259.3 🩺 內科專科考前版

259.3.0.1 1⃣ STEMI Inferior + RV Workup

  • Inferior STEMI (II, III, aVF) → always check V4R for RV infarct
  • RV infarct: hypotension with NTG → IV fluids essential (don’t use NTG-related vasodilators if RV infarct)
  • Bezold-Jarisch reflex: bradycardia + hypotension

259.3.0.2 2⃣ Sgarbossa Modified Criteria

  • Updated 2012 — more sensitive
  • ST/S ratio: discordant ST elevation / S wave depth ≥ 0.25 → diagnostic
  • Better for diagnosing MI in setting of LBBB

259.3.0.3 3⃣ AI-ECG Advances 2024

  • LVEF estimation from 12-lead ECG (Mayo Clinic; FDA approved)
  • AF prediction from sinus rhythm ECG
  • Hyperkalemia detection from ECG patterns
  • Improving accuracy + integration in clinical workflow
  • Caveat: validation in diverse populations ongoing

259.3.0.4 4⃣ Long QT Drug Considerations

  • Liverpool QT Drug Interaction Database for review
  • High-risk drugs in combination: avoid or monitor
  • Methadone particularly QT-prolonging
  • Combination of QT prolongers + electrolyte abnormalities (especially hypokalemia) → high torsades risk

259.3.0.5 5⃣ Brugada Syndrome

  • Type 1 (coved) — diagnostic + risk SCD
  • Type 2 (saddle-back) — suggestive; confirm with provocative test (procainamide, ajmaline, flecainide IV)
  • Genetic testing (SCN5A) for first-degree relatives
  • ICD for symptomatic or high-risk

259.3.0.6 6⃣ Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)

  • Epsilon wave (small upstroke in V1)
  • T-wave inversion V1-V3 (not in BBB)
  • Family history of SCD
  • MRI for diagnosis
  • ICD for high-risk

259.3.0.7 7⃣ 健保 / Taiwan

  • 12-lead ECG widely available
  • AI-ECG implementation 增加 (recent tertiary centers)
  • 健保 covers ECG for indication
  • Cardiology + electrophysiology referrals

259.3.0.8 8⃣ Ambulatory ECG Monitoring

  • Holter (24-48 hr): for symptomatic intermittent
  • Event monitor (14-30 d): for less frequent
  • Implantable loop recorder (ILR): for rare / recurrent unexplained syncope
  • Wearables (Apple Watch, Fitbit): increasing role in AF detection
  • Mobile ECG devices (KardiaMobile): patient-driven

259.3.0.9 9⃣ Stress ECG Interpretation

  • Exercise stress test for ischemia screening

  • 1 mm horizontal / downsloping ST depression at peak exercise + recovery = positive

  • Sensitivity + specificity limited; combined with imaging (echo, nuclear) increasingly preferred

259.3.0.10 10. ECG Pitfalls + Pearls

  • Lead misplacement: common (V1-V2 confused with V3-V4)
  • Skin artifact + electrode position errors
  • Right-sided + posterior leads for specific MI workup
  • Comparison with prior ECG essential for context