Heart Transplant Patients: What Residents Need to Know¶
Learning Objectives¶
By the end of this rotation, you should be able to:
- Recognize signs of rejection in transplant patients
- Understand infection risks in immunosuppressed patients
- Know which medications require cardiology input before changing
- Appreciate the urgency of concerning symptoms
Transplant Basics for Residents¶
Why These Patients Are Different¶
| Feature | Why It Matters |
|---|---|
| Immunosuppressed | High infection risk, atypical presentations |
| Denervated heart | No chest pain with ischemia; HR won't increase normally |
| Rejection risk | Ongoing risk, especially first year |
| Drug interactions | Many medications interact with immunosuppression |
Common Immunosuppression Regimen¶
Most patients are on triple therapy: 1. Tacrolimus (Prograf) - calcineurin inhibitor 2. Mycophenolate (CellCept) - antiproliferative 3. Prednisone - corticosteroid (often weaned over time)
Warning Signs - Call Cardiology/Transplant Team¶
Urgent¶
| Finding | Concern |
|---|---|
| Fever | Infection in immunosuppressed patient |
| New heart failure symptoms (dyspnea, edema, fatigue) | Rejection |
| Arrhythmias | Rejection or graft dysfunction |
| Hypotension | Rejection, sepsis |
| Decreased exercise tolerance | Early rejection sign |
Important¶
- Any GI symptoms (may affect drug absorption)
- Any new infection
- Medication changes (check interactions!)
Infection in Transplant Patients¶
Key Principles¶
- Fever is always concerning - low threshold to evaluate
- Atypical presentations - may not mount typical inflammatory response
- Opportunistic infections - CMV, EBV, fungal, PJP
- Prophylaxis - many are on Bactrim (PJP), valganciclovir (CMV)
Common Infections by Timing¶
| Timeframe | Common Infections |
|---|---|
| <1 month | Nosocomial, wound, donor-derived |
| 1-6 months | CMV, EBV, opportunistic |
| >6 months | Community-acquired, late CMV |
Rejection: What Residents Should Know¶
Types (Simplified)¶
- Acute cellular rejection (ACR) - T-cell mediated, most common
- Antibody-mediated rejection (AMR) - B-cell/antibody mediated
How It Presents¶
- Often nonspecific: fatigue, malaise, low-grade fever
- Heart failure symptoms: dyspnea, edema, decreased exercise tolerance
- Arrhythmias
- May be asymptomatic - found on surveillance biopsy
Your Role¶
If you suspect rejection: Call the transplant team immediately. They will arrange biopsy and treatment.
Drug Interactions - CRITICAL¶
Many common medications interact with tacrolimus and cyclosporine:
| Avoid/Use Caution | Effect |
|---|---|
| Azithromycin, clarithromycin | ↑ tacrolimus levels |
| Fluconazole, itraconazole | ↑ tacrolimus levels |
| NSAIDs | Nephrotoxicity |
| Live vaccines | CONTRAINDICATED |
Before prescribing ANYTHING: Check with transplant pharmacist or team.
Practical Tips for Residents¶
Do's¶
- Call transplant team early for any concerns
- Check drug interactions before prescribing
- Take fever seriously - sepsis workup if warranted
- Check tacrolimus level if patient is ill or on new medications
Don'ts¶
- Don't give live vaccines (MMR, varicella, live flu)
- Don't change immunosuppression without transplant team
- Don't assume chest pain = ischemia - heart is denervated
- Don't delay calling if you're concerned
Key Teaching Points for Residents¶
- Transplant patients are immunosuppressed - atypical infection presentations
- Fever = serious until proven otherwise
- Rejection may be subtle - fatigue, decreased exercise tolerance
- Heart is denervated - no chest pain with ischemia, blunted HR response
- Drug interactions are common - always check before prescribing
- When in doubt, call the transplant team - they want to hear from you
Key Guidelines¶
ISHLT Guidelines for the Care of Heart Transplant Recipients J Heart Lung Transplant. 2023 Updated regularly at ISHLT.org
Board Pearls¶
Pearl: Transplanted hearts are denervated - no chest pain with ischemia
Patients won't have typical angina. Heart rate response to exercise is also blunted.
Pearl: Fever in a transplant patient = serious until proven otherwise
These patients are immunosuppressed and may not mount typical inflammatory responses. Low threshold for full workup.
Pearl: Check drug interactions before prescribing ANYTHING to transplant patients
Many common medications (azithromycin, fluconazole) increase tacrolimus levels. Consult transplant pharmacist.