Management

Transplant patients may seem reasonably well despite having a sinister underlying illness. Threshold for admission should therefore be low. Liaison with the transplant centre should take place at an early stage. A high index of suspicion must be maintained for infection, rejection and vasculopathy.

Infection

Infection should be sought and treated aggressively. Broad spectrum antibiotics may be used until culture results become available. Opportunistic infections must be considered, e.g. CMV may be identified on serological testing and can be treated with gancyclovir.

Rejection

This is diagnosed on endomyocardial biopsy. The severity of rejection is graded and treatment determined accordingly. The mildest cases need not be treated. The next grade may be managed with a temporary increase in steroid regime. Severe rejection requires lympholytic therapy with antithymocyte globulin. Plasmapheresis may be used when rejection is antibody mediated.

Ischaemia due to graft vasculopathy

Thrombolysis tends to be unhelpful for transplant patients. With the absence of pain, it is difficult to be confident about the time course of an ischaemic event. Often the patient will have felt unwell for a while before presenting to hospital. Revascularisation, either with balloon angioplasty and stenting or with surgery is often not feasible because the disease is diffuse. Management of transplant patients presenting due to myocardial ischaemia tends to be directed towards medical therapy for complications such as heart failure or arrhythmia. It is necessary to investigate for graft vasculopathy and also to exclude graft rejection. The only definitive treatment for vasculopathy is re-transplantation. Even when this can be accomplished, it tends to have a much poorer outcome the second time around.

A minority of transplant patients may present with ischaemic chest pain. On these occasions they can be managed much more like a conventional acute coronary syndrome with respect to the timing of the onset of pain and attempting thrombolytic therapy or urgent percutaneous intervention. Although graft vasculopathy is a diffuse process, there are many instances of individuals having a target for percutaneous coronary intervention (PCI). An artery with significant thrombus in its lumen has the potential for intervention. Therefore, although angiography may simply demonstrate severe diffuse disease with no potential for revascularisation, an attempt should be made to image the coronary arteries promptly if there is good reason to suspect ischaemia. A patient who has had his transplant a few years previously and who presents with new evidence of heart failure, a suspicious ECG and a troponin rise should be discussed with the cardiologists at an early stage with a view to imaging his coronaries.

Heart failure and arrhythmias

Myocardial ischaemia will most commonly present with heart failure or arrhythmias. Rhythm disturbances may present with palpitations, dizziness or syncope. Heart failure may be treated with diuretics and nitrates. Beta blockers must be used with caution. Hypertension and hypercholesterolaemia are common problems for transplant patients and they should receive aggressive secondary prevention if vascular disease is diagnosed.