269.2 📚 國考版

269.2.0.1 必背 — HFrEF Quadruple Therapy (2024)

  1. ARNI (sacubitril/valsartan) — preferred (PARADIGM-HF)
  2. β-blocker (carvedilol, metoprolol succinate, bisoprolol)
  3. MRA (spironolactone or eplerenone)
  4. SGLT2i (dapagliflozin or empagliflozin) — regardless of diabetes

269.2.0.2 必背 — ARNI

  • Sacubitril/valsartan
  • 36-hour washout from ACEi
  • Avoid in pregnancy + angioedema history
  • 20% mortality reduction vs enalapril (PARADIGM-HF)
  • Start within hospitalization (PIONEER-HF)

269.2.0.3 必背 — β-Blockers for HFrEF

  • Carvedilol, metoprolol succinate (extended-release), bisoprolol (not all β-blockers!)
  • Start low + titrate up
  • Mortality benefit

269.2.0.4 必背 — MRA

  • Spironolactone, eplerenone
  • Monitor K+ + renal function
  • Hyperkalemia risk especially with ACEi/ARB

269.2.0.5 必背 — SGLT2i Benefit

  • Dapagliflozin or empagliflozin for HFrEF + HFpEF + HFmrEF
  • Mortality + hospitalization reduction
  • Benefit independent of diabetes
  • DAPA-HF + EMPEROR-Reduced (HFrEF); DELIVER + EMPEROR-Preserved (HFpEF)

269.2.0.6 必背 — Additional HFrEF Therapies

  • Loop diuretics (symptomatic)
  • Ivabradine (sinus rhythm + HR ≥ 70 on β-blocker)
  • Hydralazine + nitrates (African American NYHA III-IV)
  • Digoxin (symptomatic, with AF — no mortality)
  • IV iron (iron deficiency + HFrEF)

269.2.0.7 必背 — HFpEF Treatment 2024

  • SGLT2i (Class I — DELIVER + EMPEROR-Preserved)
  • Loop diuretics for symptoms
  • Comorbidity management (HTN, AF, obesity, DM, OSA)
  • Tirzepatide / Semaglutide for HFpEF + obesity (STEP-HFpEF 2024)
  • Finerenone modest benefit (FINEARTS-HF)

269.2.0.8 必背 — ICD Primary Prevention

  • HFrEF EF ≀ 35% + NYHA II-III on optimal GDMT ≥ 3 months
  • Mortality reduction (MADIT-II, SCD-HeFT)

269.2.0.9 必背 — CRT Indication

  • HFrEF + EF ≀ 35% + LBBB + QRS > 130 ms + NYHA II-III on optimal GDMT
  • Mortality + symptom + hospitalization reduction (CARE-HF, MADIT-CRT)

269.2.0.10 必背 — Advanced HF Therapies

  • LVAD: bridge to transplant or destination
  • Heart transplant: 1-year 90%, 5-year 75%
  • Palliative care: end-stage

269.2.0.11 必背 — Specific HFpEF Sub-Treatments

  • Cardiac amyloidosis ATTR: tafamidis; patisiran (TTR silencer RNA)
  • HCM: mavacamten (myosin inhibitor); β-blocker, CCB
  • Constrictive pericarditis: surgical pericardiectomy

269.2.0.12 必背 — What Doesn’t Work in Pure HFpEF

  • ACEi, ARB, β-blocker, MRA — no consistent mortality benefit (some subgroup benefit)
  • ARNI borderline (PARAGON-HF)

269.2.0.13 必背 — TRED-HF

  • HFrEF that recovers → continue GDMT lifelong (don’t stop)
  • TRED-HF trial showed 40% relapse with discontinuation