Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for routine post-transplant surveillance. History significant for orthotopic heart transplantation [Date]. Currently asymptomatic, denying angina, dyspnea, or orthopnea. No history of syncope or palpitations. Medication adherence is reported as excellent. Recent surveillance coronary angiography/IVUS/OCT findings reviewed.
Clinical Examination Findings
Cardiovascular: Heart sounds regular, S1/S2 present, no murmurs, rubs, or gallops. No jugular venous distention. Peripheral pulses 2+ and symmetric. No peripheral edema. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, non-tender, no hepatosplenomegaly. Skin: No signs of immunosuppression-related dermatological complications.
Treatment Protocol
Optimization of immunosuppressive regimen (e.g., adjustment of calcineurin inhibitors/mTOR inhibitors). Initiation/titration of high-intensity statin therapy (e.g., Atorvastatin 80mg). Consideration of ACE inhibitor or ARB for vascular protection. Antiplatelet therapy (Aspirin 81mg) continued. Referral for repeat coronary angiography/IVUS if progression suspected.