269.3 🩺 內科專科考前版

269.3.0.1 1⃣ ARNI Initiation + Switching

  • New patients: start sacubitril/valsartan 24/26 mg bid (very symptomatic, hypotensive) or 49/51 bid
  • Titrate to 97/103 bid as tolerated
  • Switching from ACEi: 36-hour washout (avoid angioedema)
  • Switching from ARB: no washout
  • Renal + age + BP considerations

269.3.0.2 2⃣ Early HFrEF Optimization

  • 2024: rapid initiation of all 4 pillars (ARNI + β-blocker + MRA + SGLT2i) within 6 weeks of diagnosis
  • Reduces mortality + hospitalization compared to gradual sequential addition
  • Multiple “STRONG-HF” trial supports

269.3.0.3 3⃣ SGLT2i for HF — Key Considerations

  • Mechanism beyond glycosuria (anti-inflammatory, anti-fibrotic, diuretic, metabolic)
  • Use regardless of diabetes
  • Renal function: GFR > 20 mL/min/1.73 m² typically
  • Caution with diuretic combinations (volume depletion)
  • Euglycemic DKA (rare but serious — especially with fasting, illness, alcohol)
  • Mycotic genitourinary infections

269.3.0.4 4⃣ Tirzepatide STEP-HFpEF (2024)

  • GIP/GLP-1 dual agonist (Mounjaro, Zepbound)
  • Phase 3 success: improves symptoms + exercise capacity in HFpEF + obesity
  • Weight loss synergy
  • Expected expanded indication in 2024-2025
  • Game changer for HFpEF + obesity phenotype

269.3.0.5 5⃣ Cardiac Amyloidosis ATTR Therapies

  • Tafamidis (Vyndaqel/Vyndamax) — TTR stabilizer; FDA 2019; reduces mortality + hospitalization (ATTR-ACT trial)
  • Patisiran (Onpattro), inotersen (Tegsedi), vutrisiran (Amvuttra) — TTR silencer RNA-based (ATTR amyloid polyneuropathy + emerging cardiomyopathy)
  • Diflunisal (off-label, generic TTR stabilizer)
  • Cost barriers (tafamidis $200K+/yr); generic alternatives in development

269.3.0.6 6⃣ Mavacamten for HCM (EXPLORER-HCM)

  • Selective myosin inhibitor
  • For obstructive HCM with symptomatic LVOT obstruction
  • Improves symptoms, exercise capacity, LVOT gradient
  • Reduces need for septal reduction (myectomy, alcohol septal ablation)
  • FDA 2022

269.3.0.7 7⃣ Wearable Cardioverter Defibrillator (LifeVest)

  • Bridge to ICD or recovery
  • Post-MI early period (40 days)
  • New HF without confirmed permanent EF
  • WCD-LVAD bridging

269.3.0.8 8⃣ 健保 / Taiwan

  • 健保 ACEi/ARB/ARNI + β-blocker + MRA + diuretics widely covered
  • SGLT2i covered for HF indications
  • 健保 ICD + CRT for indications
  • LVAD limited but growing (transplant centers)
  • Heart transplant program established
  • Multi-disciplinary HF programs

269.3.0.9 9⃣ Hospital Discharge Optimization

  • All 4 pillars on discharge (STRONG-HF approach)
  • Education (weight monitoring, sodium, fluid)
  • Follow-up within 7-14 days (cardiology)
  • HF clinic referral
  • Cardiac rehabilitation

269.3.0.10 10. Future + Innovations

  • AI-guided HF management (LVEF estimation from ECG, prediction, monitoring)
  • Implantable hemodynamic monitors (CardioMEMS)
  • Remote monitoring + telehealth
  • mRNA therapies in development
  • Cardiac regenerative therapies (stem cells, iPS) — research
  • Pharmacogenomics (personalized HF therapy)