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cardio.stemi.transplant-recipient.v1

STEMI in cardiac transplant recipient (CAV-driven)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.stemi.core.v1 — narrowed to STEMI in cardiac transplant recipients. Pathophysiology dominated by cardiac allograft vasculopathy (CAV) — alloimmune-driven concentric coronary intimal hyperplasia per ISHLT 2010/2023; classical plaque-rupture STEMI also occurs but less commonly. Denervated grafts often present with silent ischemia — any ECG ST elevation + troponin rise + new LV dysfunction is a STEMI-equivalent. Diagnostic specialization: coronary angiography + IVUS (CAV gold standard — intimal thickness >0.5 mm); cardiac MRI for CAV burden if eGFR ≥30; DSA + endomyocardial biopsy if concurrent rejection suspected. Treatment specialization: standard ACS bundle BUT diffuse CAV may not be amenable to standard PCI; IVUS-guided PCI for focal lesions; CABG rare given diffuse pattern + redo-sternotomy risk; re-transplant evaluation if severe CAV + non-recoverable graft. Statin must be CYP3A4-safe (pravastatin / pitavastatin) — simvastatin/lovastatin CONTRAINDICATED with CNI. AVOID NSAIDs absolutely. Cautious CCB selection (avoid diltiazem/verapamil with CNI — CYP3A4 toxicity). Long-term: mTOR inhibitor (sirolimus, everolimus) substitution for CNI to slow CAV progression per CAVS-1 / CRAD trials; annual CAV imaging; transplant program co-management mandatory; cross-link to cardio.acute-hf.transplant-recipient.v1 for residual HFrEF management. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute as Phase E wave 16 adjacent-disease variant.

Entry points (4)

  • imaging
    New ST elevation ≥1 mm in ≥2 contiguous leads on ECG in cardiac transplant recipient
    st_elevation_in_transplant_recipient
  • lab_abnormality
    Unexplained troponin rise + new LVEF reduction on echo in transplant recipient (STEMI-equivalent in denervated graft)
    unexplained_troponin_rise_with_lvef_drop_in_transplant
  • history
    Transplant recipient (denervated graft) with new dyspnea / hemodynamic deterioration + ST changes — silent ischemia pattern (no classic angina)
    transplant_recipient_with_silent_ischemia_pattern
  • imaging
    Known CAV ISHLT grade 2-3 + new LV dysfunction → emergent angiography for CAV-driven STEMI assessment
    cav_progression_with_new_lv_dysfunction

Required inputs (13)

  • agerequired
    demographic • used at CONTEXT
    Recipient age + transplant vintage shape CAV burden vs concurrent rejection probability
  • transplant_daterequired
    history • used at CONTEXT
    Time post-transplant: <1 yr → ACR/AMR more likely co-driver; >5 yr → CAV dominates (ISHLT 2023)
  • current_immunosuppressionrequired
    history • used at CONTEXT
    Tacrolimus / cyclosporine (CNI) trough levels + MMF + prednisone regimen drives differential and adjustment plan; CYP3A4 interactions with statins, CCB, antibiotics
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension + STEMI in transplant recipient → cardiogenic-shock pathway; CNI-related vasoplegia possible
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Graft injury marker; persistent rise + ST elevation = STEMI-equivalent; persistent rise without ST changes → rejection workup
  • nt_probnprequired
    lab • used at INITIAL_WORKUP
    Diagnostic + monitoring; rises with STEMI, CAV-driven dysfunction, and concurrent rejection
  • creatininerequired
    lab • used at CONTEXT
    CNI nephrotoxicity baseline; informs imaging contrast safety + AC dosing; AVOID NSAIDs absolutely
  • cni_troughrequired
    lab • used at CONTEXT
    Sub-therapeutic CNI trough → concurrent rejection risk; supratherapeutic → toxicity (KDIGO transplant 2009)
  • dsa_panel
    lab • used at BRANCHING_WORKUP
    Donor-specific antibodies — required if concurrent AMR suspected (ISHLT 2013 AMR criteria)
  • echo_statrequired
    imaging • used at INITIAL_WORKUP
    STAT echo for new LV/RV dysfunction; restrictive pattern can suggest concurrent rejection; baseline LVEF comparison critical
  • cor_angio_with_ivusrequired
    imaging • used at TREATMENT
    Coronary angiography typically shows diffuse pruning + small-vessel disease + epicardial stenosis (CAV signature); IVUS gold standard for CAV detection (intimal thickness >0.5 mm) per ISHLT staging
  • cardiac_mri_for_cav_burden
    imaging • used at BRANCHING_WORKUP
    Gadolinium-enhanced cardiac MRI for CAV burden + scar + ischemia (avoid if eGFR <30)
  • endomyocardial_biopsy_if_rejection_suspected
    imaging • used at BRANCHING_WORKUP
    Gold standard for ACR (ISHLT 2010) and AMR (pAMR0–pAMR3) — perform if concurrent rejection suspected (sub-therapeutic CNI, DSA positivity, restrictive echo pattern)

12-phase flow (12)

  1. 1FRAME
    Cardiac transplant recipient with ST elevation — differential dominated by CAV-driven STEMI; concurrent rejection (ACR/AMR) possible; classical plaque rupture less common; inherits STEMI arc from cardio.stemi.core.v1
    inputs: transplant_date, current_immunosuppression
    advance: Transplant context + CAV vs rejection vs plaque-rupture framed
  2. 2ENTRY
    Notify transplant cardiology immediately; emergent cath lab activation; concurrent biopsy planning if rejection suspected; bedside echo
    inputs: age
    advance: Transplant team activated + cath lab booked
  3. 3CONTEXT
    Transplant vintage, full immunosuppression regimen with troughs, baseline LVEF, CAV history, DSA history, CYP3A4 drug-interaction screen for statins / CCB / antibiotics (KDIGO transplant 2009)
    inputs: transplant_date, current_immunosuppression, cni_trough, creatinine
    advance: Transplant context complete
  4. 4RED_FLAGS
    Cardiogenic shock (graft failure SCAI C+ — DanGer Shock PMID 38587234 Impella benefit); concurrent severe rejection (AMR or 3R ACR) compounding ischemia; opportunistic infection mimic (CMV myocarditis can present like ACS)
    inputs: sbp, troponin
    actions: cardiogenic_shock
    advance: Red flags screened or escalated
  5. 5INITIAL_WORKUP
    STAT echo + troponin + NT-proBNP + BMP + CBC + CMV/EBV PCR + lactate; CXR; pulse CNI trough; standard ACS labs
    inputs: troponin, nt_probnp, echo_stat, creatinine, cni_trough
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: Baseline transplant labs + STAT echo documented
  6. 6BRANCHING_WORKUP
    Coronary angiography with IVUS for CAV substrate; cardiac MRI if eGFR ≥30 for ischemia/scar burden; DSA panel + endomyocardial biopsy if concurrent rejection suspected
    inputs: cor_angio_with_ivus
    advance: CAV substrate documented + concurrent rejection assessed
  7. 7DIFFERENTIAL
    CAV-driven STEMI (diffuse) vs CAV focal lesion (PCI-amenable) vs classical plaque-rupture STEMI vs concurrent ACR/AMR vs CMV myocarditis vs Takotsubo per ISHLT 2023 + 4th UDMI 2018
    inputs: cor_angio_with_ivus
    advance: Substrate identified
  8. 8RISK_STRATIFICATION
    TIMI / HEART for ACS risk; CAV ISHLT staging (1/2/3) for graft prognosis; CAV ISHLT 3 + new STEMI = re-transplant trigger; concurrent AMR worst prognosis
    inputs: age, sbp, troponin, creatinine
    actions: calc.timi_nstemi, calc.heart, calc.ckd_epi_2021
    advance: Risk band documented
  9. 9TREATMENT
    Standard ACS bundle (ASA + P2Y12 + UFH + CYP3A4-safe statin) per ACC/AHA 2025 — but PCI strategy depends on CAV pattern: focal lesion → IVUS-guided PCI; diffuse CAV → medical management + re-transplant evaluation. AVOID NSAIDs absolutely. Cautious CCB selection (avoid diltiazem/verapamil with CNI). β-blocker per standard post-MI; preserved adrenergic response in denervated graft uncertain
    inputs: cni_trough, creatinine
    actions: protocol.stemi
    advance: Targeted PCI/medical/re-transplant strategy started
  10. 10DISPOSITION
    CICU post-PCI mandatory; transplant program co-management; transplant ward thereafter; never to telemetry only
    advance: Unit + transplant team co-management activated
  11. 11MONITORING
    Repeat troponin q6h × 24 h; CNI troughs daily; surveillance biopsy at 2 wk if any rejection suspicion; DSA q month × 3; echo at 5–7 d for thrombus + LV recovery; annual CAV imaging
    inputs: troponin, cni_trough, echo_stat
    actions: panel.cardiac, panel.renal
    advance: Post-treatment monitoring plan in place
  12. 12FOLLOWUP
    Transplant cardiology long-term: annual angio/IVUS for CAV; surveillance biopsy per program; mTOR inhibitor (sirolimus / everolimus) substitution for CNI to slow CAV progression per CAVS-1 / CRAD; statin maintenance (CYP3A4-safe); cardiac rehab; re-transplant listing if CAV ISHLT 3 with non-recoverable graft
    advance: Transplant program plan + mTOR consideration documented