Allergen-Related Coronary Vasospasm “Kounis Syndrome” Requiring Administration of Epinephrine and a Coronary Vasodilator

Shintani, Ryosuke; Sekino, Motohiro; Egashira, Takashi; Yano, Rintaro; Inoue, Hakuai; Matsumoto, Shoichi; Higashijima, Ushio; Matsumoto, Shuhei; Yonekura, Tsuyoshi; Hara, Tetsuya

doi:10.1053/j.jvca.2020.08.009

Cited by 7 publications

(9 citation statements)

References 9 publications

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“…3,5 As stated previously, the use of epinephrine has been cautioned in the setting of KS; however, some case studies have reported success with slowed infusions. 16 This area of practice requires further investigation.…”

Section: Treatment and Managementmentioning

confidence: 99%

“…3 While there are no large studies or guidelines on epinephrine use in this setting, literature has suggested avoiding its use in type 1 KS. 15,16 Type II KS, those with existing coronary disease, is best managed with standard ACS protocol in addition to the use of antihistamines or corticosteroids. 5 Beta-blockers were associated with an increase in coronary vasospasm and ischemia and are generally avoided if possible.…”

Section: Treatment and Managementmentioning

confidence: 99%

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Kounis Syndrome: A Review of an Uncommon Cause of Acute Coronary Syndrome

Douedi

Odak

Mararenko

et al. 2022

Cardiology in Review

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Kounis syndrome is a hypersensitivity disorder secondary to allergy or anaphylaxis that can result in acute coronary syndrome. Kounis syndrome has an increasing prevalence since its first identification in 1950. Divided into 3 subtypes, each with diagnostic criteria, the management of Kounis syndrome presents a clinical challenge. We aim to identify the pathophysiological mechanisms and review the diagnosis, epidemiology, management strategies, and future directions of Kounis syndrome. As Kounis syndrome becomes more widely recognized in the medical community, the role of diagnosis, treatment, and future immunomodulatory prevention strategies will continue to unfold.

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Section: Treatment and Managementmentioning

confidence: 99%

Section: Treatment and Managementmentioning

confidence: 99%

Kounis Syndrome: A Review of an Uncommon Cause of Acute Coronary Syndrome

Douedi

Odak

Mararenko

et al. 2022

Cardiology in Review

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“…Therefore, we believe that, in cases of fatal anaphylaxis and anaphylactic shock, including Kounis syndrome, the use of adrenaline should not be avoided. [8,20] However, hemodynamics should be carefully monitored (particularly by using ECG) to prevent myocardial ischemia. In addition, attention should be given to the dosage and method of administration to minimize the adverse effects of adrenaline.…”

Section: Discussionmentioning

confidence: 99%

“…In addition, attention should be given to the dosage and method of administration to minimize the adverse effects of adrenaline. [19,20] Finally, if adrenaline and other vasopressors prove to be ineffective, extracorporeal cardiopulmonary resuscitation should be considered; however, this is an invasive technique and should be avoided if possible.…”

Section: Discussionmentioning

confidence: 99%

Refractory cardiac arrest caused by type I Kounis syndrome treated with adrenaline and nicorandil: A case report

et al. 2023

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Rationale: Kounis syndrome is a rare but life-threatening anaphylactic reaction that can lead to acute coronary syndrome and cardiac arrest, and requires prompt diagnosis. Adrenaline, which is used to treat anaphylaxis, may cause coronary vasoconstriction and worsen ischemia, whereas coronary vasodilators may dilate systemic vessels and exacerbate hypotension. Delayed diagnosis of Kounis syndrome and inadequate therapeutic intervention may thus lead to a poor outcome. Patient concerns: A 59-year-old man was treated for sepsis due to a liver abscess. Following administration of daptomycin, the patient developed severe anaphylactic shock leading to refractory cardiac arrest. Because conventional cardiopulmonary resuscitation was ineffective, extracorporeal cardiopulmonary resuscitation was considered as an alternative approach. Diagnoses: On bedside monitoring during cardiopulmonary resuscitation, unexpected ST-segment elevation was found on lead II electrocardiogram. Accordingly, the patient was clinically diagnosed with Kounis syndrome. Interventions: Nicorandil (6 mg/h), a coronary vasodilator with minimal blood pressure effects, was administered along with high doses of vasopressors, including adrenaline 0.2 µg/kg/min. Outcomes: After the initiation of nicorandil administration, the patient achieved return of spontaneous circulation and did not require extracorporeal cardiopulmonary resuscitation. Based on the elevated serum tryptase level, normal creatine kinase-MB range, and lack of stenosis on coronary angiography, the patient was definitively diagnosed with type I (coronary vasospasm) Kounis syndrome. He was subsequently transferred to the referring hospital without neurological sequelae. Lessons: If anaphylaxis leads to refractory shock and cardiac arrest, ischemic changes on the electrocardiogram should be investigated to identify underlying Kounis syndrome. In addition to adrenaline, coronary dilators are the definitive treatment. Nicorandil may be a useful treatment option because of its minimal effect on blood pressure.

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“…In patients with myocardial ischemia caused by Kounis syndrome, it is proposed to start with the continuous administration of small doses and taper the dose while monitoring vital signs. [ 24 ] Irrespective of intravenous or continuous intravenous administration of adrenaline, it is important to start with a small dose and taper the dose while monitoring the patient's condition and response to adrenaline. Landiolol should also be cautiously administered as it may cause a dose-dependent reduction in heart rate, [ 25 ] and its efficacy varies among individuals.…”

Section: Discussionmentioning

confidence: 99%

Anaphylactic shock in a patient with severe aortic stenosis treated with adrenaline and landiolol for circulatory management

et al. 2021

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Rationale: We present the first case of a patient with severe aortic stenosis who developed anaphylactic shock and was successfully treated with adrenaline and landiolol, a highly selective β1-receptor blocker, to prevent disruption of the myocardial oxygen supply–demand balance caused by tachycardia. Patient concerns: An 86-year-old woman was scheduled for simultaneous anterior–posterior fixation for a burst fracture of the 12th thoracic vertebra; 200 mg sugammadex, a neuromuscular blocking agent antagonist, was administered postoperatively, and she was extubated without complications. However, 6 min after extubation, her blood pressure decreased abruptly to 55/29 mm Hg, and her heart rate increased to 78 bpm. Then, we intervened with fluid loading, an increased dose of noradrenaline, and phenylephrine administration. However, her blood pressure did not increase. Diagnoses: A general observation revealed urticaria on the lower leg; thus, we suspected anaphylactic shock due to sugammadex administration. Interventions: We carefully administered 2 doses of 0.05 mg adrenaline and simultaneously administered landiolol at 60 μg/kg/min to suppress adrenaline-induced tachycardia. Adrenaline administration resulted in a rapid increase in blood pressure to 103/66 mm Hg and a maximum heart rate of 100 bpm, suppressing excessive tachycardia. Outcomes: The patient's general condition was stable after the intervention, and circulatory agonists could be discontinued the following day. She was discharged from the intensive care unit on the fourth postoperative day. Lessons: Landiolol may help control the heart rate of patients with aortic stenosis and anaphylactic shock. The combined use of landiolol and adrenaline may improve patient outcomes; however, their efficacy and risks must be evaluated by studying additional cases.

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Allergen-Related Coronary Vasospasm “Kounis Syndrome” Requiring Administration of Epinephrine and a Coronary Vasodilator

Cited by 7 publications

References 9 publications

Kounis Syndrome: A Review of an Uncommon Cause of Acute Coronary Syndrome

Kounis Syndrome: A Review of an Uncommon Cause of Acute Coronary Syndrome

Refractory cardiac arrest caused by type I Kounis syndrome treated with adrenaline and nicorandil: A case report

Anaphylactic shock in a patient with severe aortic stenosis treated with adrenaline and landiolol for circulatory management

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