Abstract 16404: Allergy Associated Myocardial Infarction: A Comprehensive Review of Clinical Presentation, Diagnosis and Management of Kounis Syndrome

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Anastasios Roumeliotis ◽  
Periklis Davlouros ◽  
Maria Anastasopoulou ◽  
Grigorios Tsigkas ◽  
Georgios Hahalis ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Coronary Artery ◽  
Coronary Arteries ◽  
Clinical Presentation ◽  
Type I ◽  
Type Ii ◽  
Kounis Syndrome ◽  
Normal Coronary Arteries ◽  
Type Iii ◽  
Coronary Syndrome

Introduction: Kounis syndrome (KS) is defined as acute coronary syndrome (ACS) in the context of a hypersensitivity reaction. Patients may present with normal coronary arteries (Type I), established coronary artery disease (Type II) or in-stent thrombosis and restenosis (Type III). Hypothesis: We sought to investigate the clinical presentation, underlying pathophysiology, diagnosis and medical management of patients with KS. Methods: We searched PubMed until 1/1/2020 for case reports of KS. Patients with age <18 years, non-coronary vascular manifestations and without an established KS diagnosis were excluded. Information regarding patient demographics, medical history, clinical presentation, allergic reaction trigger, angiographic results as well as management were manually extracted from every report. All data were pulled in a combined data set and descriptive statistics were analyzed. Results: Out of the 269 unique patients with KS, 157 (58.4%) had Type I, 64 (23.8%) Type II and 18 (6.7%) Type III while 30 (11.2%) could not be classified. Their mean age was 54.1 years and 190 (70.6%) were male. The majority presented with a combination of cardiac and allergic symptoms [Panel A] and medication was the most commonly reported trigger [Panel B]. Electrocardiographically, 75.1% of cases had ST segment elevation with only 3.3% demonstrating no abnormalities. Coronary imaging was available in 228 (84.8%) patients showing occlusive lesions (32.5%), vascular spasm (16.2%), or normal coronary arteries (51.3%). Percutaneous coronary intervention or coronary artery bypass grafting was performed in 70 (29.4%) of the 238 patients with available information. Conclusions: Hypersensitivity induced ACS is most frequently triggered by medications, and the majority of patients have patent coronary arteries suggesting microvascular dysfunction. KS should be considered in the differential diagnosis of myocardial infarction with non-obstructive coronary arteries.

scholarly journals Allergy Associated Myocardial Infarction: A Comprehensive Report of Clinical Presentation, Diagnosis and Management of Kounis Syndrome

Vaccines ◽  
2021 ◽  
Vol 10 (1) ◽  
pp. 38
Author(s):  
Anastasios Roumeliotis ◽  
Periklis Davlouros ◽  
Maria Anastasopoulou ◽  
Grigorios Tsigkas ◽  
Ioanna Koniari ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Coronary Arteries ◽  
Case Reports ◽  
Type I ◽  
Type Ii ◽  
Kounis Syndrome ◽  
Normal Coronary Arteries ◽  
St Segment Elevation ◽  
Type Iii ◽  
Coronary Syndrome

Kounis syndrome (KS) has been defined as acute coronary syndrome (ACS) in the context of a hypersensitivity reaction. Patients may present with normal coronary arteries (Type I), established coronary artery disease (Type II) or in-stent thrombosis and restenosis (Type III). We searched PubMed until 1 January 2020 for KS case reports. Patients with age <18 years, non-coronary vascular manifestations or without an established diagnosis were excluded. Information regarding patient demographics, medical history, presentation, allergic reaction trigger, angiography, laboratory values and management were extracted from every report. The data were pulled in a combined dataset. From 288 patients with KS, 57.6% had Type I, 24.7% Type II and 6.6% Type III, while 11.1% could not be classified. The mean age was 54.1 years and 70.6% were male. Most presented with a combination of cardiac and allergic symptoms, with medication being the most common trigger. Electrocardiographically, 75.1% had ST segment elevation with only 3.3% demonstrating no abnormalities. Coronary imaging was available in 84.8% of the patients, showing occlusive lesions (32.5%), vascular spasm (16.2%) or normal coronary arteries (51.3%). Revascularization was pursued in 29.4% of the cases. In conclusion, allergic reactions may be complicated by ACS. KS should be considered in the differential diagnosis of myocardial infarction with non-obstructive coronary arteries.

Safety and Efficacy of Drug-Coated Balloons Versus Drug-Eluting Stents in Acute Coronary Syndromes: A Prespecified Analysis of BASKET-SMALL 2

2022 ◽  
Author(s):  
Norman Mangner ◽  
Ahmed Farah ◽  
Marc-Alexander Ohlow ◽  
Sven Möbius-Winkler ◽  
Daniel Weilenmann ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Significant Interaction ◽  
Clinical Presentation ◽  
Small Vessel ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
Drug Eluting ◽  
Artery Disease

Background: Drug-coated balloons (DCBs) are an established treatment strategy for coronary artery disease. Randomized data on the application of DCBs in patients with an acute coronary syndrome (ACS) are limited. We evaluated the impact of clinical presentation (ACS versus chronic coronary syndrome) on clinical outcomes in patients undergoing DCB or drug-eluting stent (DES) treatment in a prespecified analysis of the BASKET-SMALL 2 trial (Basel Kosten Effektivitäts Trial–Drug-Coated Balloons Versus Drug-Eluting Stents in Small Vessel Interventions). Methods: BASKET-SMALL 2 randomized 758 patients with small vessel coronary artery disease to DCB or DES treatment and followed them for 3 years regarding major adverse cardiac events (cardiac death, nonfatal myocardial infarction, and target vessel revascularization). Results: Among 758 patients, 214 patients (28.2%) presented with an ACS (15 patients [7%], ST-segment–elevation myocardial infarction; 109 patients [50.9%], non–ST-segment–elevation myocardial infarction; 90 patients [42.1%], unstable angina pectoris). At 1-year follow-up, there was no significant difference in the incidence of the primary end point by randomized treatment in patients with ACS (hazard ratio, 0.50 [95% CI, 0.19–1.26] for DCB versus DES) or chronic coronary syndrome (hazard ratio, 1.29 [95% CI, 0.67–2.47] for DCB versus DES). There was no significant interaction between clinical presentation and treatment effect ( P for interaction, 0.088). For cardiac death ( P for interaction, 0.049) and nonfatal myocardial infarction ( P for interaction, 0.010), a significant interaction between clinical presentation and treatment was seen at 1 year with lower rates of these secondary end points in patients with ACS treated by DCB. At 3 years, there were similar major adverse cardiac event rates throughout groups without significant interaction between clinical presentation and treatment ( P for interaction, 0.301). All-cause mortality was higher in ACS compared with chronic coronary syndrome; however, there was no difference between DCB and DES irrespective of clinical presentation. Conclusions: In this subgroup analysis of the BASKET-SMALL 2 trial, there was no interaction between indication for percutaneous coronary intervention (acute versus chronic coronary syndrome) and treatment effect of DCB versus DES in patients with small vessel coronary artery disease. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01574534.

scholarly journals KOUNIS SYNDROME - ALLERGIC MYOCARDIAL INFARCTION. A CASE REPORT

2019 ◽  
Vol 72 (1) ◽  
pp. 137-141
Author(s):  
Olga Wajtryt ◽  
Tadeusz M Zielonka ◽  
Aleksandra Kaszyńska ◽  
Andrzej Falkowski ◽  
Katarzyna Życińska
Keyword(s):  
Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
Coronary Artery ◽  
Allergic Reaction ◽  
Anaphylactic Shock ◽  
Coronary Artery Spasm ◽  
Kounis Syndrome ◽  
Permanent Damage ◽  
Coronary Syndrome

Kounis syndrome or allergic myocardial infarction is an acute coronary syndrome in the course of an allergic reaction. In allergic patients in response to a specific condition - nourishment, inhalation, environmental substances, drug or insect bite there is an allergic reaction involving many different cells and mediators that can cause coronary artery spasm or initiate the process of rupture and activation of atherosclerotic plaque resulting in acute coronary syndrome. The paper describes a case of a young man with allergy to pollen and confirmed sensitization to nuts, who developed a full-blown anaphylactic shock after eating the nut mix and experienced a rapidly passing acute coronary syndrome with troponin up to 4.7 μg/L. An increased concentration of tryptase (15 μg/L), total IgE (> 3,000 IU/mL) and specific anti-nut IgE (55.1 kUA/L) were found. Based on the course of the disease and the results of allergic and cardiac tests, allergic type 1 myocardial infarction, i.e. caused by coronary artery spasm, was diagnosed. During the hospitalization, the patient’s condition improved quickly and after a few days he left the hospital without the signs of permanent damage to the heart muscle.

scholarly journals Kounis syndrome uncovers severe coronary disease: an unusual case of acute coronary syndrome secondary to allergic coronary vasospasm

2019 ◽  
Vol 12 (12) ◽  
pp. e232472
Author(s):  
Luca Conti ◽  
Kelly Gatt ◽  
Christopher Zammit ◽  
Karen Cassar
Keyword(s):  
Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
High Signal ◽  
Type I ◽  
Kounis Syndrome ◽  
Coronary Syndrome ◽  
Triple Vessel Disease ◽  
Appropriate Treatment ◽  
St Elevation ◽  
Type I Hypersensitivity

Acute coronary syndrome occurring during the course of a type I hypersensitivity reaction constitutes Kounis syndrome. We report a case of a 64-year-old man who presented with a non-ST elevation myocardial infarction and peripheral blood eosinophilia. He had rhinitis and constitutional symptoms for several days prior to presentation. Blood investigations revealed moderate eosinophilia and elevated IgE levels. A cardiac MRI showed generalised oedema with a subtle wall motion abnormality in basal inferior/inferolateral wall, and subendocardial high signal on late gadolinium enhancement suggesting a localised myocardial infarction. A coronary angiogram then revealed triple vessel disease. A diagnosis of Kounis syndrome was made. Within days of starting appropriate treatment, the patient’s eosinophil count returned to normal with improvement of clinical picture.

Coexistence and outcome of coronary artery disease in Takotsubo syndrome

2020 ◽  
Vol 41 (34) ◽  
pp. 3255-3268 ◽  
Author(s):  
L Christian Napp ◽  
Victoria L Cammann ◽  
Milosz Jaguszewski ◽  
Konrad A Szawan ◽  
Manfred Wischnewsky ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Coronary Arteries ◽  
Coronary Artery Occlusion ◽  
Coronary Intervention ◽  
Artery Occlusion ◽  
Takotsubo Syndrome ◽  
Normal Coronary Arteries ◽  
Coronary Syndrome ◽  
Artery Disease

Abstract Aims Takotsubo syndrome (TTS) is an acute heart failure syndrome, which shares many features with acute coronary syndrome (ACS). Although TTS was initially described with angiographically normal coronary arteries, smaller studies recently indicated a potential coexistence of coronary artery disease (CAD) in TTS patients. This study aimed to determine the coexistence, features, and prognostic role of CAD in a large cohort of patients with TTS. Methods and results Coronary anatomy and CAD were studied in patients diagnosed with TTS. Inclusion criteria were compliance with the International Takotsubo Diagnostic Criteria for TTS, and availability of original coronary angiographies with ventriculography performed during the acute phase. Exclusion criteria were missing views, poor quality of angiography loops, and angiography without ventriculography. A total of 1016 TTS patients were studied. Of those, 23.0% had obstructive CAD, 41.2% had non-obstructive CAD, and 35.7% had angiographically normal coronary arteries. A total of 47 patients (4.6%) underwent percutaneous coronary intervention, and 3 patients had acute and 8 had chronic coronary artery occlusion concomitant with TTS, respectively. The presence of CAD was associated with increased incidence of shock, ventilation, and death from any cause. After adjusting for confounders, the presence of obstructive CAD was associated with mortality at 30 days. Takotsubo syndrome patients with obstructive CAD were at comparable risk for shock and death and nearly at twice the risk for ventilation compared to an age- and sex-matched ACS cohort. Conclusions Coronary artery disease frequently coexists in TTS patients, presents with the whole spectrum of coronary pathology including acute coronary occlusion, and is associated with adverse outcome. Trial registration ClinicalTrials.gov number: NCT01947621.

scholarly journals Role of cardiovascular magnetic resonance in the prognosis of patients with myocardial infarction with non-obstructive coronary arteries

2021 ◽  
Vol 23 (1) ◽  
Author(s):  
Nuria Vicente-Ibarra ◽  
Eloisa Feliu ◽  
Vicente Bertomeu-Martínez ◽  
Pedro Cano-Vivar ◽  
Pilar Carrillo-Sáez ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
Cardiovascular Magnetic Resonance ◽  
Coronary Artery ◽  
Magnetic Resonance ◽  
Coronary Arteries ◽  
Coronary Artery Lesions ◽  
Cardiac Events ◽  
Coronary Syndrome ◽  
Adverse Cardiac Events

Abstract Background It is estimated that 5% to 10% of patients with myocardial infarction (MI) present with no obstructive coronary artery lesions. Until now, most studies have focused on acute coronary syndrome, including different clinical entities with a similar presentation encompassed under the term MINOCA (MI with non-obstructive coronary arteries). The aim of this study is to assess the prognosis of patients diagnosed with true infarction, confirmed by cardiovascular magnetic resonance (CMR), in the absence of significant coronary lesions. Methods Prospective multicenter registry study, including 120 consecutive patients with a CMR-confirmed MI without obstructive coronary artery lesions. The primary clinical outcome was major adverse cardiovascular events (MACE: death, non-fatal infarction, stroke, or cardiac readmission), assessed over three years. Results Seventy-six patients (63.3%) were admitted with a diagnosis of acute coronary syndrome, and 44 (36.6%) for other causes (mainly heart failure); the definitive diagnosis was established by CMR. Most patients (64.2%) were men, and the mean age was 58.8 ± 13.5 years. Patients presented with small infarcts: 83 (69.1%) showed late gadolinium enhancement (LGE) in one or two myocardial segments, mainly transmural (in 77.5% of patients) and with a preserved left ventricular ejection fraction (median 54.8%, interquartile range 37–62). The most frequent infarct location was inferolateral (n = 38, 31.7%). During follow-up, 43 patients (35.8%) experienced a MACE, including 9 (7.5%) who died. In multivariable analysis, LGE in two versus one myocardial segment doubled the risk of adverse cardiac events (hazard ratio [HR] 2.32, 95% confidence interval [CI] 0.97–5.83, p = 0.058). Involvement of three or more myocardial segments almost tripled the risk (HR 2.71, 95% CI 1.04–7.04, p = 0.040 respectively). Conclusions Patients with true MI but without significant coronary artery lesions predominantly had small infarcts. Myocardial 3-segment LGE involvement is associated with a significantly higher risk of adverse cardiac events.

scholarly journals SAT-462 Coronary Vasospasm-Induced Myocardial Infarction: An Uncommon Presentation of Thyrotoxicosis

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Basma Ataallah ◽  
Barjinder Buttar ◽  
Georgia Kulina ◽  
Alan Kaell
Keyword(s):  
Myocardial Infarction ◽  
Chest Pain ◽  
Coronary Artery ◽  
Coronary Arteries ◽  
Coronary Artery Spasm ◽  
Coronary Spasm ◽  
Coronary Vasospasm ◽  
Graves Disease ◽  
Normal Coronary Arteries ◽  
Coronary Artery Vasospasm

Abstract Background: Coronary artery vasospasm-induced myocardial infarction is a rare cardiac complication of untreated thyrotoxicosis. Diagnosis is difficult due to the transient and unpredictable occurrence of coronary spasm [1]. Clinical Case: A 47-year-old Hispanic female smoker presented with a one-week history of severe, intermittent substernal chest pain radiating to the left arm. The pain was associated with palpitations and shortness of breath. She was afebrile with a heart rate of 100, a blood pressure of 119/59, a fine tremor, and brisk reflexes. No lid lag or proptosis was appreciated. The thyroid was enlarged, non-tender, without palpable nodules. ECG showed T- Wave Inversions in leads V1-V2 and ST depressions in V4-V5. Chest pain was relieved by SL nitroglycerin. Lab results showed a peak Troponin of 0.20 (N &lt; 0.06), TSH 0.01 mU/L (N &gt; 0.45mU/L), free T4 5.54 (N &lt; 1.46 ng/dl), total T3 4.50 pg/mL (N &lt; 1.37 ng/mL), free T3 21.0 ng/mL (N &lt; 4.4 pg/ml), TSI 3.61 IU/L (N &lt; 0.55 IU/L), thyrotropin R Ab 7.47 IU/L (N &lt; 1.75 IU/L) and thyroglobulin Ab 1.3 IU/ml (ULN &lt; 0.9 IU/ml). Thyroid US showed a heterogeneous enlarged thyroid gland with increased vascularity. For her NSTEMI she was treated with a heparin drip, aspirin, clopidogrel, atorvastatin, propranolol, and isosorbide mononitrate. Methimazole was started to treat thyrotoxicosis. Cardiac catheterization revealed coronary vasospasm without evidence of valvular or coronary artery disease. Methimazole restored euthyroidism and she has not had recurrence of angina. Discussion: Rarely, hyperthyroidism can present with transient myocardial ischemia secondary to coronary artery vasospasm in patients with normal coronary arteries. The etiopathogenesis is unclear and may relate to a direct metabolic effect of excess thyroid hormone on the myocardium. In a Korean study evaluating chest pain in patients who underwent coronary angiography, the incidence of coronary vasospasm was 5%, occurring most frequently in women under 50 years of age with thyrotoxicosis [2]. Conclusion: Patients who present with angina and are thyrotoxic should be evaluated for vasospasm. Females under 50 years old with Graves’ disease are at highest risk. Treatment includes antithyroid medications along with nitroglycerin, and we can consider calcium channel blockers including diltiazem. Treatment of thyrotoxicosis eliminates recurrence of vasospasm [3]. References 1. Chudleigh RA, Davies JS: Grave’s thyrotoxicosis and coronary artery spasm. Postgrad Med J. 2007, 83(985):e1-e2. 2. Zheng W, Zhang YJ, Li SY, et al: Painless thyroiditis-induced acute myocardial infarction with normal coronary arteries. Am J Emerg Med. 2015, 33:5-10. 3. Marah N, Bryant K, Haq S, Khan M: Graves’ disease-induced coronary vasospasm. JACC: Cardiovascular Interventions. 2016, 9(23):2452-2453.

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