- Differential Diagnosis
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Possible Causes For Kounis syndrome/Allergic Coronary Spasm - Causes
Available only to registered users.
- 13 possible causes found
- Allergic, Collagen, Auto-Immune Disorders
- Atopic allergic diseases
- Drug allergy
- Anaphylaxis, generalized
- Bee/wasp venom allergy
- Angioedema/Angioneurotic edema
- Food allergy
- Myocarditis, hypersensitivity/allergy
- Functional, Physiologic Variant Disorders
- Reference to Organ System
- Mastocytosis, systemic
- Lepirudin (Refluden) Administration/Toxicity
- Streptokinase (Streptase) Administration/Toxicity
- Urokinase (Abbokinase) Administration/Toxicity
Mast cell degranulation (atopic, stress or infection trigger) causing coronary spasm event; this is one primary theory for stress induced sudden death seen
with acute anaphylaxis and includes some drug induced events.
Kounis syndrome: the hypersensitivity coronary syndrome. What is?
“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”. “It is caused by inflammatory mediators such as histamine, neutral proteases, arachidonic acid products, platelet activating factor and a variety of cytokines and chemokines released during the activation process”
1950: Pfister CW, et al. Acute myocardial infarction during a prolonged allergic reaction to penicillin. Am Heart J 1950; 40: 945
1965: Zosin P, et al. Allergic myocardial infarction. Romanian Medical Review 1965;19: 26
1991: Kounis NG, et al. Histamine-induced coronary artery spasm: the syndrome of allergic angina. Br J Clin Pract 1991; 45: 121
1995: Constantinides P. “ Allergic reactions can promote plaque disruption” Circulation 1995; 92: 1083
1996: Kounis NG, et al. Allergic angina and allergic myocardial infarction. Circulation 1996; 94: 1789
1998: Braunwald E. “ Allergic reactions with mediators such as histamine or leukotrienes acting on coronary smooth muscle can induce vasospastic angina” Circulation 1998;98: 2219
2003: Zavras GM, et al. Kounis syndrome secondary to allergic reaction. Int J Clin Pract 2003; 57: 62
2006: Kounis NG. Kounis syndrome. Int J Cardiol 2006; 119: 7
2006: Kounis NG, et al. Hypersensitivity to DES: a manifestation of Kounis syndrome? J Am Coll Cardiol 2006; 48: 592
2007: Kounis NG, et al. Coronary stents , Hypersensitivity and the Kounis Syndrome. J Interv Cardiol 2007; 20: 314
2008:Tavil Y, et al. Kounis syndrome secondary to amoxicillin/clavulanic acid use. Int J Cardiol. 2008 20; 124: e4-7
Kounis syndrome variants:
Type I variant: includes patients with normal coronary arteries without predisposing factors for coronary artery disease in whom the acute release of inflammatory mediators can induce either coronary artery spasm without increase of cardiac enzymes and troponins or coronary artery spasm progressing to acute myocardial infarction with raised cardiac enzymes and troponins
Type II variant: includes patients with culprit but quiescent pre-existing atheromatous disease in whom the acute release of inflammatory mediators can induce either coronary artery spasm with normal cardiac enzymes and troponins or plaque erosion or rupture manifesting as acute myocardial infarction
Causes of Kounis syndrome:
Exercise induced anaphylaxis
Limpet ingestion (The kiss of death)
Shellfish eating (The kiss of death)
Viper venom poisoning
Drug-nduced Kounis syndrome:
Thrombolytics and anticoagulants
Management of Kounis syndrome:
1. Treatment of allergic event (alone can abolish type I variant!)
2. Treatment of acute coronary event
Clinical implications of Kounis syndrome
So far, it has been shown that the same mediators, released during acute allergic
episodes, are increased in blood or urine
of patients suffering from acute coronary syndromes of nonallergic
etiology. Consequently, the same substances from the same cells are
present in both acute allergic episodes and acute coronary
syndromes. Does, therefore, Kounis syndrome represent a magnificent
natural paradigm and nature’s own experiment in a
final trigger pathway implicated in cases of coronary artery
spasm and plaque rupture? Drugs and natural molecules which stabilize mast cell membrane and monoclonal antibodies that protect mast cell surface could emerge as novel therapeutic modalities capable to prevent acute coronary and cerebrovascular events.
[PLUS contribution/CRM 2008]
- External Links Related to Kounis syndrome/Allergic Coronary Spasm - Causes
- PubMed (National Library of Medicine)
- NGC (National Guideline Clearinghouse)
- Medscape (eMedicine)
- Harrison's Online (accessmedicine)
- NEJM (The New England Journal of Medicine)