273.2 🩺 國考版

273.2.1 高頻考點

273.2.1.1 Universal Definition of MI (2018)

  • Type 1: plaque rupture (atherothrombotic)
  • Type 2: supply-demand mismatch (anemia, sepsis, tachy)
  • Type 3-5: sudden death, PCI, stent thrombosis, CABG

273.2.1.2 ECG Patterns (HIGH-YIELD)

  • Wellens: deep symmetric T inversion V2-V3 → critical LAD stenosis
  • De Winter: upsloping ST↓ + tall T → proximal LAD equivalent
  • aVR STE + diffuse ST↓: LM or 3VD
  • Posterior MI: tall R in V1-V2 + ST↓ V1-V3 (mirror image)

273.2.1.3 Trial Highlights

  • PLATO: ticagrelor > clopidogrel in ACS
  • TRITON-TIMI 38: prasugrel > clopidogrel in STEMI/PCI; avoid > 75 yo or prior stroke
  • TIMACS / VERDICT: early invasive (< 24h) for high-risk NSTE-ACS
  • MASTER DAPT 2021: short DAPT 1 mo OK for HBR
  • PRECISE-DAPT score for bleeding risk

273.2.1.4 Drug Doses

  • ASA 300 mg load → 81-100 mg/d
  • Ticagrelor 180 mg load → 90 mg BID (12 mo)
  • Prasugrel 60 mg load → 10 mg/d
  • Clopidogrel 300-600 mg load → 75 mg/d
  • Enoxaparin 1 mg/kg SC BID (1 mg/kg q24 if CrCl < 30)
  • Atorvastatin 80 mg lifelong
  • Bisoprolol 5-10 mg lifelong

273.2.2 易混淆比范

Feature UA NSTEMI STEMI
ECG ST↓/T↓ or normal ST↓/T↓ or normal ST↑ ≥ 1 mm (2 leads)
Troponin Negative Positive Positive
Pathology Partial thrombus Partial thrombus + necrosis Complete occlusion
Reperfusion Selective invasive Early invasive Primary PCI < 90 min (Ch273)

273.2.3 Special Topics

273.2.3.1 Killip Classification

  • I: no HF
  • II: rales, S3
  • III: pulmonary edema
  • IV: cardiogenic shock

273.2.3.2 Mechanical Complications (rare in NSTEMI, more common in STEMI)

  • Papillary muscle rupture → acute MR
  • Free wall rupture → tamponade
  • VSR
  • LV aneurysm