293.2 🩺 國考版

293.2.1 高頻考點

293.2.1.1 Common Cardiotoxic Agents

  • Anthracyclines (doxorubicin): dose-dependent HF
  • Trastuzumab: reversible HF
  • VEGF inhibitors (bevacizumab): HTN, thromboembolism, LV dysfunction
  • TKIs: HTN, LV dysfunction
  • BCR-ABL TKI (ponatinib): arterial thrombosis
  • BTK inhibitor (ibrutinib): AF, bleeding
  • ICI: myocarditis (rare but severe)
  • 5-FU / capecitabine: vasospasm
  • Radiation: late CAD, valve, conduction

293.2.1.2 ICI Myocarditis Pearls

  • Incidence 0.5-1.5%; mortality 50% if severe
  • 2-12 weeks after start (often early)
  • Combination ICI > monotherapy
  • Troponin elevation key (very sensitive)
  • ECG: arrhythmia, conduction (esp AV block)
  • CMR: Lake Louise criteria
  • EMB: gold standard
  • Treatment: stop ICI + IV methylpred 1 g/d × 3 + immunomodulators if refractory

293.2.1.3 Anthracycline Cardiotoxicity

  • Cumulative dose:
    • < 240 mg/m²: < 1% HF
    • 400-550 mg/m²: 5-7%

    • 550 mg/m²: 18-48%

  • Liposomal less cardiotoxic
  • Dexrazoxane (iron chelator) protective
  • Mostly HFrEF, often irreversible

293.2.1.4 Trastuzumab Cardiotoxicity

  • Reversible LV dysfunction
  • Often after anthracycline → synergistic
  • Recovery in 50-70%
  • Hold and re-challenge

293.2.1.5 Radiation Cardiotoxicity

  • Late effect (years post-radiation)
  • Premature CAD
  • Pericardial disease (effusion, constrictive)
  • Valvular (AR/AS)
  • Conduction (AV block)
  • Restrictive cardiomyopathy

293.2.1.6 Cardioprotection

  • Dexrazoxane (anthracycline)
  • Liposomal anthracycline
  • Limit cumulative dose
  • Primary prevention with ARNI/ACEi + β-blocker (emerging)
  • Statin (STOP-CA 2023)

293.2.1.7 Key Trials

  • PRADA (2024): candesartan + metoprolol
  • MANTICORE 101: perindopril or bisoprolol for trastuzumab
  • OVERCOME: enalapril + carvedilol
  • STOP-CA (2023): atorvastatin
  • PROACT (2024): enalapril

293.2.2 易混淆比范

Agent Toxicity Reversible? Management
Anthracycline HFrEF (dose-dep) Often no Dexrazoxane, GDMT
Trastuzumab LV dysfunction Yes (50-70%) Hold, HF therapy, re-challenge
VEGF inh HTN, thrombosis, proteinuria Yes (usually) BP control
BCR-ABL (ponatinib) Arterial thrombosis No (recurrent) ASA, RF control
Ibrutinib AF, bleeding Variable AC, BP control
ICI Myocarditis No (severe) Stop ICI, steroids
5-FU Vasospasm Yes Stop, nitrate/CCB
Radiation Late CAD, valve No Lifelong f/u

293.2.3 Special Topics

293.2.3.1 CARDIOTOX Risk Score (2022 ESC)

  • Pre-treatment risk stratification
  • Categories: very high, high, moderate, low
  • Influences monitoring intensity + cardioprotection

293.2.3.2 GLS (Global Longitudinal Strain)

  • Earlier marker of LV dysfunction than EF
  • ↓ > 15% predicts future EF drop
  • Used in cardio-oncology surveillance