261.3 🩺 內科專科考前版

261.3.0.1 1⃣ STEMI Treatment

  • Primary PCI: gold standard if available within 90 min door-to-balloon
  • Goal: < 60 min DTB
  • Fibrinolysis if PCI not available within 120 min from first medical contact
    • Transfer for rescue PCI / PCI within 24 hr

261.3.0.2 2⃣ DAPT Optimization

  • P2Y12 choice:
    • Clopidogrel: standard
    • Prasugrel: more potent; avoid > 75 yr, < 60 kg, prior stroke
    • Ticagrelor: more potent + reversible; ESC preferred
  • Aspirin lifelong post-PCI
  • DAPT duration individualized (DAPT score + bleeding risk + ischemic risk)

261.3.0.3 3⃣ Contrast Nephropathy Prevention

  • Hydration: IV normal saline 1-1.5 mL/kg/hr × 12 hr before and after
  • Limit contrast volume
  • Low-osmolar non-ionic contrast
  • Withhold metformin 48 hr (CIN risk)
  • N-acetylcysteine: equivocal evidence
  • Identify high-risk: CKD eGFR < 60, DM, elderly, prior CIN

261.3.0.4 4⃣ Radial Access Best Practices

  • Radial artery patency check (modified Allen test)
  • Heparin pre-puncture
  • Hemostatic radial band post
  • Watch for radial artery occlusion (rare but serious)

261.3.0.5 5⃣ Heart Transplant Evaluation Hemodynamics

  • PA pressure
  • Pulmonary vascular resistance (PVR)
  • Wood units
  • If PVR > 4-5 → may need vasodilator + repeat
  • If irreversibly elevated → consider heart-lung transplant

261.3.0.6 6⃣ FFR + iFR Implementation

  • 2024 increasing use
  • Reduces unnecessary PCI in intermediate lesions
  • Better outcomes
  • Cost-effective
  • Real-time decision support

261.3.0.7 7⃣ Tropomyosin / Atherectomy

  • Rotational atherectomy for heavily calcified lesions
  • Orbital atherectomy alternative
  • Lithotripsy (intracoronary) for calcified — newer
  • Adjunctive for difficult lesions

261.3.0.8 8⃣ Cardiogenic Shock + Mechanical Support

  • Intra-aortic balloon pump (IABP): traditional; limited evidence (IABP-SHOCK II — no mortality benefit)
  • Impella: percutaneous LV assist device
  • VA-ECMO: refractory shock
  • Surgical LVAD: bridge to transplant or destination
  • Decision based on shock severity + reversibility

261.3.0.9 9⃣ 健保 / Taiwan

  • 健保 PCI widely available
  • Tertiary cardiology centers
  • Radial access expanding
  • FFR + iFR + IVUS increasingly used
  • 健保 DAPT covered

261.3.0.10 10. Future + Innovations

  • Bioresorbable stents (next-generation in development)
  • Drug-coated balloons expanding indications
  • AI-guided lesion assessment
  • Robotic PCI (limited centers)
  • Imaging-guided PCI (IVUS, OCT)