Highlights
- •Kounis syndrome pathogenesis and epidemiology have been described.
- •Treatment of Kounis syndrome has been discussed.
- •A treatment flow-chart has been proposed.
- •This narrative review has been conducted analyzing the scientific literature.
- •More recent scientific evidence have been highlighted into this review.
Abstract
Kounis syndrome is defined as the co-incidental occurrence of an acute coronary syndrome
with hypersensitivity reactions following an allergenic event and was first described
by Kounis and Zavras in 1991 as an allergic angina syndrome.
Multiple causes have been described and most of the data in the literature are derived
from the description of clinical cases – mostly in adult patients – and the pathophysiology
remains only partly explained.
Three different variants of Kounis syndrome have been defined: type I (without coronary
disease) is defined as chest pain during an acute allergic reaction in patients without
risk factors or coronary lesions in which the allergic event induces coronary spasm
that electrocardiographic changes secondary to ischemia; type II (with coronary disease)
includes patients with pre-existing atheromatous disease, either previously quiescent
or symptomatic, in whom acute hypersensitive reactions cause plaque erosion or rupture,
culminating in acute myocardial infarction; more recently a type-III variant of Kounis
syndrome has been defined in patients with preexisting coronary disease and drug eluting
coronary stent thrombosis.
The pathogenesis of the syndrome is discussed, and a therapeutic algorithm is proposed.
Abbreviations:
KS (Kounis syndrome), ACS (Acute coronary syndrome)Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to European Journal of Internal MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Histamine-induced coronary artery spasm: the concept of allergic angina.Br J Clin Pract. 1991; 45: 121-128
- Kounis syndrome: a manifestation of drug-eluting stent thrombosis associated with allergic reaction to contrast material.Int J Cardiol. 2010; 139: 206-209
- Kounis syndrome secondary to cefuroxime–axetil use in an octogenarian.J Am Geriatr Soc. 2008; 56: 1757-1758
- Kounis syndrome following the performance of skin test to amoxicillin.Int J Cardiol. 2014;
- Allergic myocardial infarction in childhood: Kounis syndrome.Eur J Pediatr. 2010; 169: 27-29
- Kounis syndrome.South Med J. 2010; 103: 1148-1155
- A new classification of Kounis syndrome.Int J Cardiol. 2010; 22: 553
- An insight into classification of Kounis syndrome: letter to the editor.Turkiye Klin J Cardiovas Sci. 2010; 22: 367
- Late drug eluting stent thrombosis due to acemetacine: type III Kounis syndrome: Kounis syndrome due to acemetacine.Int J Cardiol. 2012; 155: 461-462
- Drug-eluting stent thrombosis: the Kounis hypersensitivity-associated acute coronary syndrome revisited.JACC Cardiovasc Interv. 2009; 2: 583-593
- Morphologic findings of coronary atherosclerotic plaques in diabetics: a postmortem study.Arterioscler Thromb Vasc Biol. 2004; 24: 1266-1271
- Correlation of intravascular ultrasound findings with histopathological analysis of thrombus aspirates in patients with very late drug-eluting stent thrombosis.Circulation. 2009; 120: 391-399
- The human mast cell: functions in physiology and disease.Front Biosci. 2001; 6: D1109-D1127
- Integrated signalling pathways for mast-cell activation.Nat Rev Immunol. 2006; 6: 218-230
- The human mast cell.J Allergy Clin Immunol. 1997; 99: 155-160
- Cardiovascular aspects of anaphylaxis: implications for treatment and diagnosis.Curr Opin Allergy Clin Immunol. 2005; 5: 359-364
- Immunological characterization and functional importance of human heart mast cells.Immunopharmacology. 1995; 31: 1-18
- Mast cell distribution, activation, and phenotype in atherosclerotic lesions of human carotid arteries.J Pathol. 1997; 182: 115-122
- Accumulation of activated mast cells in the shoulder region of human coronary atheroma, the predilection site of atheromatous rupture.Circulation. 1994; 90: 1669-1678
- Kounis syndrome (allergic acute coronary syndrome): different views in allergologic and cardiologic literature.Intern Emerg Med. 2012;
- Allergic angina and allergic myocardial infarction: a new twist on an old syndrome.Can J Cardiol. 2002; 18: 508-511
- Current understanding of Kounis syndrome.Expert Rev Clin Immunol. 2010; 6: 1-12
- Coronary microvascular spasm causes myocardial ischemia in patients with vasospastic angina.J Am Coll Cardiol. 2002; 39: 847-851
- Anisakis simplex: a new etiological agent of Kounis syndrome.Int J Cardiol. 2013; 167: e187-e189
Kounis NG, Hahalis G, Kourelis T, Manola A, Theoarides TC: Kounis syndrome (allergic angina and allergic myocardial infarction). In Gall AP, Jones ML, Ed Pectoris Etiol Pathog Treat. Edited by Gallo AP, Jones ML. Hauppauge NY: Nova Science Publishers; 2008:77–150.
- [Tryptase levels are elevated during spontaneous ischemic episodes in unstable angina but not after the ergonovine test in variant angina].Cardiol. 1998; 43: 189-193
- Kounis syndrome: report of 5 cases.J Investig Allergol Clin Immunol. 2010; 20: 162-165
- Coronary spasm secondary to an allergic reaction or kounis syndrome: report of one case.Rev Med Chil. 2009; 137: 811-814
- Coronary hypersensitivity disorder: the Kounis syndrome.Clin Ther. 2013; 35: 563-571
- ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.Eur Heart J. 2015; (2015:ehv320)
- World Allergy Organization anaphylaxis guidelines: summary.J Allergy Clin Immunol. 2011; 127: e1-22
- Treatment of Kounis syndrome.Int J Cardiol. 2010; 143: 223-226
- Drug-induced expansion of infarct: morphologic and functional correlations.Circulation. 1984; 69: 611-617
- Meta-analysis of corticosteroid treatment in acute myocardial infarction.Am J Cardiol. 2003; 91: 1055-1059
- Third universal definition of myocardial infarction.Circulation. 2012; 126: 2020-2035
- 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with th.Catheter Cardiovasc Interv. 2013; 82: E1-27
- 2014 ESC/EACTS guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) developed with the special contribution o.Eur Heart J. 2014; 35: 2541-2619
- Quercetin is more effective than cromolyn in blocking human mast cell cytokine release and inhibits contact dermatitis and photosensitivity in humans.PLoS One. 2012; 7e33805
- Pharmacological stabilization of mast cells abrogates late thrombotic events induced by diesel exhaust particles in hamsters.Circulation. 2004; 110: 1670-1677
- Surgical extraction of occluded stents: when stenting becomes a problem.Interact Cardiovasc Thorac Surg. 2009; 9: 736-738
- Mast cells squeeze the heart and stretch the gird: their role in atherosclerosis and obesity.Trends Pharmacol Sci. 2011; 32: 534-542
- Perivascular mast cells promote atherogenesis and induce plaque destabilization in apolipoprotein E-deficient mice.Circulation. 2007; 115: 2516-2525
Article info
Publication history
Published online: January 12, 2016
Accepted:
December 13,
2015
Received in revised form:
December 7,
2015
Received:
January 11,
2015
Footnotes
☆This study was conducted without any external financial support.
Identification
Copyright
© 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Author's reply: Kounis syndrome: Aspects on pathophysiology and managementEuropean Journal of Internal MedicineVol. 32
- Kounis syndrome: Aspects on pathophysiology and managementEuropean Journal of Internal MedicineVol. 32
- PreviewWe read with the great interest the excellent and concise review of Filippo Fassio et al. [1] focused on Kounis syndrome and its treatment. Since the description of this syndrome has paved the possibility for prevention of the progression of coronary plaques to unstable lesions with inhibition of mast cell activation, that has been already achieved experimentally [2], we believe that the following observations and additions on its pathophysiology and management would be of value.
- Full-Text
- Preview
