This handout is for stemi in cardiac transplant recipient (cav-driven). Your care team identified this based on: new st elevation ≥1 mm in ≥2 contiguous leads on ecg in cardiac transplant recipient.
Other reasons your team may use this plan: unexplained troponin rise + new lvef reduction on echo in transplant recipient (stemi-equivalent in denervated graft); transplant recipient (denervated graft) with new dyspnea / hemodynamic deterioration + st changes — silent ischemia pattern (no classic angina); known cav ishlt grade 2-3 + new lv dysfunction → emergent angiography for cav-driven stemi assessment.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| aspirin | 162–325 mg load → 81 mg | PO chewed | load once → 81 mg daily | Universal STEMI — ACC/AHA 2025 Class I; same as parent cardio.stemi.core.v1; no CNI interaction |
| ticagrelor | 180 mg load → 90 mg BID | PO | BID × 12 mo | PLATO PMID 19717846; ACC/AHA 2025 Class I; minor CYP3A4 interaction with CNI but tolerated; clopidogrel acceptable alternative if drug-drug concerns |
| unfractionated heparin | 70–100 U/kg bolus → infusion to ACT 250–300 during PCI | IV | continuous, ACT-guided | ACC/AHA 2025 Class I parenteral AC; reversible; renal-friendly; preferred over enoxaparin in transplant given CNI nephrotoxicity baseline |
| pravastatin | 40–80 mg | PO | daily | ISHLT 2023 Class I + Kobashigawa NEJM 1995 PMID 7637810 — pravastatin is CYP3A4-neutral so does not interact with calcineurin inhibitors; standard transplant statin; AVOID simvastatin/lovastatin (CYP3A4 metabolised) |
| pitavastatin | 2–4 mg | PO | daily | CYP-neutral high-intensity statin alternative; ISHLT 2023 acceptable; consider if pravastatin insufficient for LDL target <70 (or <55 very-high-risk) |
| methylprednisolone | 1000 mg IV daily × 3 d (pulse therapy) | IV | daily × 3 | ISHLT 2010 (Stewart PMID 21177015) — pulse steroids first line for ≥2R ACR; also adjunct in AMR; for STEMI patients with concurrent rejection on biopsy |
| tacrolimus | Maintain trough 5–10 ng/mL late post-transplant; AVOID over-reduction | PO | BID | KDIGO transplant 2009 — narrow therapeutic window; sub-therapeutic trough is a modifiable rejection driver and may compound CAV-driven STEMI substrate |
| sirolimus | Trough 4–8 ng/mL with CNI reduction | PO | daily | CAVS-1 / CRAD trial — mTOR inhibitor switch (with CNI reduction) slows CAV progression; consider after STEMI in transplant recipient with confirmed CAV substrate; NOT acute therapy |
| carvedilol | 3.125 mg BID titrate | PO | BID | Standard post-MI BB per ACC/AHA 2025; denervated graft adrenergic response uncertain but BB still reasonable for HFrEF; CAPRICORN PMID 11356436 historical context |
Plan: STEMI in cardiac transplant recipient — CAV-aware ACS bundle; CYP3A4-safe statin selection; AVOID NSAIDs absolutely; cautious CCB (CNI interactions); mTOR substitution for long-term CAV progression
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
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
Guideline: ISHLT 2010 ACR grading + ISHLT 2013 AMR working formulation + ISHLT 2023 update + 2025 ACC/AHA ACS Guideline (Rao) + KDIGO transplant 2009