When managing transplant patients it is important to keep in mind the anatomic and physiologic changes that occur with the complete extraction of one person's body part to replace another's.
For cardiac transplant patients with symptomatic bradycardia:
Remember that due to lack of autonomic/vagal innervation, resting HR should be around 90 bpm.
HR will not respond to atropine. Use direct sympathomimetics like epinephrine instead.
If medication is unsuccessful, proceed to transcutaneous or transvenous pacing.
For cardiac transplant patients with tachyarrythmias:
They are particularly sensitive to adenosine; for SVT start with 1 to 3mg adenosine push (3mg is usually effective) to avoid sustained bradycardia or asystole.
Digoxin is not effective as an antiarrhythmic.
Diltiazem can decrease the metabolism of calcineurin inhibitor immunosuppressive agents (such as cyclosporine and tacrolimus), so while it can be used there may need to be dose adjustments to these medications.
References
Stecker EC, Strelich KR, Chugh SS, et al. Arrythmias after orthotopic heart transplantation. J Card Fail. 2005;11(6):464-72.
Thajudeen A, Stecker EC, Shehata M, et al. Arrhythmias after heart transplantation: Mechanisms and management. J Am Heart Assoc. 2012;1(2):e001461.
