Allergic Reactions Following Implantation of Drug-Eluting Stents: A Manifestation of Kounis Syndrome?

Kounis, Nicholas G.; Kounis, George N.; Kouni, Sophia N.; Soufras, George D.; Niarchos, Constantinos; Mazarakis, Andreas

doi:10.1016/j.jacc.2006.05.007

Cited by 34 publications

(25 citation statements)

References 8 publications

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“…In the same year attention was drawn to a potential relationship between drug-eluting coronary stent thrombosis and hypersensitivity to coronary stent components [14].…”

Section: Historical Backgroundmentioning

confidence: 99%

Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management

Kounis¹

2016

Clinical Chemistry and Laboratory Medicine (CCLM)

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Kounis syndrome has been established as a hypersensitivity coronary disorder induced by various conditions, drugs, environmental exposures, foods and coronary stents. Allergic, hypersensitivity, anaphylactic and anaphylactoid reactions are associated with this syndrome. Vasospastic allergic angina, allergic myocardial infarction and stent thrombosis with occluding thrombus infiltrated by eosinophils and/or mast cells constitute are the three reported, so far, variants of this syndrome. Apart from coronary arteries, it affects the cerebral and mesenteric arteries. Its manifestations are broadening and its etiology is continuously increasing. Kounis syndrome is a ubiquitous disease which represents a magnificent natural paradigm and nature's own experiment in a final trigger pathway implicated in cases of coronary artery spasm and plaque rupture. Kounis syndrome seems to be not a rare disease but an infrequently diagnosed clinical entity which has revealed that the same mediators released from the same inflammatory cells are also present and in acute coronary events of non allergic etiology. These cells are not only present in the culprit region before plaque erosion or rupture but they release their contents just before an actual coronary event. Therefore, awareness of etiology, epidemiology, pathogenesis and clinical manifestations seems to be important for its prognosis, diagnosis, treatment, prevention.

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“…In the same year attention was drawn to a potential relationship between drug-eluting coronary stent thrombosis and hypersensitivity to coronary stent components [14].…”

Section: Historical Backgroundmentioning

confidence: 99%

Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management

Kounis¹

2016

Clinical Chemistry and Laboratory Medicine (CCLM)

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322

421

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“…8 Three variants have been described (Table 2). 9,16,85 Transthoracic or trans-oesophageal echocardiography can reveal regional wall motion abnormalities suggestive of acute coronary syndromes, and can help distinguish between other causes of chest pain and/or hypotension (such as aortic dissection, pericarditis, pericardial effusion and pulmonary embolism).…”

Section: Clinical Variantsmentioning

confidence: 99%

“…Drug-eluting stent thrombosis (late stent thrombosis) secondary to hypersensitivity reactions has recently been proposed as a third type. 9 Historical background (see Figure 1) Paul Ehrlich published his seminal description of mast cells in 1878. 10 Anaphylaxis was characterised by Richet and Portier in 1901, which won Richet the Nobel Prize in 1913.…”

Section: Introductionmentioning

confidence: 99%

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Kounis syndrome: a narrative review

Fourie

2016

Southern African Journal of Anaesthesia and Analgesia

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Inflammatory mediators released from activated mast cells and basophils during hypersensitivity reactions have direct pathological effects on the myocardium and coronary vasculature. It was traditionally thought that cardiovascular signs and symptoms in anaphylaxis are largely due to peripheral vasodilation and increased vascular permeability. However, there is extensive evidence of primary cardiac involvement during hypersensitivity reactions, most notably coronary vasoconstriction as well as atherosclerotic plaque erosion and rupture, leading to angina pectoris and acute coronary syndromes. Furthermore, mast cells are well established as effector cells in atherosclerosis, through their effects on atherosclerotic plaque progression and destabilisation. It was noted over 30 years ago that cardiac patients have a markedly higher concentration of biologic amines (especially histamine) in their coronary vasculature, and, additionally, are hyper-reactive to the effects thereof. This is borne out by the disproportionate mortality rate of those with cardiac disease that suffer a hypersensitivity reaction. Kounis syndrome refers to angina pectoris or an acute coronary syndrome secondary to a hypersensitivity reaction, with the subtypes dependent on the underlying state of the coronaries and presence of a drug-eluting stent or not. This review will focus mainly on the aetiology, pathophysiology, diagnoses and treatment of this important syndrome.

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“…Indeed, newer stent devices (eg, Endeavor with zotarolimus (Medtronic, Minneapolis, MN) and Xience V with everolimus eluting drugs (Abbott Laboratories, Abbott Park, IL)), avoid nickel struts and use cobaltchromium struts which are less allergenic, thus following our recommendations. 10 The same should be applied in the newer Amplatzer atrial septal occluder devices. …”

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confidence: 99%

Nickel Allergy, Amplatzer Atrial Septal Occluder Device, and the Risk of Kounis Syndrome

Almpanis

Tsigkas

Kounis

et al. 2010

Clinical Cardiology

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In a very interesting report published in this journal 1 concerning a 52-year-old woman with an Amplatzer atrial septal occluder device implantation, the authors reported that the patient experienced repeated attacks of severe, burning left-sided chest pain which disappeared following explantation of the device. The Amplatzer occluder device is made from nitinol which is a nickel-titanium alloy. Although the electrocardiographic findings during the chest pain attacks have not been given, the patient's chest pain is characteristic for Kounis hypersensitivity coronary syndrome. 2It is known that hypersensitivity reactions to nickel occur in up to 17.2% of the population and are the most frequent cause of allergic contact dermatitis.3 In patients undergoing percutaneous atrial septal defect and patent foramen ovale closure, nickel allergy can be the cause of systemic reactions such as chest discomfort, palpitation, and migraine headache with or without aura. 4 Local nickel allergy from intracardiac devices and subsequent systemic allergic reactions confirmed by patch tests as an allergy to nitinol have necessitated the removal of these devices. 5 Reports concerning hypersensitivity reactions to various metals used in orthodontics have also been published and nickel was the metal provoking the most severe responses. 6 Delayed hypersensitivity reactions to nickel and molybdenum might be part of the inflammatory process and one of the triggering factors for development of in-stent restenosis. 7 The rate of nickel allergy following initial stent implantation has been estimated to be 9.2%. 8Skin clips containing nickel, chromium, molybdenum, cobalt, and titanium can induce allergic reactions and may be the cause of delayed wound healing. 9 It is known that the metal strut in coronary stents is made from 316L stainless steel containing nickel, chromium, manganese, titanium, and molybdenum.Based on the above clinical observations, we believe that nickel allergy history should be ascertained in all patients prior to undergoing Amplatzer device or coronary stent implantation. Indeed, newer stent devices (eg, Endeavor with zotarolimus (Medtronic, Minneapolis, MN) and Xience V with everolimus eluting drugs (Abbott Laboratories, Abbott Park, IL)), avoid nickel struts and use cobaltchromium struts which are less allergenic, thus following our recommendations. 10 The same should be applied in the newer Amplatzer atrial septal occluder devices.

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Allergic Reactions Following Implantation of Drug-Eluting Stents: A Manifestation of Kounis Syndrome?

Cited by 34 publications

References 8 publications

Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management

Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management

Kounis syndrome: a narrative review

Nickel Allergy, Amplatzer Atrial Septal Occluder Device, and the Risk of Kounis Syndrome

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