265.3 🩺 內科專科考前版

265.3.0.1 1⃣ DOAC Choice Considerations

  • Apixaban: lowest bleeding (especially GI); reduced dose criteria
  • Rivaroxaban: once daily (compliance); higher GI bleed
  • Edoxaban: similar to rivaroxaban; once daily
  • Dabigatran: only reversal agent (idarucizumab); GI side effects (dyspepsia)
  • Renal dose adjustments for all

265.3.0.2 2⃣ DOAC Reversal Agents

  • Idarucizumab (Praxbind) for dabigatran (FDA 2015)
  • Andexanet alfa (Andexxa) for apixaban + rivaroxaban + edoxaban (FDA 2018)
  • 4-factor PCC + antifibrinolytic as alternatives
  • Indicated: life-threatening bleed or emergent surgery

265.3.0.3 3⃣ AF + Stroke Risk + Anticoagulation Algorithm

  • Calculate CHA2DS2-VASc
  • Men ≥ 1 (women ≥ 2) → strongly consider anticoagulation
  • Calculate HAS-BLED — address modifiable bleeding risks
  • DOAC preferred (most patients)
  • Warfarin for mechanical valve, severe MS, specific scenarios
  • LAA occlusion if contraindication

265.3.0.4 4⃣ Catheter Ablation Patient Selection

  • Symptomatic paroxysmal AF (highest success rate)
  • Persistent AF (lower success but still beneficial)
  • HFrEF + AF
  • Younger patients (more durable success)
  • AF resulting in tachycardia-induced cardiomyopathy
  • Failed antiarrhythmic drug

265.3.0.5 5⃣ CASTLE-HF Trial

  • HFrEF (EF ≀ 35%) + AF + symptomatic
  • Ablation vs medical therapy
  • Mortality reduction + HF hospitalization reduction with ablation
  • Standard of care for HFrEF + AF (selected patients)

265.3.0.6 6⃣ EAST-AFNET 4 Trial

  • Recently diagnosed AF (within 1 year)
  • Early rhythm control (ablation or antiarrhythmic) vs usual care
  • Lower CV events with early rhythm control
  • Paradigm shift in AF management

265.3.0.7 7⃣ Weight Loss + AF

  • LEGACY trial: 10% weight loss reduces AF burden
  • Multi-disciplinary approach
  • Integrated with risk factor modification
  • Pillar of AF management

265.3.0.8 8⃣ OSA + AF

  • Strong bidirectional association
  • CPAP treatment reduces AF recurrence post-ablation
  • Underlying mechanism (intermittent hypoxia, sympathetic surges)
  • AF management should include OSA assessment + treatment

265.3.0.9 9⃣ 健保 / Taiwan

  • 健保 DOACs covered (paid by patient or partial coverage depending plan)
  • 健保 catheter ablation covered for indication
  • LAA occlusion increasingly available
  • AF management integrated with primary care + cardiology

265.3.0.10 10. Future + Innovations

  • AI-ECG + wearables: early AF detection
  • Pulsed field ablation (PFA): emerging energy source for ablation (better safety profile)
  • Subcutaneous + leadless devices
  • Combined CARDIO-RISK + STROKE-RISK biomarkers
  • Personalized anticoagulation (genetic, biomarker-guided)