292.3 🏥 內科專科考前版

292.3.1 Mechanistic Deep Dive

292.3.1.1 Cellular Aging in Heart

  • Telomere shortening
  • Mitochondrial dysfunction
  • Oxidative stress
  • Cell senescence
  • Inflammaging (chronic low-grade inflammation)
  • Reduced regenerative capacity

292.3.1.2 Amyloid in Aging

  • ATTR-CM (wild-type transthyretin)
  • TTR misfolding + amyloid deposition
  • Cardiac > peripheral
  • Increasing recognition (PYP scan, CMR)

292.3.2 Recent Trials & Updates

292.3.2.1 SPRINT-Senior (2016)

  • ≥ 75 yo subgroup of SPRINT
  • Intensive (< 120) vs standard (< 140) BP
  • ↓ MACE 33%, ↓ all-cause mortality 32%
  • Even frail benefit (with monitoring for orthostasis)

292.3.2.2 STEP (2021)

  • Chinese 60-80 yo with HTN
  • < 130 vs < 150 SBP
  • ↓ CV events
  • Confirms benefit in Asian elderly

292.3.2.3 EARLY-TAVR (2024)

  • Asymptomatic severe AS
  • Early TAVR vs surveillance
  • Class IIa now

292.3.2.4 Tafamidis (ATTR-ACT 2018)

  • ATTR-CM
  • ↓ Mortality + hospitalization
  • Long-term data positive

292.3.2.5 ELDERCARE-AF (2020)

  • Edoxaban 15 mg/d in fragile elderly with AF + low body weight, CrCl 15-30, no bleeding tendency
  • ↓ Stroke without ↑ bleeding
  • Demonstrated AC feasible in frail elderly

292.3.2.6 REHAB-HF (2021)

  • Acute decompensated HF (HFrEF + HFpEF) physical rehab
  • ↑ Physical function in elderly
  • ↓ 6-month rehospitalization

292.3.2.7 Anticoagulation in Frail Elderly

  • Bleeding risk concerns often over-emphasized
  • Stroke prevention typically outweighs bleeding
  • ELDERCARE-AF, AVERROES (apixaban vs ASA), ARISTOTLE provided robust data

292.3.2.8 Senolytic Trials in Elderly Heart

  • Investigational (dasatinib + quercetin, fisetin)
  • Anti-aging cellular targets

292.3.2.9 TAVR in Octogenarians + Nonagenarians

  • Excellent outcomes despite advanced age
  • Frailty matters more than chronologic age
  • TAVR in 95+ feasible with selection

292.3.3 High-Yield Specialist Points

292.3.3.1 Drug Half-Lives in Elderly

  • ↑ Half-life for many lipophilic drugs (fat redistribution)
  • ↓ Renal clearance → adjust dose
  • ↓ Hepatic clearance → adjust dose
  • Drug-drug interactions amplified

292.3.3.2 Anticoagulation Decisions

  • CHA₂DS₂-VASc ≥ 2 → AC
  • Bleeding risk should NOT exclude AC unless very high
  • Falls do not contraindicate AC (need very high fall rate, ~ 1000/year, to outweigh stroke benefit)
  • DOACs preferred
  • LAA closure (Watchman) for those who cannot tolerate AC

292.3.3.3 Diastolic Dysfunction

  • Common in elderly
  • Treatment HFpEF style (SGLT2i, finerenone)
  • Tafamidis for ATTR
  • Diuretics for symptoms
  • BP, HR, weight management

292.3.3.4 Conduction Disorders

  • Sinus node dysfunction (SSS)
  • AV block (degenerative)
  • Permanent pacer indications expand in elderly
  • Leadless pacer (Micra) for selected
  • His bundle / LBB pacing emerging

292.3.3.5 Geriatric Syndromes + CV

  • Sarcopenia: ↓ exercise capacity, ↑ frailty
  • Cachexia: HF marker; nutritional support
  • Falls: orthostasis, polypharmacy, frailty
  • Delirium: ICU, post-cardiac surgery; multifactorial

292.3.3.6 Cognitive Function + CV

  • Vascular dementia (multi-infarct, lacunar)
  • Mixed dementia (Alzheimer + vascular)
  • HF + cognitive impairment co-exist
  • Pre-procedure cognitive assessment
  • Anticoagulation adherence with cognitive impairment

292.3.3.7 Palliative Cardiology

  • HF symptom management
  • ICD deactivation conversations
  • LVAD considerations end-of-life
  • Family + hospice integration

292.3.3.8 Post-Op Delirium

  • 40-60% of cardiac surgery
  • Risk factors: age, cognitive baseline, polypharmacy, sleep deprivation
  • Prevention: avoid BZD, multimodal pain, early mobilization, family
  • Treatment: identify cause, behavioral, low-dose antipsychotic if severe agitation

292.3.3.9 Hypertension in Frail Elderly

  • Individualize target
  • Avoid orthostasis (fall risk)
  • Start low, go slow
  • Standing BP check
  • Tolerable < 140 in many frail

292.3.3.10 Anti-Aging Drugs Studied in CV

  • Metformin (TAME trial)
  • Rapamycin (animal models)
  • Senolytics (early trials)
  • Caloric restriction mimetics

292.3.4 Pearls

  • Aging CV physiology: arterial stiffening, diastolic dysfunction, baroreflex impairment
  • HFpEF predominant in elderly; check for ATTR-CM (tafamidis)
  • AF anticoagulation: don’t avoid AC due to age/fall risk alone (DOAC preferred)
  • TAVR ≥ 65 all risk levels
  • Frailty more important than chronologic age
  • SPRINT-Senior + STEP: < 130 SBP benefits in elderly with monitoring
  • REHAB-HF: cardiac rehab beneficial even in elderly
  • Polypharmacy + Beers/STOPP — review regularly
  • ELDERCARE-AF: edoxaban 15 mg low-dose feasible in fragile elderly