Kounis syndrome: a narrative review

Abstract

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.

Contrast Media Induced Kounis Syndrome: A Case Report

“…Intravenous corticosteroids (hydrocortisone: 1-2 mg/kg/day) and antihistamine agents (diphenhydramine: 1-2 mg/kg) are useful to control the allergic reaction [13]. Aspirin is, however, potentially detrimental because of cyclooxygenase inhibition, promoting arachidonic acid release into the leukotriene pathway [14]. Calcium channel blockers and nitrates can relieve the vasospasm.…”

Kounis syndrome: Anaphylaxis causing coronary occlusion

“…The concurrence of acute coronary syndrome with hypersensitivity reactions is known as Kounis Syndrome. 1 There are three variants of the syndrome in decreasing prevalence.…”

“…5 Caution with nitrates in hypotension. 1 Beta-blockers contraindicated 1,5 , patients may benefit from glucagon. 5 Opioids administered with caution Opioids administered with caution 1,5 , consider fentanyl.…”

“…5 Opioids administered with caution Opioids administered with caution 1,5 , consider fentanyl. 1 Type I: Allergy-related angina due to coronary spasm; Type II: Allergy-related myocardial infarction due to plaque rupture and thrombus formation; Type III: Drug eluting stent thrombosis secondary to hypersensitivity reaction…”

We need more prospective studies for Kounis syndrome

“…Symptoms and/or findings of systemic allergic response accompanying electrocardiographic or laboratory findings of myocardial ischaemia should remind us of the possibility of Kounis syndrome. [8] However, sometimes Kounis syndrome can be observed without classic clinical findings of hypersensitivity such as skin lesion (urticaria, angiooedema, mucosal involvement) or hypotension. [7] The diagnosis of the syndrome is made primarily via symptoms and signs, electrocardiographic and laboratory features, and echocardiographic and angiographic changes in patients.…”