michael s
(Michael S)
#1
62 Can a cardiac transplant patient get angina?
How is this investigated?
Brendan Madden
Post-transplant cardiac denervation theoretically abolishes the
perception of cardiac chest pain. However, some patients may
develop postoperative typical anginal chest pain precipitated by
exercise or by increasing heart rate. This has been associated with
ECG evidence of ischaemia and coronary angiography has
confirmed transplant associated coronary artery disease. Such
symptoms, however, are usually described by patients who are
more than five years following transplantation. Chest pain
associated with coronary artery disease is uncommon in patients
who are less than five years post-cardiac transplantation.
Interestingly, recent evidence shows an absence of bradycardic
response to apnoea and hypoxia in cardiac transplant recipients
with obstructive sleep apnoea. It may be that prospective
overnight polysomnography studies will identify parasympa-
thetic re-innervation in this group.
The majority of patients with transplant associated coronary
artery disease do not get chest pain. Presenting features include
progressive dyspnoea with exertion or the signs and symptoms of
cardiac failure. Cardiac auscultation may reveal a third or fourth
heart sound or features of heart failure. The ECG may show
rhythm disturbances or a reduction in total voltage (the
summation of the R and S wave in leads I, II, III, V1 and V6).
Transthoracic 2D echocardiography may reveal evidence of poor
biventricular function. Most units do not advocate routine annual
coronary angiography for asymptomatic patients, since the angio-
graphic findings do not usually alter clinical managment.
Furthermore, conventional coronary angiography does not always
confirm the diagnosis; intravascular ultrasound may be more
sensitive. The condition is frequently diffuse and distal and not
usually amenable to intervention, e.g. with angioplasty, stent
insertion or bypass surgery. In those patients who have a localised
lesion, the disease may progress despite successful intervention.
The majority of centres do not usually offer cardiac re-transplan-
tation on account of shortage of donor organs and poor results
attendant on cardiac re-transplantation. Therefore patients who
develop this condition are usually managed medically.
