Kounis syndrome (allergic acute coronary syndrome): different views in allergologic and cardiologic literature

Abstract

The clinical picture of myocardial ischemia accompanying allergic reactions is defined in the cardiologic literature as Kounis syndrome (KS) or allergic angina/myocardial infarction. In PubMed, a search for "Kounis syndrome", "allergic angina" or "allergic myocardial infarction" retrieves more than 100 results (among case reports, case series and reviews), most of which are published in cardiology/internal medicine/emergency medicine journals. In allergologic literature, heart involvement during anaphylactic reactions is well documented, but Kounis syndrome is hardly mentioned. Single case reports and small case series of angina triggered by allergic reactions have been reported for many years, and involvement of histamine and others mast cell mediators in the pathogenesis of coronary spasm has long been hypothesized, but the existence of an allergic acute coronary syndrome (ACS) is still questioned in the allergologic scientific community. Putative mechanisms of an allergic acute coronary syndrome include coronary spasm or heart tissue-resident mast cell activation (precipitating coronary spasm or inducing plaque rupture and coronary or stent thrombosis) due to systemic increase of allergic mediators, or heart tissue-resident mast cell activation by local stimuli. Indeed, the pathogenic mechanism of an ACS after an allergic insult might be related to direct effects of mast cell mediators on the myocardium and the atherosclerotic plaque, or to exacerbation of preexisting disease by the hemodynamic stress of the acute allergic/anaphylactic reaction. Which of these mechanisms is most important is still unclear, and this review outlines current views in the cardiologic and allergologic literature.

A Case of Coronary Spasm with Resultant Acute Myocardial Infarction: Likely the Result of an Allergic Reaction

“…Several pathophysiologic mechanisms have been proposed to explain the cardiac involvement during anaphylactic reactions (1,5). Mast cell activation takes place by antigenantibody complex or the allergen itself following allergen exposure.…”

“…Mast cell activation takes place by antigenantibody complex or the allergen itself following allergen exposure. Thereafter, several vasoconstricting and collagen degrading products, such as histamine, platelet activating factor, cytokines, chemokines, neutral proteases (tryptase, chymase), and renin are released into circulation (1,5,6). Moreover, the endothelial and platelet activation induced by histamine may further contribute to coronary plaque denudation and/or rupture, resulting in thrombus formation (1).…”

Síndrome de Kounis: una posibilidad a tener en cuenta como causa de muerte súbita cardiaca

“…Los mediadores de nueva síntesis incluyen citoquinas, quimioquinas, factores de crecimiento y productos del metabolismo del ácido araquidónico. Además, los mastocitos constituyen el único sistema renina-angiotensina extrarrenal constituyendo una fuente adicional de renina 12,13 .…”

Tako-Tsubo cardiomyopathy or allergic acute coronary syndrome: that is the question

“…We read with great interest the article by Fassio et al [1] which provided a detailed review on Kounis syndrome (allergic acute coronary syndrome). The authors approached the issue both from the cardiologist's and the allergist's view.…”