274.2 🩺 國考版

274.2.1 高頻考點

274.2.1.1 Time Windows

  • Symptoms within 12h: reperfusion (PCI > lysis)
  • 12-24h symptoms: consider PCI if ongoing ischemia or instability
  • Fibrinolysis: best within 30 min of arrival
  • Pharmaco-invasive: lyse → PCI in 3-24h

274.2.1.2 ECG Localization Memorization

  • II, III, aVF: inferior → RCA
  • V1-V2: septal
  • V3-V4: anterior → LAD
  • V5-V6: apex/lateral
  • I, aVL: high lateral → LCx
  • V7-V9: posterior
  • V4R: RV → proximal RCA
  • aVR + diffuse ST↓: LM or LAD ostial

274.2.1.3 Fibrinolysis Contraindications (MUST MEMORIZE)

Absolute: - Prior ICH any time - Ischemic stroke < 3 mo - Intracranial neoplasm - AVM - Aortic dissection - Active bleeding (excl menses) - Significant closed head trauma < 3 mo

Relative: - BP > 180/110 - Oral anticoagulant - Recent surgery < 3 wk - Recent bleeding < 4 wk - Pregnancy - Age > 75 (relative for some)

274.2.1.4 Key Trials

  • PAMI / DANAMI-2: pPCI > lysis
  • STREAM: pharmaco-invasive ≈ pPCI if delay
  • COMPLETE 2019: multi-vessel STEMI → complete revasc ↓ MACE
  • CULPRIT-SHOCK 2017: shock → culprit only
  • EMPACT-MI 2024: empagliflozin post-MI ↓ HF hospitalization
  • PARADISE-MI 2021: sacubitril/valsartan = ramipril post-MI (no superiority)

274.2.2 易混淆比范

Complication Time Murmur Key Test
Papillary muscle rupture 2-7 d New holosystolic MR (apex → axilla) Echo
VSR 2-7 d New holosystolic (LSB) Echo / RHC
Free wall rupture 2-7 d None Tamponade; emergency surgery
LV aneurysm Weeks None Persistent ST↑
Dressler 2-10 wk Friction rub Fever, pericarditis
LV thrombus 1-2 wk None Echo (apical)