297.3 🏥 內科專科考前版

297.3.1 Mechanistic Deep Dive

297.3.1.1 Atherosclerosis Initiation + Progression

  • Endothelial dysfunction → LDL infiltration → oxidized LDL → macrophage foam cells
  • Fatty streak → fibrous plaque → vulnerable plaque
  • Rupture → ACS

297.3.1.2 Inflammation in Atherosclerosis

  • IL-6, IL-1β, TNF-α, CRP
  • CANTOS trial 2017: canakinumab (anti-IL-1β) ↓ MACE
  • LoDoCo2 + COLCOT: colchicine

297.3.2 Recent Trials & Updates

297.3.2.1 SELECT (2023) — Semaglutide

  • N = 17,604 obese (BMI ≥ 27) + ASCVD without DM
  • Semaglutide 2.4 mg weekly vs placebo
  • ↓ MACE 20%
  • Expanded GLP-1 indication beyond DM

297.3.2.2 CLEAR Outcomes (2023) — Bempedoic Acid

  • N = 13,970 statin-intolerant + ↑ ASCVD risk
  • Bempedoic acid vs placebo
  • ↓ MACE 13%
  • Established for statin-intolerant

297.3.2.3 PREVENT (2024 AHA)

  • New risk calculator
  • Includes social determinants
  • Separate 10-year + 30-year risks

297.3.2.4 LoDoCo2 (2020) Long-Term Follow-Up

  • Colchicine 0.5 mg/d in CCS
  • ↓ MACE
  • AHA/ACC 2023 Class IIa

297.3.2.5 REDUCE-IT Subgroups (2024 updates)

  • High TG + ASCVD + on statin → icosapent ethyl benefit
  • Mechanism likely beyond TG reduction (anti-inflammatory)

297.3.2.6 EMPA-KIDNEY (2023)

  • Empagliflozin in CKD (with or without DM)
  • ↓ progression of kidney disease + CV events
  • Non-DM CKD benefit confirmed

297.3.3 High-Yield Specialist Points

297.3.3.1 Statin Intolerance

  • True intolerance: 5-10% (vs nocebo effect 80-90% of complaints)
  • SAMS (statin-associated muscle symptoms): myalgia, weakness
  • Less common: rhabdomyolysis, hepatotoxicity, diabetes (small increase)
  • Manage: dose ↓, alternate-day, switch agent
  • Add ezetimibe, PCSK9i, bempedoic acid

297.3.3.2 When to Use CAC

  • Borderline (5-7.5%) → CAC informs decision
  • Intermediate (7.5-19.9%) → CAC + risk enhancers
  • High (≥ 20%) → already statin warranted
  • Family hx of premature CAD without other RF → CAC

297.3.3.3 Apo B / Non-HDL

  • Apo B more accurate than LDL in select populations
  • Diabetic, insulin resistance, hypertriglyceridemia
  • 2024 guidelines: Apo B optional secondary target

297.3.3.4 Lipoprotein(a) Pearls

  • Genetic, not modifiable by lifestyle
  • High Lp(a) ≥ 50 mg/dL → independent risk
  • Single test in lifetime
  • Aggressive other RF control
  • Future: pelacarsen, olpasiran, muvalaplin

297.3.3.5 Diabetes Primary Prevention Pearls

  • SGLT2i + GLP-1 RA both reduce CV events in DM + ASCVD
  • ADA + ACC alignment 2024
  • Earlier intervention paying off
  • Tirzepatide weight + glycemic

297.3.3.6 Pediatric + Young Adult

  • Family hx + lipid measurement age 9-11
  • FH screening
  • Lifestyle + statin (over 8 yo for FH)

297.3.3.7 Sex Differences

  • Women: protective until menopause
  • Microvascular more common
  • Treatment thresholds similar but consider sex-specific risk enhancers (preeclampsia, early menopause)

297.3.3.8 Social Determinants of Health (SDOH)

  • Income, education, access, food insecurity, housing
  • Major CV risk modifiers
  • PREVENT calculator integrates

297.3.3.9 Personalized Prevention

  • Polygenic risk scores (emerging)
  • Lp(a) testing
  • CAC scoring
  • Imaging-guided therapy

297.3.4 Pearls

  • PCE / SCORE2 / PREVENT for risk assessment
  • LDL target: very high < 55, high < 70, intermediate < 100
  • Statin start ASCVD ≥ 7.5%; high-intensity ≥ 20%
  • ASA primary prevention 2024: avoid ≥ 70 yo (ASPREE)
  • CAC for borderline / intermediate decisions
  • SELECT (2023): semaglutide for obese + ASCVD ↓ MACE
  • CLEAR Outcomes (2023): bempedoic acid for statin-intolerant
  • Lp(a) once in lifetime; aggressive other RF control
  • Lifestyle: Mediterranean diet + 150 min/wk exercise + 戒菞 + 限酒 + 控重
  • Emerging: pelacarsen (Lp(a)), tirzepatide, polygenic risk scores