277.2 🩺 國考版

277.2.1 高頻考點

277.2.1.1 Drug Mechanism + Indications

  • ACEi/ARB: ↓ Ang II → vasodilate; DM + CKD + HFrEF + post-MI
  • CCB-DHP: vasodilate; elderly, African Americans, angina, pregnancy
  • CCB-non-DHP: ↓ HR + contractility; AF rate control
  • Thiazide: chlorthalidone preferred; HFpEF, African Americans
  • β-blocker: post-MI, HFrEF, angina, AF, migraine, pregnancy (labetalol)
  • MRA: resistant HTN, HFrEF; spironolactone first

277.2.1.2 Compelling Indications Algorithm

Comorbidity First-line
HFrEF ARNI/ACEi/ARB + β-blocker + MRA + SGLT2i
Post-MI β-blocker + ACEi/ARB + MRA
CKD + proteinuria ACEi/ARB
DM ACEi/ARB
AF β-blocker or non-DHP CCB
Angina β-blocker, CCB
BPH α-blocker (add-on)
Migraine β-blocker
Pregnancy Methyldopa, labetalol, nifedipine

277.2.1.3 Key Trials

  • SPRINT 2015: < 120 vs < 140 — intensive better
  • STEP 2021: Chinese elderly, same benefit
  • PATHWAY-2 2015: spironolactone best 4th drug
  • ALLHAT 2002: chlorthalidone > amlodipine > lisinopril (overall similar)
  • ASCOT-BPLA 2005: amlodipine + perindopril > atenolol + thiazide
  • HOPE 1999: ramipril ↓ MACE
  • SSaSS 2021: salt substitute ↓ stroke + death
  • SYMPLICITY HTN-3 / SPYRAL-HTN-OFF / RADIANCE-HTN: renal denervation

277.2.2 易混淆比范

Drug Class Black Patients DM CKD HF Pregnancy
ACEi/ARB Less effective alone First-line First-line First-line AVOID
CCB-DHP Effective Add-on Add-on OK First-line
Thiazide First-line Add-on Avoid eGFR<30 OK (HFpEF) OK
β-blocker Less effective alone OK OK First-line (rEF) Labetalol OK
MRA OK OK (watch K) OK First-line (rEF) AVOID

277.2.2.1 Drug Pearls

  • ACEi cough: switch to ARB
  • DHP edema: reduce dose or add ACEi/ARB
  • Thiazide hypokalemia: monitor K+; consider K-sparing
  • β-blocker bradycardia: bisoprolol or carvedilol if HFrEF
  • Spironolactone gynecomastia: switch to eplerenone