266.3 🩺 內科專科考前版

266.3.0.1 1⃣ PROCAMIO Trial (Procainamide vs Amiodarone for Stable Sustained VT)

  • Procainamide superior in terminating VT
  • Less hypotension than amiodarone IV
  • Preferred for stable monomorphic VT (without HF)
  • Amiodarone alternative

266.3.0.2 2⃣ CASTLE-HF (Ablation in HFrEF + AF)

  • Different from VT ablation
  • But underscores ablation role in HF context

266.3.0.3 3⃣ ICD Decision-Making in HFrEF

  • EF ≀ 35% on optimal medical therapy ≥ 3 months (not ≥ 1 month after MI; not first 40 days post-MI per DINAMIT)
  • Reassess EF after optimization
  • Wearable cardioverter defibrillator (LifeVest) as bridge in select
  • Patient preference + life expectancy + comorbidities

266.3.0.4 4⃣ HCM SCD Risk Factors

  • Family hx SCD (especially < 50 yr)
  • Recent unexplained syncope
  • NSVT on Holter
  • LV wall thickness ≥ 30 mm
  • Abnormal BP response to exercise (failure to rise > 25 mmHg)
  • Extensive LGE on cardiac MRI
  • Combined risk stratification + ICD decision

266.3.0.5 5⃣ CPVT Management

  • β-blockers (nadolol) + flecainide (calcium handling)
  • Exercise restriction
  • ICD for refractory
  • Left cardiac sympathetic denervation (LCSD) for refractory — surgical removal of stellate ganglion + thoracic sympathetic chain on left

266.3.0.6 6⃣ Brugada Syndrome

  • Type 1 (coved) — diagnostic
  • Type 2 (saddle-back) — suggestive; provocative test (procainamide, ajmaline, flecainide IV)
  • Avoid drugs unmasking Brugada (sodium channel blockers, propofol)
  • ICD for symptomatic or family hx SCD
  • Avoid fever (febrile illness — cooling + Tx underlying)

266.3.0.7 7⃣ ARVC Management

  • Family screening (first-degree relatives)
  • Exercise restriction (especially competitive)
  • ICD for high-risk features
  • Anti-arrhythmic drugs (sotalol, amiodarone, flecainide)

266.3.0.8 8⃣ Familial SCD Screening

  • First-degree relatives of SCD victims
  • ECG + echo + cardiac MRI + Holter + exercise test
  • Genetic testing for known mutations
  • Refer to cardiogenetic specialty
  • Risk stratification + family counseling

266.3.0.9 9⃣ 健保 / Taiwan

  • 健保 ICDs covered for indications
  • Catheter ablation widely available
  • Genetic testing limited (高 cost)
  • Specialized arrhythmia centers in tertiary

266.3.0.10 10. Future + Innovations

  • Subcutaneous + leadless ICDs
  • Pulsed field ablation (PFA) for VT (safer + faster)
  • AI for ECG-based SCD risk prediction
  • Genetic-guided treatment decisions
  • Wearables + remote monitoring for high-risk