ventricular: PVCs, VT (sustained/non-sustained), VF
  • Sudden cardiac arrest (SCA) → SCD
257.1.0.2.4 Structural / Valvular Heart Disease
  • Aortic stenosis (degenerative — elderly; congenital bicuspid)
  • Aortic regurgitation (chronic vs acute — endocarditis, dissection)
  • Mitral stenosis (rheumatic predominantly worldwide)
  • Mitral regurgitation (degenerative MVP, secondary functional, primary)
  • Tricuspid + pulmonary disease
  • Congenital heart disease (ASD, VSD, PDA, tetralogy)
  • Cardiomyopathies (DCM, HCM, RCM, ARVC, takotsubo, peripartum)
  • Pericardial disease (effusion, tamponade, constrictive)
  • Endocarditis (Ch 152)
257.1.0.2.5 Vascular Disease
  • Aortic disease: aneurysm (thoracic, abdominal), dissection
  • Peripheral arterial disease (PAD)
  • Venous thromboembolism (DVT, PE)
  • Pulmonary hypertension (Group 1-5)
  • Vasculitis (large + medium + small vessel)

257.1.0.3 2⃣ Symptomatic Approach

257.1.0.3.1 Chest Pain — Differential
257.1.0.3.1.1 Cardiac
  • Angina / MI (effort-related; relieved by rest/NTG; radiation to arm/jaw/back)
  • Pericarditis (sharp, pleuritic, positional, friction rub)
  • Aortic dissection (severe sudden, tearing, between scapulae)
  • Pulmonary embolism (pleuritic, dyspnea, tachycardia)
257.1.0.3.1.2 Non-Cardiac
  • GERD / esophageal spasm (often mimics angina)
  • Musculoskeletal (tender, reproducible)
  • Anxiety / panic disorder
  • Pleural / pulmonary
  • Costochondritis
  • Herpes zoster
  • Biliary / GI
257.1.0.3.1.3 High-Yield Features Cardiac
  • Effort-related onset
  • Substernal location
  • Radiation to arms / jaw / back
  • Associated dyspnea / nausea / diaphoresis
  • Relief with rest / NTG
  • Age > 50
  • Risk factors
257.1.0.3.1.4 Atypical Presentations
  • Women, diabetics, elderly often atypical (dyspnea, fatigue, nausea, indigestion)
  • Diabetic neuropathy → silent ischemia
257.1.0.3.2 Dyspnea — Differential
257.1.0.3.2.1 Cardiac
  • HF (orthopnea, PND, JVP elevated, peripheral edema)
  • Ischemia (anginal equivalent)
  • Arrhythmia
  • Valvular disease
  • Pulmonary embolism
  • Cardiac tamponade
257.1.0.3.2.2 Pulmonary
  • Asthma, COPD exacerbation
  • Pneumonia
  • Pneumothorax
  • ILD
  • Pulmonary HTN
257.1.0.3.2.3 Other
  • Anemia
  • Anxiety
  • Deconditioning
  • Obesity
  • Neuromuscular
257.1.0.3.2.4 Approach
  • BNP / NT-proBNP elevated → HF
  • Echo for cardiac structure / function
  • CTA / VQ scan for PE
  • Pulmonary function tests
  • Imaging (CXR + CT chest)
257.1.0.3.3 Palpitations — Differential
257.1.0.3.3.1 Tachyarrhythmia
  • AF / atrial flutter
  • Supraventricular tachycardia (AVNRT, AVRT)
  • Ventricular tachycardia
  • Sinus tachycardia (compensated or pathologic)
257.1.0.3.3.2 Ectopy
  • PACs (premature atrial contractions)
  • PVCs (premature ventricular contractions)
  • Often felt as “skipped beat” or “thump”
257.1.0.3.3.3 Non-Cardiac
  • Anxiety / panic
  • Hyperthyroidism
  • Anemia
  • Caffeine / stimulants / drugs (cocaine, amphetamines)
  • Hypoglycemia
  • Pheochromocytoma
257.1.0.3.3.4 Workup
  • ECG during episode (gold standard)
  • Ambulatory monitoring (Holter, event monitor, implantable loop recorder)
  • TSH + CBC + BMP + drug history
  • Echo for structural / function
257.1.0.3.4 Syncope — Differential
257.1.0.3.4.1 Cardiovascular
  • Arrhythmia (bradycardia, tachyarrhythmia)
  • Structural / valvular (aortic stenosis, HOCM, tamponade)
  • Ischemia (anginal equivalent)
  • Pulmonary embolism (massive)
257.1.0.3.4.2 Reflex (Vasovagal)
  • Most common
  • Provoked (heat, pain, prolonged standing, emotion)
  • Prodrome (nausea, sweating, blurring)
  • Brief LOC
257.1.0.3.4.3 Orthostatic
  • Postural hypotension (drop > 20 systolic or > 10 diastolic on standing)
  • Autonomic dysfunction (diabetes, Parkinson, MSA)
  • Volume depletion
  • Drugs (alpha-blockers, diuretics, vasodilators)
257.1.0.3.4.4 Neurologic
  • Seizures (often misdiagnosed as syncope)
  • TIA / stroke (rare cause of brief LOC)
  • Migraine
257.1.0.3.4.5 Red Flags
  • During exertion (cardiac)
  • Family history of sudden death
  • Structural heart disease history
  • Abnormal ECG
  • Without prodrome
  • Older age + comorbidities
257.1.0.3.4.6 Workup
  • ECG mandatory
  • Echo
  • Tilt table for vasovagal
  • Carotid massage (carotid sinus hypersensitivity)
  • Ambulatory monitoring (Holter, ILR)

257.1.0.4 3⃣ Risk Factors + Stratification

257.1.0.4.1 Traditional Risk Factors
  • Age (men > 45, women > 55)
  • Male sex
  • Family history (premature CAD)
  • Smoking (current + recent)
  • Diabetes mellitus
  • Dyslipidemia (LDL elevated, HDL low)
  • Hypertension
  • Obesity (especially central / metabolic syndrome)
  • Physical inactivity
  • Unhealthy diet (processed, high sodium, low fiber, sugary)
257.1.0.4.2 Newer / Enhancing Risk Factors
  • Family history of premature CAD
  • Ethnicity (S Asian, African American higher risk)
  • Chronic kidney disease (CKD)
  • Inflammatory diseases (RA, lupus, psoriasis)
  • HIV (cardiovascular complications)
  • Pregnancy complications (preeclampsia, gestational diabetes)
  • Premature menopause (women)
  • High Lp(a)
  • High triglycerides
  • High hs-CRP
  • Coronary artery calcium (CAC) score elevation
  • Apolipoprotein B (ApoB) elevation
257.1.0.4.3 Risk Calculators
257.1.0.4.3.1 ASCVD Risk Calculator (USA — ACC/AHA Pooled Cohort Equations)
  • Age + sex + race + total chol + HDL + SBP + treated HTN + DM + smoker
  • 10-year ASCVD risk
  • Updated 2018 + 2023
257.1.0.4.3.2 PREVENT (AHA 2023+)
  • Newer calculator
  • Includes CKD + metabolic syndrome
  • Predicts atherosclerotic + heart failure + all CVD
257.1.0.4.3.3 SCORE2 (Europe)
  • Similar to ASCVD
  • Updated 2021 + 2023
257.1.0.4.3.4 Other
  • Framingham, Reynolds, QRISK3 (UK)
  • Tailored to populations
257.1.0.4.4 Risk Enhancers (Beyond Calculator)
  • Family history premature CAD (men < 55, women < 65)
  • Ethnicity (S Asian, others)
  • CKD
  • Inflammatory disease
  • Premature menopause + pregnancy complications
  • Persistent high triglycerides
  • High Lp(a) > 50 mg/dL
  • High hs-CRP > 2 mg/L
  • Coronary artery calcium (CAC) score > 100 or > 75th percentile
  • Ankle-brachial index < 0.9
257.1.0.4.5 Treatment Targets (2024 Updates)
257.1.0.4.5.1 LDL Targets
  • Primary prevention (10-yr ASCVD > 7.5%): high-intensity statin → LDL < 100 mg/dL (or > 50% reduction)
  • Very high risk + secondary prevention: LDL < 70 mg/dL (some guidelines < 55)
  • Familial hypercholesterolemia + severe CVD: PCSK9 inhibitor / ezetimibe addition
257.1.0.4.5.2 Blood Pressure Targets
  • Most adults: BP < 130/80
  • Older adults: individualized
  • Diabetic: < 130/80
  • CKD: < 130/80 (per ACC/AHA; some ESC < 140/90)
257.1.0.4.5.3 Lifestyle
  • Mediterranean / DASH diet
  • 150 min/wk moderate exercise
  • Weight management (BMI 20-25)
  • Smoking cessation
  • Alcohol moderation
  • Stress + sleep optimization

257.1.0.5 4⃣ Cardiovascular Biomarkers (Modern Era)

257.1.0.5.1 Cardiac Troponin (hs-cTn)
  • Myocardial injury marker
  • High-sensitivity assays (hs-cTn) since 2010s
  • 0/1-hr rule-in/rule-out algorithm for MI
  • Cutoffs depend on assay
  • Sex-specific cutoffs (women lower)
  • 5x ULN diagnostic for MI
257.1.0.5.2 Natriuretic Peptides (BNP, NT-proBNP)
  • BNP: B-type natriuretic peptide
  • NT-proBNP: N-terminal pro-BNP (inactive metabolite, longer half-life)
  • HF diagnosis + severity + monitoring
  • Cutoffs: BNP < 100 unlikely HF; NT-proBNP < 300 unlikely; higher cutoffs for diagnosis
  • Affected by: age (rises), obesity (lower), renal function (rises), AF (rises)
257.1.0.5.3 D-dimer
  • Fibrin degradation product
  • Exclude PE / DVT with low pretest probability + age-adjusted cutoff
  • Exclude aortic dissection (with caveats)
  • Elevated in many conditions (inflammation, infection, cancer, post-surgery)
257.1.0.5.4 Lipid Markers
  • LDL-C — traditional
  • Non-HDL-C = TC - HDL-C (better marker)
  • ApoB — increasingly recommended (especially in metabolic syndrome)
  • Lp(a) — genetic risk marker (independent of LDL)
  • HDL-C — protective historically (revised understanding)
  • Triglycerides — independent risk + atherogenic remnant lipoproteins
257.1.0.5.5 CRP / hs-CRP
  • Inflammatory marker
  • hs-CRP > 2 mg/L = risk enhancer
  • JUPITER trial used hs-CRP to identify statin candidates
  • Caveat: many inflammatory causes elevate (infection, RA, etc.)
257.1.0.5.6 Other Emerging
  • Galectin-3 (HF)
  • ST2 (HF)
  • Procalcitonin (sepsis-related)
  • Multi-omics + AI-driven biomarkers

257.1.0.6 5⃣ 2024 CKM Syndrome (AHA 2023+)

257.1.0.6.1 Concept
  • Cardiac-Kidney-Metabolic syndrome — integrated framework
  • Recognizes inter-related disease processes
  • Multi-system approach to prevention + treatment
257.1.0.6.2 Stages
Stage Description
0 No CKM risk factors
1 Excess adiposity (BMI > 25 or waist circumference) / dysfunctional adipose / pre-diabetes
2 Metabolic risk factors (T2DM, HTN, dyslipidemia, MetS) or CKD
3 Subclinical CVD (CAC, etc.) or high-risk equivalents
4 Clinical CVD (CAD, HF, stroke, PAD)
257.1.0.6.3 Implications
  • Integrated prevention beyond individual organs
  • SGLT2i + GLP-1 RA + finerenone = cross-system therapies
  • Multi-disciplinary team (cardiology + nephrology + endocrinology + primary care)
  • New risk calculators (PREVENT incorporates CKD + metabolic)
257.1.0.6.4 Therapeutics Crossing Systems
  • SGLT2i: HF + CKD + DM + diabetic CKD
  • GLP-1 RA: weight + CVD + DM + HF (semaglutide STEP-HFpEF, FLOW)
  • Finerenone: CKD + DM
  • Statins: CVD + LDL
  • Tirzepatide (GIP/GLP-1 RA dual): weight + DM + HF in development