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

Abstract

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.

Cardiac troponins and mortality in type 1 and 2 myocardial infarction

“…Thus, it is reasonable that the lower increase of both cardiac troponins after a type 2 MI would not translate into a higher mortality rate, in that type 2 MI patients have many other conditions that would ultimately increase the individual risk of morbidity and mortality, perhaps including the so-called Kounis syndrome [28]. This is clearly reflected by the much longer hospital stay that has been recorded throughout the studies reviewed in this literature analysis.…”

Perioperative Anaphylaxis Including Kounis Syndrome due to Selective Cefazolin Allergy

“…The concurrent presence of anaphylaxis and cardiac symptoms (KS) was recently described as “allergic angina syndrome” with coronary spasm, which represents a manifestation of endothelial dysfunction or microvascular angina and leads to allergic acute myocardial infarction [20, 21]. KS has increasingly been reported in the literature, it being associated to an endless list of specific triggers including multiple drugs, contrast media, skin disinfectants, foods, several environmental exposures as hymenoptera stings, exercise-induced anaphylaxis, and even in a scenario of idiopathic anaphylaxis [21]. Recently, Renda et al [22] published the largest overview of pharmacovigilance international data on KS for all drugs, which included 51 cases, antibiotics being the most common culprit.…”

We need more prospective studies for Kounis syndrome

“…[5,6] Only one study shows the prospective incidence of Kounis syndrome, [3,7] conducted in our institution. In this study, Akoz et al [7] found the incidence of the disease to be 19.4/100 000.…”

“…[7] The diagnosis of the syndrome is made primarily via symptoms and signs, electrocardiographic and laboratory features, and echocardiographic and angiographic changes in patients. [3] Our prospective study showed that cardiac magnetic resonance imaging (MRI) can also be used as an alternative to these methods, [7] especially in patients who have contrast allergy or who need to be careful about radiation exposure. Cardiac MRI is successful in the early diagnosis of the syndrome, making the disease diagnosable in individuals whose electrocardiogram and troponin are normal, distinguishing between ischaemic and non-ischaemic cases.…”

“…[3] In the treatment stage, although there are some differences in the variants, it is difficult to know which exact type of Kounis syndrome the patient has during the first evaluation of an individual at emergency services. Thus, early patient treatment should include management of acute coronary syndrome and alleviation of the allergic symptoms.…”