Kounis syndrome: A review article on epidemiology, diagnostic findings, management and complications of allergic acute coronary syndrome

Abdelghany, Mahmoud; Subedi, Rogin; Shah, Siddharth; Kozman, Hani

doi:10.1016/j.ijcard.2017.01.124

Cited by 218 publications

(288 citation statements)

References 29 publications

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“…Only a few data are available on cardiac dysfunction during AS and most of them are case reports of coronary spasm or stress cardiomyopathy . Among other mediators released by myocardial mast cells during AS, PAF is known to have a direct negative inotropic effect and could play an important role in this cardiac dysfunction .…”

Section: Discussionmentioning

confidence: 99%

Treatment with a platelet‐activating factor receptor antagonist improves hemodynamics and reduces epinephrine requirements, in a lethal rodent model of anaphylactic shock

Tacquard

Oulehri

Collange

et al. 2019

Clin Experimental Allergy

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Background In some cases, anaphylactic shock (AS) is still lethal, despite rapid use of epinephrine. High doses of epinephrine are associated with severe complications. Platelet‐activating factor (PAF) is secreted in massive amounts during AS, and a high plasma level is correlated with increased AS severity. Objective To assess the effect of ABT‐491, a PAF‐receptor antagonist and possible adjunct treatment, alone or in combination with epinephrine during AS. Methods AS was induced by intravenous injection of 1 mg ovalbumin into ovalbumin‐sensitized rats. Rats were then randomly assigned to 5 groups (n = 10 per group): SHAM (vehicle only), SHOCK (no treatment), ABT (ABT‐491 1 mg/kg), EPI (epinephrine 5 µg as a bolus then 10 µg kg−1 min−1 by continuous infusion, followed by a reducing protocol) and EPI‐ABT (both treatments). Results Ovalbumin injection resulted in a severe decrease in mean arterial pressure, left ventricular inotropy (max dP/dt) and left ventricular shortening fraction (LVSF). All rats from the ABT group survived until the end of the experiment. ABT‐491 prevented the LVSF decrease observed in the SHOCK group (at T15: ABT 50% ± 11% vs SHOCK 36% ± 9%, P = .01), significantly reduced the dose of epinephrine needed to treat anaphylactic shock (EPI‐ABT 314 ± 67 µg/kg vs EPI 475 ± 69 µg/kg, P < .001) and reduced the time to restore basal MAP (ABT 23 ± 7 minutes vs EPI‐ABT 13 ± 5 minutes, P < .01). Conclusions and Clinical Relevance AS was characterized by early cardiac dysfunction in our model. Treatment with ABT‐491 allowed survival until the end of the experiment and reduced cardiac dysfunction. Use of the PAF‐R antagonist had a synergistic effect with epinephrine and allowed a significant reduction in epinephrine consumption. Use of PAF‐R antagonists during AS could reduce epinephrine‐related complications and improve the treatment of epinephrine refractory cases.

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Section: Discussionmentioning

confidence: 99%

Treatment with a platelet‐activating factor receptor antagonist improves hemodynamics and reduces epinephrine requirements, in a lethal rodent model of anaphylactic shock

Tacquard

Oulehri

Collange

et al. 2019

Clin Experimental Allergy

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“…Cardiovascular allergic reactions have been described for more than 70 years [2]. Kounis syndrome was first described in 1991, which was defined as ACS associated with mast-cell and platelet activation in the setting of allergic insults [1].…”

Section: Discussionmentioning

confidence: 99%

“…Kounis syndrome was first described in 1991, which was defined as ACS associated with mast-cell and platelet activation in the setting of allergic insults [1]. Mast cells activate macrophages and T-lymphocytes and release inflammatory mediators, such as histamine, tryptase, and cytokines [1,2]. ese mediators induce coronary vasospasm and sometimes degrade collagen caps, leading to plaque rupture [1,2].…”

Section: Discussionmentioning

confidence: 99%

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Two Cardiac Arrests that Occurred after the Administration of Sugammadex: A Case of Kounis Syndrome

Yanai

Ariyoshi

2020

Case Reports in Emergency Medicine

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Kounis syndrome is a form of acute coronary syndrome caused by allergic reactions. No cases of cardiac arrest caused by Kounis syndrome that arose after the administration of sugammadex have been reported. A 71-year-old female suffered two cardiac arrests. e first occurred after sugammadex was administered at the end of an operation for a right radial distal fracture. e patient was resuscitated and transferred to our intensive care unit. She was subsequently discharged home. Five months later, she suffered a second cardiac arrest after sugammadex was administered at the end of an operation for a right femoral neck fracture at our hospital. Urgent coronary angiography revealed multiple coronary spasms. Kounis syndrome was diagnosed based on the patient's elevated serum trypsin levels and a positive result in a skin allergy test of sugammadex. In cases of cardiac arrest with unclear etiologies, Kounis syndrome should be considered.

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“…We checked the contents of epinephrine ampoules used in our hospital and they are preservative-free. Finally, the authors of the letter asked the question about possibility of Kounis syndrome, which is defined as the concurrence of acute coronary syndromes with conditions associated with mast cell activation, involving interrelated and interacting inflammatory cells, and including allergic or hypersensitivity and anaphylactic or anaphylactoid insults [5][6][7]. Again, it is an excellent point and all anaesthesiologists should be aware of this phenomenon.…”

mentioning

confidence: 99%

In response to: Anaphylaxis during cardiac surgery for hypetrophic cardiomyopathy: pathophysiologic and therapeutic considerations

Wąsowicz

Yee

2017

Anaesthesiol Intensive Ther

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We are most appreciative for the comments from Dr. Nicholas G. Kounis [1] and his colleagues regarding our recent publication describing the challenging case of anaphylactic shock in patients suffering from hypertrophic obstructive cardiomyopathy (HOCM) scheduled for surgical treatment, namely myectomy [2] Their letter raises several important concerns regarding anaphylaxis in anaesthesia and particularly in patients with HOCM. Before we address each point, we would like to mention that several topics discussed by authors were mentioned in our case report but could not be described in detail due to space limitations. In this context, several comments made by Dr. Kounis provide excellent complimentary information to our case reports.The authors of this letter have indicated that the diagnosis of anaphylaxis may be difficult while the patient is under general anaesthesia and subsequently during emerge from anaesthesia [3]. In the described case, patient presented several symptoms typical for severe anaphylactic reaction: arterial hypotension, high airway pressures, airway swelling and skin rash. Additionally, after initiating a cardiopulmonary bypass which stabilized patient hemodynamic collapse, we obtained a blood sample to test for mast cell tryptase. This approach is in agreement with current practice of diagnosing anaphylaxis during the perioperative period [3,4]. The test came positive, confirming the occurrence of severe anaphylactic reaction. Finally, after recovery following cardiac surgery, the patient was referred to an allergologist and additional skin tests confirmed a strong sensitivity to chlorhexidine.

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Kounis syndrome: A review article on epidemiology, diagnostic findings, management and complications of allergic acute coronary syndrome

Cited by 218 publications

References 29 publications

Treatment with a platelet‐activating factor receptor antagonist improves hemodynamics and reduces epinephrine requirements, in a lethal rodent model of anaphylactic shock

Treatment with a platelet‐activating factor receptor antagonist improves hemodynamics and reduces epinephrine requirements, in a lethal rodent model of anaphylactic shock

Two Cardiac Arrests that Occurred after the Administration of Sugammadex: A Case of Kounis Syndrome

In response to: Anaphylaxis during cardiac surgery for hypetrophic cardiomyopathy: pathophysiologic and therapeutic considerations

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