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cardio.nstemi.post-transplant-cav.v1PRODUCTION
cardio.nstemi.post-transplant-cav.v1

NSTEMI in heart-transplant recipient — cardiac allograft vasculopathy (CAV)-driven

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12/12 authored

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Heart-transplant recipient with NSTE-ACS pattern — differential dominated by CAV-driven NSTEMI; concurrent rejection (ACR/AMR) possible; classical plaque rupture less common; denervated graft blunts angina (silent ischemia rule); inherits NSTEMI arc from cardio.nstemi.core.v1; treatment paradox vs atherosclerotic NSTEMI: CYP3A4-safe statin + NSAID absolute avoidance + cautious CCB selection + CNI management

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Transplant context + CAV vs rejection vs plaque-rupture framed

Patient inputs (17)

Recipient age + transplant vintage shape CAV burden vs concurrent rejection probability; older patients more likely to have multi-territory CAV

Time post-transplant: <1 yr → ACR/AMR more likely co-driver; 1-5 yr → CAV emerging; >5 yr → CAV dominates per ISHLT 2023 registry data

Tacrolimus / cyclosporine (CNI) trough levels + MMF + prednisone regimen drives differential and adjustment plan; CYP3A4 interactions with statins, CCB, antibiotics critical for medication safety

Known CAV ISHLT grade (1/2/3 per Mehra PMID 26277690) + IVUS history + prior PCI/CABG/re-transplant evaluation drives current management decisions

Prior ACR/AMR episodes + DSA positivity history + complement-binding (C1q) DSA + biopsy results inform current rejection probability and treatment plan

Denervated graft has higher resting HR baseline (~90-110 bpm); tachycardia triggers supply-demand mismatch in CAV substrate; new tachyarrhythmia raises infection / rejection / volume status concerns

Sub-therapeutic CNI trough → concurrent rejection risk; supratherapeutic → toxicity (KDIGO transplant 2009); STAT trough on arrival drives immunosuppression adjustment

Defines NSTEMI per 4th UDMI (PMID 30153967) rise/fall criteria; chronic mild troponin elevation common in transplant recipients (CAV baseline) — ACUTE rise/fall above baseline drives NSTEMI label; persistent rise without ECG changes → rejection workup

Diagnostic + monitoring; rises with NSTEMI, CAV-driven dysfunction, and concurrent rejection; trended for decongestion if HF features present

CNI nephrotoxicity baseline; informs imaging contrast safety + AC dosing + statin selection; AVOID NSAIDs absolutely (synergistic AKI with CNI); KDIGO 2021 race-free eGFR

CMV viremia accelerates CAV per Hosenpud Lancet 1998 + Valantine 2004 — drives preemptive valganciclovir treatment; also rules out CMV myocarditis ACS mimic

Anemia + leukopenia + thrombocytopenia common from immunosuppression; anemia worsens supply-demand mismatch in CAV substrate; baseline before any antiplatelet / AC

STAT echo for new LV/RV dysfunction; restrictive pattern can suggest concurrent rejection; baseline LVEF comparison critical for distinguishing acute event from chronic CAV trajectory

Coronary angiography + IVUS mandatory for any NSTEMI in transplant recipient — angio shows diffuse pruning + small-vessel disease + epicardial stenosis (CAV signature); IVUS gold standard for CAV detection (intimal thickness >0.5 mm) per ISHLT staging Mehra PMID 26277690

Hypotension + NSTEMI in transplant recipient → cardiogenic-shock pathway (DanGer Shock SCAI staging); CNI-related vasoplegia possible; SBP <90 triggers MCS evaluation + transplant program activation

Donor-specific antibodies + complement-binding (C1q) DSA assay — required if concurrent AMR suspected (ISHLT 2013 AMR criteria PMID 24263017); positive DSA + LV dysfunction triggers AMR pathway with plasmapheresis + IVIG + rituximab

Gold standard for ACR (ISHLT 2010 PMID 21177015) and AMR (pAMR0-pAMR3 per ISHLT 2013) — perform if concurrent rejection suspected (sub-therapeutic CNI, DSA positivity, restrictive echo pattern, recent biopsy positive)

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Severity triggers (6)

6 need judgement
  • informationallife_threateningdiffuse_cav_pattern_not_pci_amenable_in_nstemi_transplant
    Coronary angiography + IVUS reveal diffuse small-vessel CAV without focal lesion suitable for PCI — medical management + re-transplant evaluation indicated
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningre_transplant_decision_for_severe_cav_with_nstemi
    NSTEMI in transplant recipient with biopsy-confirmed CAV ISHLT 3 + LVEF <30 + non-recoverable graft — re-transplant listing decision
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningconcurrent_amr_with_nstemi_in_transplant
    Endomyocardial biopsy pAMR2 or pAMR3 + DSA positive in transplant recipient with NSTEMI — compounded ischemia + rejection requires multimodal therapy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverensaid_exposure_with_aki_in_transplant_recipient_nstemi
    Inadvertent NSAID administration to transplant recipient + creatinine rise — allograft nephrotoxicity + CNI synergistic AKI
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecyp3a4_drug_interaction_cyclosporine_or_tacrolimus_with_simvastatin_lovastatin_in_nstemi
    Inadvertent administration of CYP3A4-metabolised statin (simvastatin / lovastatin) to transplant recipient on CNI — risk of toxic statin levels and rhabdomyolysis
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecmv_viremia_with_cav_acceleration_in_nstemi_transplant
    CMV PCR positive viremia + new CAV substrate or accelerated CAV on annual screen + NSTEMI presentation — preemptive antiviral treatment indicated
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

NSTEMI in heart-transplant recipient — CAV-aware ACS bundle; CYP3A4-safe statin selection; NSAID absolute avoidance; cautious CCB (CNI interactions); mTOR substitution for long-term CAV progression — ISHLT 2010/2023 + Kobashigawa NEJM 1995 PMID 7637810 + CAVS-1/CRAD + ACC/AHA 2025 ACS (Rao)
axis: nstemi_post_transplant_cav_phenotype
Selected axis "NSTEMI in heart-transplant recipient — CAV-aware ACS bundle; CYP3A4-safe statin selection; NSAID absolute avoidance; cautious CCB (CNI interactions); mTOR substitution for long-term CAV progression — ISHLT 2010/2023 + Kobashigawa NEJM 1995 PMID 7637810 + CAVS-1/CRAD + ACC/AHA 2025 ACS (Rao)" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    162-325 mg load → 81 mg • PO chewed • load once → 81 mg daily indefinitely
    triggers: transplant_nstemi_confirmed
    Universal NSTEMI — ACC/AHA 2025 Class I; same as parent cardio.nstemi.core.v1; no CNI interaction
    rxcui 243670
  • ticagrelor
    first line
    p2y12_inhibitor
    180 mg load → 90 mg BID • PO • BID × 12 mo
    triggers: transplant_nstemi_pci_planned
    PLATO PMID 19717846; ACC/AHA 2025 Class I; minor CYP3A4 interaction with CNI but tolerated; clopidogrel acceptable alternative if drug-drug concerns
    rxcui 1116632
  • clopidogrel
    second line
    p2y12_inhibitor
    300-600 mg load → 75 mg daily • PO • daily × 12 mo
    triggers: transplant_nstemi_with_ticagrelor_intolerance, transplant_nstemi_with_high_bleeding_risk
    Lower bleeding risk than ticagrelor; CYP-neutral with CNI; preferred when ticagrelor not tolerated or bleeding risk dominates
    rxcui 309362
  • unfractionated heparin
    first line
    parenteral_anticoagulant
    70-100 U/kg bolus → infusion to ACT 250-300 during PCI • IV • continuous, ACT-guided
    triggers: transplant_nstemi_pci_planned
    ACC/AHA 2025 Class I parenteral AC; reversible; renal-friendly; preferred over enoxaparin in transplant given CNI nephrotoxicity baseline
    rxcui 5224
  • pravastatin
    first line
    statin_low_intensity_cyp3a4_safe
    40-80 mg • PO • daily
    triggers: transplant_nstemi_confirmed, cni_concomitant
    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 — toxic levels with CNI)
    rxcui 42463
  • pitavastatin
    add on
    statin_high_intensity_cyp3a4_safe
    2-4 mg • PO • daily
    triggers: transplant_nstemi_confirmed, ldl_above_target_on_pravastatin
    CYP-neutral high-intensity statin alternative; ISHLT 2023 acceptable; consider if pravastatin insufficient for LDL target <70 (or <55 very-high-risk)
    rxcui 861634
  • methylprednisolone
    comorbidity specific
    corticosteroid
    1000 mg IV daily × 3 d (pulse therapy) • IV • daily × 3
    triggers: concurrent_acr_grade_2r_or_higher, concurrent_amr_with_lv_dysfunction
    ISHLT 2010 (Stewart PMID 21177015) — pulse steroids first line for ≥2R ACR; also adjunct in AMR; for NSTEMI patients with concurrent rejection on biopsy
    rxcui 6902
  • tacrolimus
    first line
    calcineurin_inhibitor
    Maintain trough 5-10 ng/mL late post-transplant; AVOID over-reduction • PO • BID
    triggers: transplant_maintenance, sub_therapeutic_trough_with_concurrent_rejection
    KDIGO transplant 2009 — narrow therapeutic window; sub-therapeutic trough is a modifiable rejection driver and may compound CAV-driven NSTEMI substrate; coordinate with transplant team
    rxcui 42316
  • sirolimus
    comorbidity specific
    mtor_inhibitor
    Trough 4-8 ng/mL with CNI reduction • PO • daily
    triggers: cav_progression_post_nstemi, cav_ishlt_2_3_with_acceptable_renal_function
    CAVS-1 / CRAD trial + ISHLT 2024 update — mTOR inhibitor switch (with CNI reduction) slows CAV progression; strongly consider after NSTEMI in transplant recipient with confirmed CAV substrate; NOT acute therapy — chronic management decision
    rxcui 35302
  • everolimus
    comorbidity specific
    mtor_inhibitor
    Trough 3-8 ng/mL with CNI reduction • PO • BID
    triggers: cav_progression_with_renal_dysfunction_limiting_sirolimus
    mTOR alternative to sirolimus; ISHLT 2024 update; less wound-healing impact; consider when sirolimus poorly tolerated
    rxcui 141704
  • carvedilol
    add on
    mixed_alpha_beta_blocker
    3.125 mg BID titrate • PO • BID
    triggers: post_nstemi_ef_lt_40_in_transplant_recipient, documented_chronic_HF_in_graft
    Standard post-MI BB per ACC/AHA 2025; denervated graft adrenergic response uncertain but BB still reasonable for HFrEF; CAPRICORN PMID 11356436 historical context
    rxcui 20352
  • amlodipine
    comorbidity specific
    dhp_ccb
    5 mg PO daily titrate • PO • daily
    triggers: transplant_nstemi_with_uncontrolled_htn_post_event
    Preferred CCB in transplant recipients (avoid diltiazem/verapamil — CYP3A4 inhibition raises CNI levels); close CNI monitoring during titration
    rxcui 104416
  • sulfamethoxazole-trimethoprim
    comorbidity specific
    antibiotic_pjp_prophylaxis
    1 SS PO daily or 1 DS MWF (continue lifelong post-transplant) • PO • daily/MWF
    triggers: transplant_maintenance_pjp_prophylaxis
    PJP prophylaxis lifelong post-transplant per ISHLT 2023; verify continuity during NSTEMI hospitalization
    rxcui 10180
  • valganciclovir
    comorbidity specific
    antiviral_cmv
    900 mg PO BID × 21 d induction (renal-adjusted), then 900 mg daily × 3 mo • PO • BID induction → daily maintenance
    triggers: cmv_pcr_positive_with_cav_acceleration_or_myocarditis
    CMV viremia accelerates CAV per Hosenpud Lancet 1998 + Valantine 2004; preemptive treatment in transplant recipient with active viremia + new CAV/NSTEMI substrate
    rxcui 275891

outpatient playbook — drug actions (4)

  1. 1. continue DAPT through 12 mo then ASA monotherapy
    rxcui 321208
    aspirin 81 + ticagrelor 90 BID × 12 mo, then ASA 81 alone • PO • as scheduled
    trigger: Post-cath maintenance
    PARIS adherence-vs-stent-thrombosis; PLATO PMID 19717846
  2. 2. continue triple immunosuppression long-term
    rxcui 42316
    tacrolimus trough 5-8 ng/mL late + MMF 1000 BID + prednisone 2.5-5 daily • PO • as scheduled
    trigger: transplant maintenance
    ISHLT 2023; lower troughs late to balance CAV/malignancy/infection vs rejection risk
  3. 3. pravastatin or pitavastatin maintenance
    rxcui 617314
    pravastatin 40-80 mg or pitavastatin 2-4 mg • PO • daily
    trigger: transplant maintenance — CAV prevention
    ISHLT 2023 Class I; Kobashigawa NEJM 1995 PMID 7637810; LDL target <70 (or <55 very-high-risk)
  4. 4. consider mTOR switch (sirolimus/everolimus) for CAV progression
    rxcui 35302
    sirolimus per trough 4-8 ng/mL; reduce CNI • PO • daily
    trigger: CAV progression on annual angio
    CAVS-1 / CRAD / ISHLT 2024 update — mTOR slows CAV progression

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Unexplained hsTn rise/fall + ECG changes in heart-transplant recipient — NSTEMI-equivalent in denervated graft (silent ischemia rule); CAV-driven on differential; Heart-transplant recipient (denervated graft) with new dyspnea / fatigue / hypotension / syncope + non-ST-elevation ECG changes + troponin rise — silent ischemia pattern (no classic angina); Known CAV ISHLT grade 2-3 + new LV dysfunction on echo + troponin rise → emergent angiography for CAV-driven NSTEMI assessment with IVUS.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**NSTEMI in heart-transplant recipient — cardiac allograft vasculopathy (CAV)-driven** (cardio.nstemi.post-transplant-cav.v1).
Phenotype framing: CAV-driven NSTEMI (diffuse small-vessel + epicardial — most common in late transplant) vs CAV focal lesion (PCI-amenable) vs classical plaque-rupture NSTEMI vs concurrent ACR/AMR vs CMV myocarditis vs supply-demand mismatch (anemia, sepsis, hypoxia) vs Takotsubo per ISHLT 2023 + 4th UDMI 2018
Scope: Heart-transplant recipient with NSTE-ACS pattern — differential dominated by CAV-driven NSTEMI; concurrent rejection (ACR/AMR) possible; classical plaque rupture less common; denervated graft blunts angina (silent ischemia rule); inherits NSTEMI arc from cardio.nstemi.core.v1; treatment paradox vs atherosclerotic NSTEMI: CYP3A4-safe statin + NSAID absolute avoidance + cautious CCB selection + CNI management

No severity triggers fired against current inputs.

Plan

Regimen axis: **NSTEMI in heart-transplant recipient — CAV-aware ACS bundle; CYP3A4-safe statin selection; NSAID absolute avoidance; cautious CCB (CNI interactions); mTOR substitution for long-term CAV progression — ISHLT 2010/2023 + Kobashigawa NEJM 1995 PMID 7637810 + CAVS-1/CRAD + ACC/AHA 2025 ACS (Rao)**.
1. aspirin 162-325 mg load → 81 mg PO chewed load once → 81 mg daily indefinitely (antiplatelet_cox1, first line) — Universal NSTEMI — ACC/AHA 2025 Class I; same as parent cardio.nstemi.core.v1; no CNI interaction
2. ticagrelor 180 mg load → 90 mg BID PO BID × 12 mo (p2y12_inhibitor, first line) — PLATO PMID 19717846; ACC/AHA 2025 Class I; minor CYP3A4 interaction with CNI but tolerated; clopidogrel acceptable alternative if drug-drug concerns
3. clopidogrel 300-600 mg load → 75 mg daily PO daily × 12 mo (p2y12_inhibitor, second line) — Lower bleeding risk than ticagrelor; CYP-neutral with CNI; preferred when ticagrelor not tolerated or bleeding risk dominates
4. unfractionated heparin 70-100 U/kg bolus → infusion to ACT 250-300 during PCI IV continuous, ACT-guided (parenteral_anticoagulant, first line) — ACC/AHA 2025 Class I parenteral AC; reversible; renal-friendly; preferred over enoxaparin in transplant given CNI nephrotoxicity baseline
5. pravastatin 40-80 mg PO daily (statin_low_intensity_cyp3a4_safe, first line) — 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 — toxic levels with CNI)
6. pitavastatin 2-4 mg PO daily (statin_high_intensity_cyp3a4_safe, add on) — CYP-neutral high-intensity statin alternative; ISHLT 2023 acceptable; consider if pravastatin insufficient for LDL target <70 (or <55 very-high-risk)
7. methylprednisolone 1000 mg IV daily × 3 d (pulse therapy) IV daily × 3 (corticosteroid, comorbidity specific) — ISHLT 2010 (Stewart PMID 21177015) — pulse steroids first line for ≥2R ACR; also adjunct in AMR; for NSTEMI patients with concurrent rejection on biopsy
8. tacrolimus Maintain trough 5-10 ng/mL late post-transplant; AVOID over-reduction PO BID (calcineurin_inhibitor, first line) — KDIGO transplant 2009 — narrow therapeutic window; sub-therapeutic trough is a modifiable rejection driver and may compound CAV-driven NSTEMI substrate; coordinate with transplant team
9. sirolimus Trough 4-8 ng/mL with CNI reduction PO daily (mtor_inhibitor, comorbidity specific) — CAVS-1 / CRAD trial + ISHLT 2024 update — mTOR inhibitor switch (with CNI reduction) slows CAV progression; strongly consider after NSTEMI in transplant recipient with confirmed CAV substrate; NOT acute therapy — chronic management decision
10. everolimus Trough 3-8 ng/mL with CNI reduction PO BID (mtor_inhibitor, comorbidity specific) — mTOR alternative to sirolimus; ISHLT 2024 update; less wound-healing impact; consider when sirolimus poorly tolerated
11. carvedilol 3.125 mg BID titrate PO BID (mixed_alpha_beta_blocker, add on) — Standard post-MI BB per ACC/AHA 2025; denervated graft adrenergic response uncertain but BB still reasonable for HFrEF; CAPRICORN PMID 11356436 historical context
12. amlodipine 5 mg PO daily titrate PO daily (dhp_ccb, comorbidity specific) — Preferred CCB in transplant recipients (avoid diltiazem/verapamil — CYP3A4 inhibition raises CNI levels); close CNI monitoring during titration
13. sulfamethoxazole-trimethoprim 1 SS PO daily or 1 DS MWF (continue lifelong post-transplant) PO daily/MWF (antibiotic_pjp_prophylaxis, comorbidity specific) — PJP prophylaxis lifelong post-transplant per ISHLT 2023; verify continuity during NSTEMI hospitalization
14. valganciclovir 900 mg PO BID × 21 d induction (renal-adjusted), then 900 mg daily × 3 mo PO BID induction → daily maintenance (antiviral_cmv, comorbidity specific) — CMV viremia accelerates CAV per Hosenpud Lancet 1998 + Valantine 2004; preemptive treatment in transplant recipient with active viremia + new CAV/NSTEMI substrate

Setting playbook (outpatient) — Long-term transplant cardiology surveillance: annual coronary angiography or IVUS for CAV progression, surveillance biopsy schedule, DSA monitoring, CYP3A4-safe statin maintenance, mTOR substitution for CAV slowing, re-transplant listing decisions
15. continue DAPT through 12 mo then ASA monotherapy aspirin 81 + ticagrelor 90 BID × 12 mo, then ASA 81 alone PO as scheduled — Post-cath maintenance (PARIS adherence-vs-stent-thrombosis; PLATO PMID 19717846)
16. continue triple immunosuppression long-term tacrolimus trough 5-8 ng/mL late + MMF 1000 BID + prednisone 2.5-5 daily PO as scheduled — transplant maintenance (ISHLT 2023; lower troughs late to balance CAV/malignancy/infection vs rejection risk)
17. pravastatin or pitavastatin maintenance pravastatin 40-80 mg or pitavastatin 2-4 mg PO daily — transplant maintenance — CAV prevention (ISHLT 2023 Class I; Kobashigawa NEJM 1995 PMID 7637810; LDL target <70 (or <55 very-high-risk))
18. consider mTOR switch (sirolimus/everolimus) for CAV progression sirolimus per trough 4-8 ng/mL; reduce CNI PO daily — CAV progression on annual angio (CAVS-1 / CRAD / ISHLT 2024 update — mTOR slows CAV progression)

Non-pharmacologic actions:
- Annual CAV imaging
- Sun protection + dermatology yearly
- Vaccinations (no live)
- Adherence reinforcement
- Cardiac rehab maintenance phase (modified intensity)
- Re-transplant listing reassessment if CAV ISHLT 3 progression

AVOID / contraindication checks:
- Nsaid_avoid_absolutely (allograft nephrotoxicity; CNI synergistic AKI)
- Simvastatin_lovastatin_avoid_with_cni (CYP3A4 — toxic statin levels and rhabdo)
- Diltiazem_verapamil_avoid_with_cni (CYP3A4 — toxic CNI levels; if BP control needed, prefer amlodipine with close CNI monitoring)
- Clarithromycin_azole_antifungal_avoid_with_cni (CYP3A4 — toxic CNI levels)
- Cni_minimal_reduction_only (over reduction precipitates rejection — narrow therapeutic window)
- Live_vaccines_contraindicated (chronic immunosuppression)
- Gadolinium_avoid_if_egfr_below_30 (NSF risk; defer cardiac MRI)
- Decision:ivus_mandatory_for_any_transplant_recipient_nstemi (CAV substrate confirmation per ISHLT staging Mehra PMID 26277690)
- Decision:re_transplant_evaluation_if_cav_ishlt_3_and_non_recoverable_graft (ISHLT 2023 listing criteria)
- Decision:mtor_substitution_for_cav_progression_strongly_considered (CAVS 1 / CRAD / ISHLT 2024 update)

Monitoring

Regimen monitoring:
- CNI trough daily during acute NSTEMI period
- Troponin q6h × 24 h post-PCI
- Surveillance biopsy at 2 wk if concurrent rejection suspected
- DSA titer q month × 3 if AMR co-driver
- CMV PCR weekly during active viremia or 2 wk after preemptive therapy
- Echo at 5-7 d for LV thrombus + LV recovery
- Annual CAV imaging (angio + IVUS) post-event
- Hgb q12 h on triple antithrombotic (BARC 2011)
- Creatinine q24 h on AC + post-contrast (KDIGO 2026)
- CK + creatinine q month for first 3 mo on statin (rhabdo surveillance)

Setting (outpatient) monitoring:
- Quarterly clinic + labs
- Annual CAV imaging + DSA + cancer screen
- Lipid panel q 6 mo
- CMV PCR per program preemptive vs prophylactic strategy

Follow-up plan: Transplant cardiology long-term: annual angio + IVUS for CAV; surveillance biopsy per program (decreasing frequency over time); DSA q3-6 mo; mTOR inhibitor (sirolimus / everolimus) substitution for CNI to slow CAV progression per CAVS-1 / CRAD + ISHLT 2024 update strongly considered; CYP3A4-safe statin maintenance (pravastatin/pitavastatin); cardiac rehab phase II per ACC/AHA 2025 (modified intensity); re-transplant listing if CAV ISHLT 3 with non-recoverable graft per ISHLT 2023; vaccination (NO live vaccines); cancer surveillance (skin, PTLD)
- Close-out criterion: Transplant program plan + mTOR consideration documented + CAV surveillance scheduled

Monitoring phase: Repeat troponin q6h × 24 h; CNI troughs daily during acute period; surveillance biopsy at 2 wk if any rejection suspicion; DSA panel q month × 3 if AMR co-driver; echo at 5-7 d for thrombus + LV recovery; CMV PCR weekly during active CMV viremia; annual CAV imaging (angio + IVUS); BMP daily on AC + post-contrast (KDIGO 2026)

Disposition

Current setting: outpatient — Long-term transplant cardiology surveillance: annual coronary angiography or IVUS for CAV progression, surveillance biopsy schedule, DSA monitoring, CYP3A4-safe statin maintenance, mTOR substitution for CAV slowing, re-transplant listing decisions

Disposition criteria:
- Long-term continuation with transplant program; cross-link to cardio.acute-hf.transplant-recipient.v1 for residual HFrEF management

Escalation triggers (move to higher acuity):
- New LV dysfunction → STAT biopsy + DSA + cath
- CAV ISHLT 3 progression → re-transplant evaluation
- PTLD suspicion → reduce immunosuppression + oncology consult
- Recurrent ischemic event → urgent re-cath

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Coronary angiography + IVUS reveal diffuse small-vessel CAV without focal lesion suitable for PCI — medical management + re-transplant evaluation indicated
- [LIFE_THREATENING] NSTEMI in transplant recipient with biopsy-confirmed CAV ISHLT 3 + LVEF <30 + non-recoverable graft — re-transplant listing decision
- [LIFE_THREATENING] Endomyocardial biopsy pAMR2 or pAMR3 + DSA positive in transplant recipient with NSTEMI — compounded ischemia + rejection requires multimodal therapy

Citations

- ISHLT 2010 ACR grading + ISHLT 2013 AMR working formulation + ISHLT 2023 update + 2025 ACC/AHA ACS Guideline (Rao) + KDIGO transplant 2009 + ISHLT 2024 mTOR substitution update [PMID:21177015](https://pubmed.ncbi.nlm.nih.gov/21177015/)
- Cited evidence (PMID 24263017) [PMID:24263017](https://pubmed.ncbi.nlm.nih.gov/24263017/)
- Cited evidence (PMID 23446352) [PMID:23446352](https://pubmed.ncbi.nlm.nih.gov/23446352/)
- Cited evidence (PMID 25997674) [PMID:25997674](https://pubmed.ncbi.nlm.nih.gov/25997674/)
- Cited evidence (PMID 26277690) [PMID:26277690](https://pubmed.ncbi.nlm.nih.gov/26277690/)

Last reconciled with current guidelines: 2026-05-15.
References
  • ISHLT 2010 ACR grading + ISHLT 2013 AMR working formulation + ISHLT 2023 update + 2025 ACC/AHA ACS Guideline (Rao) + KDIGO transplant 2009 + ISHLT 2024 mTOR substitution update — PMID:21177015
  • Cited evidence (PMID 24263017) — PMID:24263017
  • Cited evidence (PMID 23446352) — PMID:23446352
  • Cited evidence (PMID 25997674) — PMID:25997674
  • Cited evidence (PMID 26277690) — PMID:26277690