In the ED, vitals/exam are as above. Given patient is status post orthotopic heart transplantation, they are at high risk for ACS/inflammatory coronary disease (also known as coronary insufficiency, have high suspicion if patient on sirolimus), arrhythmia (either primary or due to rejection), acute heart failure, pericardial effusion, pseudo-aneurysm/aneurysm/dissection, acute rejection, occult infection (including bacterial/viral/fungal etiologies given immunocompromised status), post-transplant lymphoproliferative disorder, and transplant medication side effect (cellcept/MMF is associated with N/V/D; tacrolimus is associated with renal toxicity/long term renal fibrosis/HTN/tremor). Hence, will proceed as below.
– Labs/Tests: Lactate x2, CBC, CMP, Lipase, Coags, Trops x2, BNP, CMV PCR, EBV PCR, Levels of immunosuppressants (if on tacrolimus, cyclosporine, sirolimus), BCx x2, UA, UCx, PRO testing
– Imaging: CXR, BSUS. If concerned PE, talk with transplant prior to obtaining CTPE given concern for contrast load. TTE as inpatient
– Treatments: Attentive fluid strategy (no maintenance fluids; consider LR 500cc x1 if dry vs. Lasix x1 otherwise), Antiemetics as needed, Pain control as needed, Low threshold for antibiotics/antifungals, Home transplant meds (if medication side effect less likely after discussion with Transplant Cardiology)
– Consults: Transplant Cardiology
– Dispo: Admission to Cardiology for likely LHC, RHC, and endomyocardial biopsy