Kounis syndrome (allergic angina and allergic myocardial infarction): a natural paradigm?

Kounis syndrome type I induced by an intramuscular injection of diclofenac: A literature review based on a case report

Key Clinical Message

The history of any allergy to the medications should be asked by physicians before administration of the medication. The coincidence of allergic and ACS symptoms after a short time of drug administration might be an indicator of Kounis syndrome. Allergic and coronary symptoms should be considered and treated.

Abstract

Ischemic heart disease is still the leading cause of death worldwide. Some medications, including NSAIDS and antibiotics, can cause allergic reactions with cardiac manifestations due to spasms of the coronary arteries. In this case, we present a patient with chest pain syndrome due to a hypersensitivity reaction caused by an intramuscular (IM) diclofenac injection. The patient was a 51-year-old male who presented to the emergency department complaining of retrosternal chest pain, breathlessness, and pruritis that started half an hour after an IM diclofenac injection he had because of low back pain. The allergic symptoms subsided with an antihistamine injection, but chest pain and dyspnea remained stable. He was admitted due to the presence of ST-segment depression in leads II, III, and AVF and underwent percutaneous coronary angiography, which was normal. The patient was discharged with the diagnosis of Kounis syndrome, and he had an uneventful follow-up 1 year later. Kounis hypersensitivity-associated acute coronary syndrome, especially type I variant coronary spasm due to endothelial dysfunction is a type of acute myocardial syndrome. The following report describes an uncommon case of anaphylaxis-associated Kounis type I syndrome manifesting ST-segment changes in a male patient following an intramuscular injection of diclofenac.

Disseminated Intravascular Coagulation in Anaphylaxis

Anaphylaxis is a life-threatening condition that involves severe cutaneous, respiratory, and cardiovascular symptoms. Disseminated intravascular coagulation (DIC) is an acquired, widespread activation of coagulation that can be caused by infectious conditions (e.g., sepsis) and noninfectious conditions. The onset of DIC following anaphylaxis is not commonly known, and information regarding the pathomechanism linking anaphylaxis to DIC is scarce. Further, demographic and clinical data in anaphylaxis-induced DIC are still missing to this day. Triggered by a case of anaphylaxis-induced DIC that seamlessly transitioned to lethal sepsis-induced DIC, we aimed to characterize the patient population affected by anaphylaxis-induced DIC by performing a review of existing literature and expand the discussion to underlying mechanisms. The overall mortality of the patient cohort (n = 30) identified by the literature review was 50%. All patients that died either suffered a bleeding event or a thrombotic event. The majority of patients (n = 25/30; 83%) had bleeding events; thrombotic events were only reported in nonsurvivors (n = 9/15 or 60% of nonsurvivors; vs. n = 0/15 in survivors; p < 0.001). Nonsurvivors of anaphylaxis-induced DIC were on average 25 years older than survivors (p = 0.068). In conclusion, DIC can complicate anaphylaxis and is expected to contribute to poor microvascular perfusion after anaphylaxis. Particularly, elderly patients with known cardiovascular disease and patients who develop thrombotic events are susceptible to lethal outcomes. As a rare and largely uncharacterized disease entity, further research is needed to investigate the link between DIC and anaphylaxis and to potentially identify better treatment strategies.

Myocardial injury in dogs: a retrospective analysis on etiological, echocardiographic, electrocardiographic, therapeutic, and outcome findings in 102 cases

INTRODUCTION

In dogs, myocardial injury (MI) is a poorly characterized clinical entity; therefore, this study aimed to provide a detailed description of dogs affected by this condition.

ANIMALS, MATERIALS, AND METHODS

Dogs diagnosed with MI according to the concentration of cardiac troponin I (cTnI) were retrospectively searched. Signalment, diagnostic, therapeutic, and outcome data were retrieved. Dogs were divided into six echocardiographic (dilated cardiomyopathy phenotype; hypertrophic cardiomyopathy phenotype; hypertrophic cardiomyopathy phenotype with systolic dysfunction; abnormal echogenicity only; endocarditis; and no echocardiographic abnormalities suggestive of MI), four electrocardiographic (abnormalities of impulse formation; abnormalities of impulse conduction; abnormalities of ventricular repolarization; and no electrocardiographic abnormalities suggestive of MI), and nine etiological (infective; inflammatory; neoplastic; metabolic; toxic; nutritional; immune-mediated; traumatic/mechanical; and unknown) categories. Statistical analysis was performed to compare cTnI values among different categories and analyze survival.

RESULTS

One hundred two dogs were included. The median cTnI value was 3.71 ng/mL (0.2-180 ng/mL). Echocardiographic and electrocardiographic abnormalities were documented in 86 of 102 and 89 of 102 dogs, respectively. Among echocardiographic and electrocardiographic categories, the dilated cardiomyopathy phenotype (n = 52) and abnormalities of impulse formation (n = 67) were overrepresented, respectively. Among dogs in which a suspected etiological trigger was identified (68/102), the infective category was overrepresented (n = 20). Among dogs belonging to different echocardiographic, electrocardiographic, and etiological categories, cTnI did not differ significantly. The median survival time was 603 days; only eight of 102 dogs died due to MI.

CONCLUSIONS

Dogs with MI often have an identifiable suspected trigger, show various echocardiographic and electrocardiographic abnormalities, and frequently survive to MI-related complications.

Fatal Outcome Due to Kounis Syndrome Following Fluorescein Retinal Angiography: A Case Report

Kounis Syndrome (KS) is a clinical entity triggered by allergic or hypersensitivity reactions capable of inducing acute coronary events. Several causes can induce KS, including drugs and insect stings. Here, a rare case of post mortem assessment of fatal KS related to fluorescein retinal angiography has been reported. An 80-year-old man in follow-up for a retinal vein thrombosis underwent a retinal fluoroangiography. Approximately 30 min later, the patient complained of sweating and dizziness, and suddenly lost consciousness due to a cardiac arrest. Despite the immediate cardiopulmonary resuscitation, he died. The autopsy revealed foamy yellowish edema in the respiratory tract and coronary atherosclerosis with eccentric plaques partially obstructing the lumen. The routine histology highlighted lung emphysema and myocyte break-up with foci of contraction band necrosis at the myocardial tissue. Biochemistry showed increased serum tryptase, troponin, and p-BNP. Activated and degranulated (tryptase) mast cells were detected, using immunohistochemistry, in the larynx, lungs, spleen, and heart. Acute myocardial ischemia due to allergic coronary vasospasm related to fluorescein hypersensitivity has been assessed as cause of death. KS-related deaths are considered rare events, and the post mortem assessment of KS quite difficult. The integration of several investigations (gross and microscopic examination, biochemistry, immunohistochemistry) can provide useful findings to support the diagnosis, helping to reduce the unrecognized cases as much as possible.

Transient Left Ventricular Dysfunction from Cardiomyopathies to Myocardial Viability: When and Why Cardiac Function Recovers

Transient left ventricular dysfunction (TLVD), a temporary condition marked by reversible impairment of ventricular function, remains an underdiagnosed yet significant contributor to morbidity and mortality in clinical practice. Unlike the well-explored atherosclerotic disease of the epicardial coronary arteries, the diverse etiologies of TLVD require greater attention for proper diagnosis and management. The spectrum of disorders associated with TLVD includes stress-induced cardiomyopathy, central nervous system injuries, histaminergic syndromes, various inflammatory diseases, pregnancy-related conditions, and genetically determined syndromes. Furthermore, myocardial infarction with non-obstructive coronary arteries (MINOCA) origins such as coronary artery spasm, coronary thromboembolism, and spontaneous coronary artery dissection (SCAD) may also manifest as TLVD, eventually showing recovery. This review highlights the range of ischemic and non-ischemic clinical situations that lead to TLVD, gathering conditions like Tako-Tsubo Syndrome (TTS), Kounis syndrome (KS), Myocarditis, Peripartum Cardiomyopathy (PPCM), and Tachycardia-induced cardiomyopathy (TIC). Differentiation amongst these causes is crucial, as they involve distinct clinical, instrumental, and genetic predictors that bode different outcomes and recovery potential for left ventricular function. The purpose of this review is to improve everyday clinical approaches to treating these diseases by providing an extensive survey of conditions linked with TLVD and the elements impacting prognosis and outcomes.

Recent advances in potential targets for myocardial ischemia reperfusion injury: Role of macrophages

Myocardial ischemia-reperfusion injury (MIRI) is a complex process that occurs when blood flow is restored after myocardium infarction (MI) with exacerbated tissue damage. Macrophages, essential cell type of the immune response, play an important role in MIRI. Macrophage subpopulations, namely M1 and M2, are distinguished by distinct phenotypes and functions. In MIRI, macrophages infiltrate in infarcted area, shaping the inflammatory response and influencing tissue healing. Resident cardiac macrophages interact with monocyte-derived macrophages in MIRI, and influence injury progression. Key factors including chemokines, cytokines, and toll-like receptors modulate macrophage behavior in MIRI. This review aims to address recent findings on the classification and the roles of macrophages in the myocardium, spanning from MI to subsequent MIRI, and highlights various signaling pathways implicated in macrophage polarization underlining the complexity of MIRI. This article will shed light on developing advanced therapeutic strategies for MIRI management.

Radiocontrast Medium-Induced Kounis Syndrome in a Dialysis Patient: A Case Report

Kounis syndrome is defined as the concurrence of acute coronary syndrome and a condition related to mast cell activation, including anaphylaxis and anaphylactoid. A 58-year-old male hemodialysis patient underwent enhanced computed tomography (CT) using the radiocontrast medium, iopamidol for investigation of a kidney tumor. Two minutes after the administration of iopamidol, he developed respiratory symptoms and chest pain. Five minutes after that, disturbed consciousness and low blood pressure were observed. On the other hand, he did not demonstrate urticaria and swelling of the skin. A 12-lead electrocardiogram (ECG) and echocardiogram suggested the presence of cardiac ischemia. Therefore, he was diagnosed with Kounis syndrome caused by radiocontrast media. Eighteen minutes after this, he received an intramuscular injection of adrenaline (0.3 mg), and his vital signs stabilized and his ECG, echocardiogram, and symptoms improved. Without undergoing emergency coronary angiography (CAG), he was hospitalized and closely monitored. The next day, his symptoms had not worsened, and he underwent hemodialysis at his local hospital. The allergen radiocontrast media could be injurious and not sufficiently excreted if administrated for patients on weekly hemodialysis with radiocontrast medium-induced Kounis syndrome manifesting; hence, indication for emergency CAG in radiocontrast medium-induced Kounis syndrome should be cautiously evaluated by close observation.

Ceftriaxone-induced Kounis syndrome: A case report and review of the literature

Kounis syndrome is defined as cardiovascular symptoms that occur secondary to allergic or hypersensitivity insults, and is also called allergic angina and allergic myocardial infarction. We report a case of pre-operative ceftriaxone-induced Kounis syndrome with no evident dermatological manifestation, and describe our diagnostic dilemma. The patient was symptomatically managed and discharged in stable condition with a warning against future use of ceftriaxone.

An Insight into Kounis Syndrome: Bridging Clinical Knowledge with Forensic Perspectives

Kounis syndrome (KS) is an acute coronary syndrome triggered by allergic or hypersensitivity reactions. Incidence rates vary, with studies reporting 19.4 per 100.000 among all admissions and 3.4% among allergy patients. This review explores the expanding understanding of KS, encompassing various manifestations, and focusing on both clinical data and forensic findings useful in performing a diagnosis. The pathophysiology of this syndrome involves a complex interplay between allergic reactions and the cardiovascular system. Mast cell activation, histamine release, leukotrienes, cytokines, and platelet activation can contribute to coronary events. Three types of classification systems (allergic angina, allergic myocardial infarction, allergic stent thrombosis) aid in categorizing presentations. The diagnosis of KS relies on clinical presentation, laboratory findings, and imaging. Postmortem assessment of KS is based on the integration of circumstantial data, autopsy, and histological findings. Biochemical and immunohistochemical analyses also contribute to postmortem diagnosis. In conclusion, a combined, multidisciplinary approach should be used to ease the diagnostic process, which is crucial for forensic practitioners in confirming KS occurrence.

Rocuronium-Induced Anaphylaxis in the Perioperative Period: A Clinical Review

Rocuronium, a nondepolarizing neuromuscular blocking agent used for muscle relaxation especially during endotracheal intubation, can cause hypersensitivity reactions. This article provides an overview of anaphylactic reactions; risk factors; and the pathophysiology, presentation, diagnosis, treatment, and nursing implications associated with rocuronium-induced anaphylaxis. Life-threatening anaphylaxis can be immunoglobulin E-mediated or non-immunoglobulin E-mediated and usually occurs after the first dose. Anaphylaxis can present with hypotension and bronchospasm; cutaneal symptoms, such as erythema, may not be obvious. Diagnosis is initially presumptive and may require a transesophageal echocardiogram to rule out other causes of hypotension (eg, pulmonary embolus). Emergency treatment begins with epinephrine administration and fluid boluses; cardiac support devices may be needed. Definitive diagnosis requires early measurement of histamine and tryptase levels and skin testing after the patient recovers from the reaction. Perioperative nurses should be prepared to participate in emergency treatment of anaphylaxis and advocate for testing for a definitive diagnosis.

Kounis syndrome: ST elevations in the setting of anaphylaxis

Acute coronary syndrome in the presence of an allergic reaction is known as Kounis syndrome, which is an underdiagnosed disorder and has nuances regarding management. We present a patient brought to the hospital as an ST segment elevation myocardial infarction (STEMI) alert in the setting of an allergic reaction triggered by food.

Kounis syndrome after anti-snake venom intradermal skin test: A case report

Snake bites are a concerning health problem in Egypt and other tropical countries that are effectively managed with anti-snake venom (ASV). ASV has common reactive complications that are usually mild. Rarely, anaphylaxis and severe systemic reactions may occur following ASV. In this case report, we present a rare condition of Kounis syndrome, acute allergic myocardial infarction, in a young man during anaphylaxis following an allergic intradermal test of VACSERA snake antivenom.

Cardiac Arrest Due to Kounis Syndrome Following Cephazolin Administration During Surgery Under Local Anesthesia

The Kounis syndrome is described as the co-occurrence of allergic responses brought on by mast cell activation and acute coronary syndromes. We present a case of Kounis syndrome leading to cardiac arrest following the cephazolin sodium administration during the surgical resection of basal cell carcinoma. An 87-year-old woman was diagnosed with basal cell cancer. She received surgical excision of the tumor while anesthetized with lidocaine hydrochloride and 1% epinephrine. This patient began to itch around five minutes after cefazolin (CEZ) administration and eventually experienced cardiac arrest following diffuse rashes that spread throughout her body and edema in her eyelids. In line with the response, the electrocardiogram (ECG) also showed an elevated ST segment in V1-6, leading to possibly the diagnosis of Kounis syndrome. We also review the literature on Kounis syndrome following CEZ administration.

A Rare Case of Kounis Syndrome Secondary to Infliximab

Kounis syndrome (KS) is an acute coronary syndrome triggered by allergic or anaphylactic reactions. It manifests as coronary artery vasospasm, acute myocardial infarction, or coronary stent thrombosis, resulting from inflammatory cytokine release and inappropriate activation of platelets and mast cells. We present a case of an 85-year-old male with Crohn's disease who suffered anaphylaxis during infliximab infusion, culminating in non-ST myocardial infarction (NSTEMI). The patient's symptoms were effectively managed with epinephrine and diphenhydramine, and KS secondary to infliximab was diagnosed. Diagnosing KS can be challenging due to the overlapping signs of an allergic reaction and myocardial infarction. Timely recognition and appropriate management of KS are crucial to enhance patient outcomes. Therefore, healthcare providers should maintain a high index of suspicion for KS in patients with acute coronary syndromes linked to allergic reactions to optimize care and minimize potential risks. This case report underscores the significance of prompt intervention and awareness of Kounis syndrome in clinical practice.

Vasospastic angina: Past, present, and future

Vasospastic angina (VSA) is characterized by episodes of rest angina that are responsive to short-acting nitrates and are attributable to coronary artery vasospasm. The condition is underdiagnosed as the provocation test is rarely performed. VSA, the most important component of non-obstructive coronary artery disease, can present with angina, be asymptomatic, or can even present with fatal arrhythmias and cardiac arrest. Although most patients with VSA respond well to vasodilating medications, prognosis does not improve as expected in most patients, suggesting the existence elusive prognostic factors and pathogenesis that warrant further exploration. Moreover, patients with either severe or refractory VSA barely respond to conventional treatment and may develop life-threatening arrhythmias or suffer sudden cardiac death during ischemic attacks, which are associated with immune-inflammatory responses and have been shown to achieve remission following glucocorticoid and immunoglobulin treatments. Our recent work revealed that inflammation plays a key role in the initiation and development of coronary spasms, and that inflammatory cytokines have predictive value for diagnosis. In contrast to the existing literature, this review both summarizes the theoretical and clinical aspects of VSA, and also discusses the relationship between inflammation, especially myocarditis and VSA, in order to provide novel insights into the etiology, diagnosis, and treatment of VSA.

56-year-old male with HIV and sudden cardiac arrest

A 56-year-old man with well-controlled human immunodeficiency virus, anxiety, depression, and hypercholesterolemia developed acute urticaria, lip angioedema, and respiratory distress after consumption of a cheeseburger, French fries, lemonade, and ibuprofen. He was evaluated in the emergency department and, during admission, developed asystole, diaphoresis, pallor, and a brief episode of posturing that was treated with two doses of epinephrine. Results of the initial workup with electrocardiogram, troponin, complete blood cell count, and comprehensive metabolic panel were normal. He was subsequently evaluated by an allergist for further recommendations.

The Role of Mast Cells in the Induction and Maintenance of Inflammation in Selected Skin Diseases

Under physiological conditions, skin mast cells play an important role as guardians that quickly react to stimuli that disturb homeostasis. These cells efficiently support, fight infection, and heal the injured tissue. The substances secreted by mast cells allow for communication inside the body, including the immune, nervous, and blood systems. Pathologically non-cancerous mast cells participate in allergic processes but also may promote the development of autoinflammatory or neoplastic disease. In this article, we review the current literature regarding the role of mast cells in autoinflammatory, allergic, neoplastic skin disease, as well as the importance of these cells in systemic diseases with a pronounced course with skin symptoms.

Intraoperative cardiac arrest due to allergic acute coronary syndrome (Kounis syndrome) triggered by cephalosporin

An acute coronary syndrome due to mast-cell activation in the presence of an allergen is known as Kounis Syndrome (KS). This relatively new entity of KS is being increasingly recognized among allergists, cardiologists, and emergency physicians; however, it is not well-known among anesthesiologists. We report here, a case of type 2 KS due to antibiotic administration causing sudden perioperative cardiac arrest.

Kounis syndrome following multiple wasp stings: A case report

This is a case of Kounis syndrome with chest tightness, lightheadedness, unconsciousness, and features of shock following multiple wasp stings. Despite cardiopulmonary resuscitation and management of allergic and cardiac symptoms, the patient died. Kounis syndrome should be suspected when a patient presents with allergic symptoms and acute coronary syndrome.

Kounis Syndrome Associated With the Use of Diclofenac

BACKGROUND

Diclofenac is a widely used analgesic, anti-inflammatory, antipyretic drug. In several case reports, its use was associated with the occurrence of Kounis syndrome. The aim of this review was to investigate and summarize published cases of Kounis syndrome suspected to be associated with the use of diclofenac.

METHODS

Electronic searches were conducted in PubMed/MEDLINE, Scopus, Web of Science, Google Scholar, and the Serbian Citation Index.

RESULTS

Twenty publications describing the 20 patients who met inclusion criteria were included in the systematic review. Specified patient ages ranged from 34 to 81 years. Eighteen (90.0%) patients were male. Five patients (25.0%) reported a previous reaction to diclofenac. Reported time from the used dose of diclofenac to onset of the first reaction symptoms ranged from immediately to 5 hours. Diclofenac caused both type I and type II Kounis syndrome, with the presence of various cardiovascular, gastrointestinal, dermatologic, and respiratory signs and symptoms. Most patients experienced hypotension (n = 15 [75.0%]) and chest pain (n = 12 [60.0%]). The most frequently reported finding on electrocardiogram was ST-segment elevations (n = 17 [85.0%]). Coronary angiogram showed normal coronary vessels in 9 patients (45.0%), with some pathologic findings in 8 patients (40.0%).

CONCLUSION

Clinicians should be aware that Kounis syndrome may be an adverse effect of diclofenac. Prompt recognition and withdrawal of the drug, with treatment of both allergic and cardiac symptoms simultaneously, is important.

Kounis syndrome following allergy injection in a paediatric patient

Kounis syndrome is the concurrence of acute coronary syndrome or coronary vasospasm with conditions associated with the release of inflammatory cytokines through mast cell activation in the setting of allergic or anaphylactic reactions. Many identified triggers have been identified in paediatric patients including exposures, drugs, and immunisations; however, to our knowledge this is the first case report of Kounis syndrome linked to immunotherapy. We present a case of a 9-year-old with seasonal allergies presenting with clinical symptoms of Kounis syndrome following her weekly subcutaneous injection of allergens. Clinicians need a high index of suspicion for Kounis syndrome in patients who develop systemic signs of anaphylaxis with clinical, laboratory, electrocardiographic, and echocardiographic findings of acute coronary syndrome to help direct therapy and improve outcomes.

Is Adrenaline Always the First Choice Therapy of Anaphylaxis? An Allergist-cardiologist Interdisciplinary Point of View

Worldwide, adrenaline is considered the first choice therapy in the international guidelines for the management of anaphylaxis. However, the heart and cardiovascular apparatus are strongly involved in anaphylaxis; for that reason, there are some cardiac conditions and certain anaphylaxis patterns that make epinephrine use problematic without adequate heart monitoring. The onset of Kounis syndrome, takotsubo cardiopathy, or the paradoxical anaphylaxis require great attention in the management of anaphylaxis and adrenaline administration by clinicians, who should be aware of the undervalued evolution of anaphylaxis and the potential cardiologic complications of epinephrine administration. Numerous case reports and studies describe the unexpected onset of cardiac diseases following epinephrine treatment, despite the latter being the recommended therapy for anaphylaxis. Our review suggests that future anaphylaxis guidelines should incorporate cardiovascular specialists since the treatment of Kounis syndrome or takotsubo cardiopathy requires cardiologist skills.

Angina and Arrhythmia Symptoms Following Multiple Bee Stings: Kounis Syndrome

Kounis syndrome (KS) is an acute coronary syndrome including coronary spasm, acute myocardial infarction, and stent thrombosis preceded by an anaphylactic, anaphylactoid, allergic, or hypersensitivity injury. In this case presentation, we discussed Type I and Type II KS. Case 1 was a 72-y-old man who presented to the emergency department with allergic symptoms and chest pain that developed after multiple bee stings. Electrocardiography showed ST depression in the lateral leads. Case 2 was a 42-y-old woman who presented to the emergency department with complaints of chest pain, dizziness, and presyncope that developed after multiple bee stings. Mobitz Type II Block with right bundle branch block was observed in 42 beats·min-1 in the electrocardiography. Both patients were first treated for allergic reaction. Although early percutaneous coronary intervention was performed for graft thrombosis in Case 1, a permanent pacemaker was inserted in Case 2. The patients were discharged without any complications. Increasing physician awareness towards the existence of KS can prevent fatal outcomes with early diagnosis and treatment.

Clinical cardiovascular emergencies and the cellular basis of COVID-19 vaccination: from dream to reality?

OBJECTIVES

SARS-CoV-2 is responsible for the global COVID-19 pandemic, with little prevention or treatment options. More than 600 million mortalities have been documented from SARS-CoV-2 infection, with the majority of fatalities occurring among elderly patients (aged >65 years). A number of vaccines have been developed in an effort to restrain the rapid spread of SARS-CoV-2. Considering the widespread administration of these vaccines, substantial side or undesired effects in multiple organ systems have emerged, necessitating essential critical care. Herein, we tabulate the adverse cardiovascular responses resulting from COVID-19 vaccines.

DESIGN OR METHODS

We searched PubMed for articles published through April, 2022, with the terms "SARS-CoV-2", "COVID-19", "cardiovascular", "SARS-CoV-2 vaccines", "COVID-19 vaccines", "myocarditis", "pericarditis", "thrombosis", "thrombocytopenia", "vaccine-induced thrombotic thrombocytopenia", "acute coronary syndrome", "myocardial infarction", "hypertension", "arrythmia", "postural orthostatic tachycardia syndrome", "Takotsubo cardiomyopathy", "cardiac arrest" and "death". We mainly selected publications from the past 3 years, but did not exclude widely referenced and highly regarded older publications. Besides, we searched the reference lists of articles identified by above search method and chose those we considered relevant.

RESULTS

COVID-19 vaccines evoke rare but fatal thrombotic events, whereas messenger RNA\055based vaccines appear to be associated with risks of pericarditis/myocarditis, with the latter being more predominant in young adults following the second dose. Reports of other cardiovascular responses, including hypertension, arrhythmia, acute coronary syndrome, and cardiac arrest, have also been indicated.

CONCLUSION

The undesired cardiovascular complications remain infrequent, giveng the large number of vaccinations inoculated to general population. And lower mortality takes precedence over the undesired cardiovascular complications.

Broad Electrocardiogram Syndromes Spectrum: From Common Emergencies to Particular Electrical Heart Disorders

Electrocardiogram (ECG) still remains a very useful diagnostic method in modern cardiology. Its broad availability, noninvasiveness and good sensitivity explain why it plays a capital role in the very beginning of the process of diagnosis for every patient, with or without cardiac-related complaints. For the practitioner, good training in ECG interpretation is mandatory. Sometimes, the ECG trace reveals particular aspects that may cause confusion and complicate decision-making. In this article, we present several less common situations underlying the general context and ECG features. The syndromes studied have a high pathological significance and may range from acute emergencies that call for a rapid therapeutical response to chronic syndromes that require prolonged observation, monitoring and risk stratification.

Epidemiology of out-of-hospital cardiac arrests caused by anaphylaxis and factors associated with outcomes: an observational study

OBJECTIVES

Describe the epidemiologic features of out-of-hospital cardiac arrest (OHCA) caused by anaphylaxis and identify outcome-associated factors.

DESIGN

Observational study.

SETTING

Data from the Japanese Fire and Disaster Management Agency database.

PARTICIPANTS

A total of 292 patients from 879 057 OHCA events between 2013 and 2019 with OHCA caused by anaphylaxis and for whom prehospital resuscitation was attempted were included in the analysis.

OUTCOME MEASURES

The incidence of anaphylaxis-induced OHCA, neurologically favourable 1-month survival, defined as cerebral performance category 1 or 2, and 1-month survival.

RESULTS

The proportion of OHCAs caused by anaphylaxis was high in non-elderly and male patients from July to September and during business hours. Bystander-witnessed (adjusted OR=4.43; 95% CI 1.84 to 10.7) and emergency medical service-witnessed events (adjusted OR=3.28; 95% CI 1.21 to 8.87) were associated with higher rates of neurologically favourable 1-month survival as well as better 1-month survival. Shockable initial ECG rhythms were recorded in only 19 patients (6.5%), and prehospital defibrillation was attempted in 16 such patients (84.2%). Neither shockable initial rhythms nor prehospital defibrillation was associated with better outcomes. Patients requiring advanced airway management had poor neurological outcomes (adjusted OR=0.17; 95% CI 0.07 to 0.42) and worse 1-month survival (adjusted OR=0.28; 95% CI 0.14 to 0.58).

CONCLUSIONS

Few cases of OHCA were attributable to anaphylaxis. Witnessed OHCAs, particularly those witnessed by bystanders, were associated with better neurological outcomes. Airway complications requiring advanced airway management were likely associated with poor outcomes.

Variant Angina is Associated with Myocarditis

Background

Vasospastic angina (VSA) is caused by severe diffuse or segmental coronary artery spasms. Patients with variant angina have poor clinical outcomes, although nitrates and calcium blockers help improve patient symptoms because there is no understanding of the etiology and causal treatment. The present study investigated whether VSA is associated with inflammation of the heart.

Patients and Methods

A total of 109 patients with VSA diagnosed by the presence of recurrent angina pectoris, typical electrocardiography, and coronary angiography were recruited, and 61 normal participants and 61 patients with acute myocardial infarction (AMI) and coronary artery stenosis were recruited as controls. The plasma levels of 24 cytokines were measured using a magnetic Luminex assay, and endothelin-1 and histamine levels tested using enzyme-linked immunosorbent assay and mass-spectrometry, respectively, for all participants. Furthermore, four patients with VSA underwent 18-fluorine fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT).

Results

The plasma levels of interleukin (IL)-12p70, IL-13, PDL-1, IL-10, IL-6, IL-15, macrophage inflammatory protein (MIP)-1α, and MIP-1β in patients with VSA were significantly higher than those in both normal controls and patients with AMI (p<0.001) but did not differ between normal controls and patients with AMI. ¹⁸F-FDG PET/CT showed that the left ventricle, coronary perivascular tissue volume, and coronary perivascular FDG uptake were significantly increased in all four patients.

Conclusion

Our findings demonstrate that VSA patients have significantly elevated plasma cytokine levels and myocardial and pericoronary inflammation, suggesting that VSA is associated with myocarditis. This study provides novel insights into the etiology and treatment of VSA.

Analysis of Clinical Features of Non-steroidal Anti-inflammatory Drugs Induced Kounis Syndrome

Background

Current knowledge of Kounis syndrome induced by non-steroidal anti-inflammatory drugs (NSAIDs) is based on case reports. This study aimed to investigate the clinical features of Kounis syndrome.

Methods

Case reports of the NSAIDs-induced Kounis syndrome were analyzed by searching Chinese and English databases from 1 January 1950 to 31 January 2022.

Results

The median age of the 45 included patients (28 women) was 51 years (20–80 years). NSAIDs that were the most frequently involved were diclofenac (26.7%, 12/45), metamizole (15.6%, 7/45), and aspirin (13.3%, 6/45). Kounis syndrome occurred mainly within 30 min after administration, with a maximum latency of 1 month. Chest pain (75.6%, 34/45), dyspnea (33.3%, 15/45), and allergic reactions (44.4%, 20/45) were the most common clinical manifestations. Thirty patients (66.7%) had an ST-segment elevation on the electrocardiogram. Echocardiogram and coronary angiography showed abnormalities in 21 patients (75%, 21/28) and 15 patients (37.5%, 15/40). Forty-four patients (97.8%) had a good prognosis after treatment with steroids, antihistamines, and vasodilators.

Conclusion

The possibility of Kounis syndrome should be considered in the presence of coronary artery disease symptoms when taking NSAIDs. Kounis syndrome can be life-threatening. It is essential to identify and treat Kounis syndrome correctly.

Case Report: Oxaliplatin-Induced Third-Degree Atrioventricular Block: First Discovery of an Important Side-Effect

Background

The adverse effects of anticancer therapy in patients with malignancies and cardiovascular diseases are complicated. Oxaliplatin is one of the most commonly used chemotherapy drugs for gastric and colorectal cancers, and oxaliplatin-induced cardiotoxicity has rarely been reported.

Case Summary

We report a 76-year-old man with adenocarcinoma of the esophagogastric junction and a 40-day history of non-ST-elevation myocardial infarction who exhibited a new third-degree atrioventricular block after oxaliplatin administration. We immediately withdrew oxaliplatin treatment and, to avoid future episodes, we implanted a permanent pacemaker for safety and added diltiazem hydrochloride. The third-degree atrioventricular block disappeared after oxaliplatin withdrawal. We detected no recurrence of the third-degree atrioventricular block in future chemotherapies.

Conclusions

This is the first reported oxaliplatin-induced third-degree atrioventricular block, likely mediated by coronary artery spasm. Cancer patients with acute coronary syndrome are a unique and vulnerable population, whom physicians should carefully evaluate and monitor during anticancer treatment. Remarkably, even the most common chemotherapy drugs can cause life-threatening cardiac adverse events.

Association of Circulating IgE and CML Levels with In-Stent Restenosis in Type 2 Diabetic Patients with Stable Coronary Artery Disease

Background: We investigated whether serum levels of immunoglobin (Ig) E and Nε-carboxymethyl-lysine (CML) are related to in-stent restenosis (ISR) in patients with stable coronary artery disease and type 2 diabetes mellitus (T2DM). Methods: Serum levels of IgE and CML were measured in 196 ISR patients and 220 non-ISR patients with stable angina and T2DM who received angiographic follow-up 12 months after percutaneous coronary intervention (PCI) with third-generation drug-eluting stent (DES) implantation for de novo lesions. Multivariate logistic regression analysis was performed to assess the association between IgE or CML and ISR. Results: Both IgE and CML levels were higher in patients with ISR compared with non-ISR patients (IgE: 187.10 (63.75−489.65) vs. 80.25 (30.65−202.50), p < 0.001; CML: 203.26 (164.50−266.84) vs. 174.26 (130.85−215.56), p < 0.001). The rate of ISR increased stepwise with increasing tertiles of IgE and CML levels (p for all trends < 0.001), and IgE correlated significantly with CML. After adjusting for potential confounders, IgE and CML levels remained independently associated with ISR. Moreover, IgE and CML levels improved the predictive capability of traditional risk factors for ISR, and there existed an interaction between IgE and CML in relation to ISR (p for interaction < 0.01). Conclusion: Elevated circulating IgE and CML levels confer an increased risk for ISR after DES-based PCI in type 2 diabetic patients with stable coronary artery disease.

High Serum Total IgE at Admission Is Associated with Coronary Artery Lesions in Children with Kawasaki Disease

Kawasaki disease (KD) is associated with allergy. As immunoglobulin E (IgE), a key element of allergic reactions, is related with coronary heart disease, we evaluated the serum total IgE levels, and investigated its clinical relevance in 339 children with KD. These patients were classified as high IgE group and normal IgE group according to the reference value of IgE. Serum IgE levels in the high group (279.76 ± 202.54 IU/mL) significantly increased compared with the normal group (5.51 ± 15.79 IU/mL) (p < 0.001). There were also no significant differences in the frequency of major clinical manifestation between the two groups. The number of patients who developed coronary artery lesions (CALs) was significantly higher in the high group (p = 0.004), and the serum levels of IgE were also markedly higher in the KD patients with CALs than in patients without CALs (p = 0.002). High total serum IgE was an independent prognostic for CALs in the multivariate analysis. In conclusion, serum IgE levels may be associated with CALs in children with KD.

Fatal outcome following multiple bee stings: A rare case

Anaphylactic shock is an unexpected, life-threatening, and sometimes fatal occurrence that affects patients in 75% of instances without a prior history of allergies. The severity of the reaction can vary among individuals. We report a case who died suddenly after being stung by bees in various parts of his body.

Deep Vein Thrombosis After a Wild Bee Sting

Allergic reactions from insect bites are mostly observed with bee stings. Bee sting reactions can be classified into 3 main headings: local, systemic, and rare reactions. Vascular thrombosis is considered both in rare and systemic reactions. The wild bee venom induces the secretion of many inflammatory mediators, including histamine, phospholipase A1, and thromboxane, leading to vasoconstriction and thrombosis. Inflammatory cytokines also cause endothelial injury and deterioration of the microcirculation. In the literature, rare reactions have been reported including various central and arterial vascular pathologies such as aortic thrombosis, cerebral infarction, and myocardial infarction; however, there is rare publication concerning peripheral deep vein thrombosis (DVT). Although DVT produces good results with effective and rapid treatment, it can be fatal because of causes such as pulmonary embolism in the absence of timely intervention. Herein, for the first time in the literature, we present a pediatric case of peripheral DVT after a wild bee sting.

Histamine receptors in heart failure

The biogenic amine, histamine, is found predominantly in mast cells, as well as specific histaminergic neurons. Histamine exerts its many and varied actions via four G-protein-coupled receptors numbered one through four. Histamine has multiple effects on cardiac physiology, mainly via the histamine 1 and 2 receptors, which on a simplified level have opposing effects on heart rate, force of contraction, and coronary vasculature function. In heart failure, the actions of the histamine receptors are complex, the histamine 1 receptor appears to have detrimental actions predominantly in the coronary vasculature, while the histamine 2 receptor mediates adverse effects on cardiac remodeling via actions on cardiomyocytes, fibroblasts, and even endothelial cells. Conversely, there is growing evidence that the histamine 3 receptor exerts protective actions when activated. Little is known about the histamine 4 receptor in heart failure. Targeting histamine receptors as a therapeutic approach for heart failure is an important area of investigation given the over-the-counter access to many compounds targeting these receptors, and thus the relatively straight forward possibility of drug repurposing. In this review, we briefly describe histamine receptor signaling and the actions of each histamine receptor in normal cardiac physiology, before describing in more detail the known role of each histamine receptor in adverse cardiac remodeling and heart failure. This includes information from both clinical studies and experimental animal models. It is the goal of this review article to bring more focus to the possibility of targeting histamine receptors as therapy for heart failure.

Hymenoptera heartaches -cardiac manifestation with hymenoptera stings, a retrospective study from a tertiary care hospital in South India

INTRODUCTION

Hymenoptera stings usually have a multitude of presentations from very subtle to life-threatening conditions. Various cardiac manifestations including Kounis syndrome often get missed due to lack of suspicion. The aim of the study was to describe the clinical profile of the cardiac etiologies associated with hymenoptera stings and review literature with focus on diagnosis and treatment strategies.

METHODOLOGY

A retrospective chart analysis was performed including all adult patients who had a hymenoptera sting during a two-year window (October 2018 - October 2020). Of these, patients with cardiac features were enrolled. A structured case record form was used to capture information like basic demography, clinical profile, and outcomes.

RESULTS

Thirteen cases presented with hymenoptera stings of which six cases had cardiac presentation and were considered. The most common presentations were breathlessness and generalised itching with only one patient complaining of chest pain. All patients(with available data) had ECG changes suggestive of ischemia and associated raised troponin levels with 2D echo changes. The diagnoses considered included Kounis syndrome, hypersensitivity myocarditis, and Takotsubo cardiomyopathy. Patients were managed conservatively with one patient undergoing a coronary angiography. All patients were stable at discharge.

CONCLUSION

Cardiac manifestations with hymenoptera stings although rare may complicate diagnosis and treatment.It should be borne in mind during assessment and standardised guidelines should be developed for ED treatment such as the one recommended in this study.

Acute coronary syndrome from scombroid poisoning: a narrative review of case reports

BACKGROUND

Scombroid syndrome constitutes a toxic illness caused by ingestion of improperly stored fish, usually contaminated by Gram-negative bacteria producing histamine and other toxins. Scombroid currently accounts for approximately 5% of food toxicities in the United States. Though cardiovascular complications are infrequent, some patients experienced acute coronary syndrome (ACS) on admission to hospital. This article focuses on the main pathophysiology, clinical features, therapy, and outcomes in scombroid-related ACS.

METHODS

Starting from the consolidated knowledge on histaminergic syndromes, we performed a literature search for studies describing patient series and single cases presenting at emergency department with scombroid toxicity complicated by myocardial ischemia.

RESULTS

After a pathophysiological overview on histaminergic syndromes, we carefully analyzed a dataset of 19 patients from 13 studies, published from 1997 to December 2020. Electrocardiographic, echocardiographic, angiographic features, clinical course, hospital complications, and therapeutic approach were described. Shared and differential aspects of scombroid ACS with typical atherosclerotic ischemia, Kounis, MINOCA and Takotsubo syndromes are also discussed.

CONCLUSION

An ischemic heart scombroid syndrome may occur in some patients after the eating of improperly stored fish food. Currently available studies indicate this as a benign condition, except for patients with history of coronary artery disease, previous ACS, or anaphylaxis. Of clinical concern, there is a potential of hemodynamic failure in the acute stage, even in apparently healthy people.

Type I Kounis syndrome variant: A case report and literature review

Kounis syndrome defined as the occurrence of acute coronary syndrome in the setting of allergic reaction due to mast cells activation and inflammatory mediators release that induces coronary vasospasm, plaque erosion, or even stent thrombosis. A 25-year-old postpartum female with asthma and recurrent episodes of chest pain was admitted with ST-segment elevation myocardial infarction in the setting of coronary artery spasms. The patient was started on calcium channel blockers and nitrite-based medication with no improvement. She was noted to have eosinophilia and initiation of corticosteroid-based regimen lead to resolution of chest pain episodes and normalization of eosinophilia. Kounis syndrome should be considered in young patients with chest pain. Coronary vasodilators are considered as the first-line of treatment. The use of corticosteroids has been described in the literature in severe or refractory cases.

COVID-19 cardiac arrest due to Prinzmetal's angina in a previously normal heart

In COVID-19 patients who develop sudden ST elevations it is necessary to consider cardiac causes other than myocardial infarction, such as coronary vasospasm.

Case Report: Phloroglucinol-Induced Kounis Syndrome

Background: Kounis syndrome is an allergy-related acute coronary syndrome that is induced by various pharmacological and environmental factors. Given that many clinicians are not aware of this condition, many cases may be underdiagnosed. We report a case of type II Kounis syndrome induced by phloroglucinol.

Case Summary: A 52-year-old man with pre-existing coronary artery stenosis presented with a 30-min history of chest pain and erythematous rash after intramuscular administration of phloroglucinol. An electrocardiogram demonstrated ST-segment elevation in leads II, III and aVF. Emergency coronary angiography revealed severe stenosis in the distal right coronary artery. Intravascular ultrasound showed plaque rupture and thrombosis, and the minimum lumen area was 3.0 mm². A 3.5 × 38 mm stent was implanted in the distal right coronary artery. Troponin I levels were elevated. A diagnosis of type II Kounis syndrome induced by phloroglucinol was made, and the condition manifested as acute ST-segment elevation myocardial infarction.

Conclusions: Clinicians should be aware of Kounis syndrome as a possible diagnosis in a patient who presents with chest pain and allergic manifestations given that an increasing number of triggers are being reported.

Kounis Syndrome and Multiorgan Failure Following Multiple Wasp Stings

Wasp and bee stings are common in Sri Lanka, and systemic envenomation causes a spectrum of clinical manifestations that includes simple local allergic reaction to life-threatening multiple organ injury or failure. However, wasp toxin-induced acute myocardial infarction is very rare in the literature. Here, we describe a pregnant lady with mass wasp stings who developed toxin-induced acute myocardial infarction with multiorgan injury. The treating physician should anticipate the complications of massive envenomation following multiple wasp stings.

Kounis syndrome presenting as ST elevation acute myocardial infarction

Allergic acute coronary syndrome, Kounis syndrome, is a rare cause of ST-segment elevation myocardial infarction triggered by an allergic reaction to a drug or environmental allergen, resulting in atheromatous plaque rupture or coronary artery vasospasm. We report three cases of Kounis syndrome presenting as ST-segment elevation myocardial infarction.