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Adame MJ, Raji M, Shan Y, Zhang Y, Kuo YF, Tripple JW. Association Between Aspirin-Exacerbated Respiratory Disease and Atherosclerotic Cardiovascular Disease: A Retrospective Review of US Claims Data. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3445-3453.e6. [PMID: 37468040 DOI: 10.1016/j.jaip.2023.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Aspirin-exacerbated respiratory disease (AERD) consists of chronic rhinosinusitis with nasal polyps (CRSwNP), asthma, and hypersensitivity to aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs). Asthma is associated with increased risk of atherosclerotic cardiovascular diseases (ASCVD). However, there is lack of data on association between AERD and ASCVD. OBJECTIVE To investigate the relationship between AERD and subsequent risk of ASCVD. METHODS An algorithm to find patients with AERD was generated and validated through chart review at our home institution. This algorithm was applied to a national insurance claims database to obtain data for a retrospective cohort study. Demographic and comorbidity data were obtained for propensity matching. Several methods of analysis were performed on the data. RESULTS A total of 571 patients met criteria for AERD; 3909 met criteria for asthma, CRSwNP, and no allergy to aspirin or NSAIDs (group 1); and 75,050 met criteria for asthma, CRS without nasal polyps, and no allergy to aspirin or NSAIDs (group 2). After covariate adjustment, AERD was significantly associated with ASCVD, including severe ASCVD, over groups 1 and 2 regardless of asthma severity. CONCLUSION Patients with AERD are at higher risk of ASCVD than patients with asthma and CRSwNP or CRS without nasal polyps, underscoring the need for early ASCVD screening and a consideration for aspirin desensitization or use of a nonaspirin antiplatelet agent in the setting of AERD and comorbid ASCVD.
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Affiliation(s)
- Michael J Adame
- Department of Internal Medicine, Division of Allergy and Immunology, the University of Texas Medical Branch, Galveston, Texas.
| | - Mukaila Raji
- Department of Internal Medicine, Division of Geriatrics, the University of Texas Medical Branch, Galveston, Texas
| | - Yong Shan
- Department of Biostatistics and Data Science, the University of Texas Medical Branch, Galveston, Texas
| | - Yuanyi Zhang
- Department of Biostatistics and Data Science, the University of Texas Medical Branch, Galveston, Texas
| | - Yong-Fang Kuo
- Department of Internal Medicine, Division of Geriatrics, the University of Texas Medical Branch, Galveston, Texas; Department of Biostatistics and Data Science, the University of Texas Medical Branch, Galveston, Texas
| | - Julia W Tripple
- Department of Internal Medicine, Division of Allergy and Immunology, the University of Texas Medical Branch, Galveston, Texas
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Borkar SK, Hande P, Bankar NJ. Kounis Syndrome: Bee Sting-Induced Acute Myocardial Infarction. Cureus 2023; 15:e47507. [PMID: 38021736 PMCID: PMC10663870 DOI: 10.7759/cureus.47507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Acute coronary syndrome or ST-elevation myocardial infarction that develops as a hypersensitive reaction following exposure to an allergen, such as chemicals or bee or wasp stings, is known as Kounis syndrome (KS). Based on angiographic characteristics, three kinds of KS have been identified. Multiple bee stings typically result in localized allergic reactions and anaphylaxis, but they can also occasionally induce severe systemic toxic reactions. Here, a case of KS in a 50-year-old male presented with swelling on the face and upper limbs and breathing difficulties resulting from bee stings which led to myocardial infarction. The risk of KS should be considered by the physician at the primary level in all situations involving multiple bee bites.
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Affiliation(s)
- Sonali K Borkar
- Community Medicine, Datta Meghe Medical College, Datta Meghe Institute of Higher Education and Research (Deemed to Be University), Nagpur, IND
| | | | - Nandkishor J Bankar
- Microbiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research (Deemed to Be University), Wardha, IND
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Gogos C, Stamos K, Tsanaxidis N, Styliadis I, Koniari I, Kouni SN, de Gregorio C, Kounis NG. Blood Transfusion Components Inducing Severe Allergic Reactions: The First Case of Kounis Syndrome Induced by Platelet Transfusion. Vaccines (Basel) 2023; 11:vaccines11020220. [PMID: 36851100 PMCID: PMC9965342 DOI: 10.3390/vaccines11020220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023] Open
Abstract
Kounis syndrome is a multisystem and multidisciplinary disease affecting the circulatory system that can be manifested as spasm and thrombosis. It can occur as allergic, hypersensitivity, anaphylactic, or anaphylactoid reactions associated with the release of inflammatory mediators from mast cells and from other interrelated and interacting inflammatory cells, including macrophages and lymphocytes. A platelet subset with high- and low-affinity IgE surface receptors is also involved in this process. Whereas the heart, and particularly the coronary arteries, constitute the primary targets of inflammatory mediators, the mesenteric, cerebral, and peripheral arteries are also vulnerable. Kounis syndrome is caused by a variety of factors, including drugs, foods, environmental exposure, clinical conditions, stent implantation, and vaccines. We report a unique case of a 60-year-old male with a past medical history of allergy to human albumin, alcoholic cirrhosis, and esophageal varices, who was admitted due to multiple episodes of hematemesis. Due to low hemoglobin levels, he was transfused with 3 units of red blood cells and fresh frozen plasma without any adverse reactions. On the third day of hospitalization, severe thrombocytopenia was observed and transfusion of platelets was initiated. Immediately following platelet infusion, the patient developed chest discomfort, skin signs of severe allergic reaction, and hemodynamic instability. The electrocardiogram revealed ST segment elevation in the inferior leads. Given the strong suspicion of Kounis syndrome/allergic coronary spasm, the patient was treated with anti-allergic treatment only, without any anti-platelet therapy. The clinical status of the patient gradually improved and the electrocardiographic changes reverted to normal. Based on these findings, Kounis hypersensitivity-associated acute coronary syndrome, specifically, type I Kounis syndrome, was diagnosed. Although platelet transfusion can be a life-saving therapy, each blood transfusion carries a substantial risk of adverse reactions. The aims of this report are to expand the existing knowledge of patient responses to blood transfusion and provide information on the incidence of various severe transfusion reactions to all blood components and especially to platelets. To the best of our knowledge, Kounis syndrome induced by platelet transfusionhas never been previously reported. Hypersensitivity to platelet external membrane glycoproteins in an atopic patient seems to be the possible etiology. Despite that Kounis syndrome remains an under-diagnosed clinical entity in everyday practice, it should always be considered in the differential diagnosis of acute coronary syndromes.
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Affiliation(s)
- Christos Gogos
- Department of Cardiology, Papageorgiou General Hospital, Nea Efkarpia, 56403 Thessaloniki, Greece
| | - Konstantinos Stamos
- Department of Cardiology, Papageorgiou General Hospital, Nea Efkarpia, 56403 Thessaloniki, Greece
| | - Nikolaos Tsanaxidis
- Department of Cardiology, Papageorgiou General Hospital, Nea Efkarpia, 56403 Thessaloniki, Greece
| | - Ioannis Styliadis
- Department of Cardiology, Papageorgiou General Hospital, Nea Efkarpia, 56403 Thessaloniki, Greece
| | - Ioanna Koniari
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | | | - Cesare de Gregorio
- Department of Clinical and Experimental Medicine, University of Messina Medical School, 98122 Messina, Italy
| | - Nicholas G. Kounis
- Department of Internal Medicine, Division of Cardiology, University of Patras Medical School, 26221 Patras, Greece
- Correspondence:
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Poggiali E, Benedetti I, Vertemati V, Rossi L, Monello A, Giovini M, Magnacavallo A, Vercelli A. Kounis syndrome: from an unexpected case in the Emergency Room to a review of the literature. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022002. [PMID: 35315408 PMCID: PMC8972874 DOI: 10.23750/abm.v93i1.11862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/12/2021] [Indexed: 11/17/2022]
Abstract
Kounis syndrome (KS) is a coronary syndrome in the setting of allergic/anaphylactic reactions and can be classified in three variants: vasospastic allergic angina (type I), allergic myocardial infarction (type II) and stent thrombosis (type III). The early diagnosis is of paramount importance for the correct management and the prognosis, being KS a life-threatening emergency condition. KS is not uncommon, but it is frequently unrecognized or undiagnosed in virtue of its broad clinical manifestations. The diagnosis should be based on the combination of cardiovascular and allergic/anaphylactic clinical symptoms and signs, as well as on laboratory, electrocardiographic, echocardiographic, and angiographic evidence. ECG monitoring, cardiac enzymes and troponin are mandatory to confirm or exclude KS in a patient with subclinical or clinical, acute, or chronic allergic reactions. Nevertheless, the treatment is a real challenge for the emergency clinicians because guidelines have not been established yet, and the therapy is based on the variant type. We herein report the case of type I KS in a woman with no prior history of allergy, admitted to our emergency department for abdominal pain, nausea and hematochezia. Starting from this case we conducted a systematic search of the following databases: PubMed, Google Scholar, Science Direct, Medline, using the keywords of “Kounis syndrome”, “coronary spams”, “cardiac arrest”, “sudden death”, “allergy”, and “anaphylaxis”. The main purpose of this review is to remind emergency clinicians to keep a high index of suspicion regarding KS when dealing with patients with allergic reactions or anaphylaxis to promptly identify and correctly manage KS. (www.actabiomedica.it)
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Affiliation(s)
- Erika Poggiali
- Emergency Department, “Guglielmo da Saliceto” Hospital, Piacenza, Italy
| | - Irene Benedetti
- Emergency Department, “Guglielmo da Saliceto” Hospital, Piacenza, Italy
| | - Valeria Vertemati
- Emergency Department, “Guglielmo da Saliceto” Hospital, Piacenza, Italy
| | - Luca Rossi
- Division of Cardiology, Department of Cardiovascular and Emergency, “Guglielmo da Saliceto” Hospital, Piacenza, Italy
| | - Alberto Monello
- Division of Cardiology, Department of Cardiovascular and Emergency, “Guglielmo da Saliceto” Hospital, Piacenza, Italy
| | - Manuela Giovini
- Intermediate Care Unit, Emergency Department, “Guglielmo da Saliceto” Hospital, Piacenza, Italy. * the authors equally contributed to this work
| | | | - Andrea Vercelli
- Emergency Department, “Guglielmo da Saliceto” Hospital, Piacenza, Italy
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Lin Y, Chen Y, Yuan J, Qin H, Dong S, Chen Q. Impact of aspirin use on clinical outcomes in patients with vasospastic angina: a systematic review and meta-analysis. BMJ Open 2021; 11:e048719. [PMID: 34326051 PMCID: PMC8323370 DOI: 10.1136/bmjopen-2021-048719] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES The use of aspirin to prevent cardiovascular disease in vasospastic angina (VSA) patients without significant stenosis has yet to be investigated. This study aimed to investigate the efficacy of aspirin use among VSA patients. DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed, Web of Science and Cochrane Central Register of Controlled Trials were searched for relevant information prior to October 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Aspirin use versus no aspirin use (placebo or no treatment) among VSA patients without significant stenosis. DATA EXTRACTION AND SYNTHESIS Two investigators extracted the study data. ORs and 95% CIs were calculated and graphed as forest plots. The Newcastle-Ottawa Quality Assessment Scale tool and Begg's funnel plot were used to assess risk of bias. RESULTS Four propensity-matched cohorts, one retrospective analysis and one prospective multicentre cohort, in total comprising 3661 patients (aspirin use group, n=1695; no aspirin use group, n=1966) were included in this meta-analysis. Aspirin use and the incidence of major cardiovascular adverse events with follow-up of 1-5 years were not significantly correlated (combined OR=0.90, 95% CI: 0.55 to 1.68, p=0.829, I2=82.2%; subgroup analysis: OR=1.09, 95% CI: 0.81 to 1.47, I2=0%). No significant difference was found between aspirin use and the incidence of myocardial infarction (OR=0.62, 95% CI: 0.09 to 4.36, p=0.615, I2=73.8%) or cardiac death (OR=1.73, 95% CI: 0.61 to 4.94, p=0.444, I2=0%) during follow-up. CONCLUSION Aspirin use may not reduce the risk of future cardiovascular events in VSA patients without significant stenosis. PROSPERO REGISTRATION NUMBER CRD42020214891.
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Affiliation(s)
- Yaowang Lin
- Department of Cardiology, Shenzhen Cardiovascular Minimally Invasive Medical Engineering Technology Research and Development Center, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, First affiliated Hospital of South University of Science and Technology, Shenzhen, China
| | - Yang Chen
- School of Pharmacy, Guangdong Medical University, Dongguan 523808, Guangdong, China
| | - Jie Yuan
- Department of Cardiology, Shenzhen Cardiovascular Minimally Invasive Medical Engineering Technology Research and Development Center, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, First affiliated Hospital of South University of Science and Technology, Shenzhen, China
| | - Haiyan Qin
- Department of Health Management, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, First affiliated Hospital of South University of Science and Technology, Shenzhen, China
| | - Shaohong Dong
- Department of Cardiology, Shenzhen Cardiovascular Minimally Invasive Medical Engineering Technology Research and Development Center, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, First affiliated Hospital of South University of Science and Technology, Shenzhen, China
| | - Qiuling Chen
- Department of Pharmacy, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, First affiliated Hospital of South University of Science and Technology, Shenzhen, China
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Pereira M, Vieitas GL, Freitas AIH, Hunkar KGO. Kounis Syndrome: Case Report in Goiânia/BR. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2021. [DOI: 10.36660/ijcs.20200019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Kounis NG, Koniari I, Tsigkas G, Davlouros P. Humanized Monoclonal Antibodies Against IgE Antibodies as Therapy for IgE-Mediated Coronary Syndromes: Are We There Yet? Can J Cardiol 2020; 36:816-819. [PMID: 32536372 DOI: 10.1016/j.cjca.2020.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 01/12/2020] [Accepted: 01/12/2020] [Indexed: 12/26/2022] Open
Affiliation(s)
- Nicholas G Kounis
- Department of Cardiology, University of Patras Medical School, Rion, Patras, Achaia, Greece.
| | - Ioanna Koniari
- Department of Electrophysiology, University Hospital of Manchester, United Kingdom
| | - Grigorios Tsigkas
- Department of Cardiology, University of Patras Medical School, Rion, Patras, Achaia, Greece
| | - Periklis Davlouros
- Department of Cardiology, University of Patras Medical School, Rion, Patras, Achaia, Greece
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Kounis NG, Koniari I, Velissaris D, Tzanis G, Hahalis G. Kounis Syndrome—not a Single-organ Arterial Disorder but a Multisystem and Multidisciplinary Disease. Balkan Med J 2019; 36:212-221. [PMID: 31198019 PMCID: PMC6636655 DOI: 10.4274/balkanmedj.galenos.2019.2019.5.62] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Coronary symptoms associated with conditions related to mast cell activation and inflammatory cell interactions, such as those involving T-lymphocytes and macrophages, further inducing allergic, hypersensitivity, anaphylactic, or anaphylactic insults, are currently referred to as the Kounis syndrome. Kounis syndrome is caused by inflammatory mediators released during allergic insults, post-inflammatory cell activation, and interactions via multidirectional stimuli. A platelet subset of 20% with high- and low-affinity IgE surface receptors is also involved in this process. Kounis syndrome is not just a single-organ but also a complex multisystem and multi-organ arterial clinical condition; it affects the coronary, mesenteric, and cerebral arteries and is accompanied by allergy–hypersensitivity–anaphylaxis involving the skin, respiratory, and vascular systems in the context of anesthesia, surgery, radiology, oncology, or even dental and psychiatric medicine; further, it has significantly influences both morbidity and mortality. Kounis syndrome might be caused by numerous and continuously increasing causes, with broad clinical symptoms and signs, via multi-organ arterial system involvement, in patients of any age, thereby demonstrating predominant anaphylactic features in terms of a wide spectrum of mast cell-association disorders. Cardiac symptoms, such as chest pain, coronary vasospasm, angina pectoris, myocardial infarction, stent thrombosis, acute cardiac failure, and sudden cardiac death associated with subclinical, clinical, acute, or chronic allergic reactions, constitute the clinical manifestations of this syndrome. Since its first description, a common pathway between allergic and non-allergic coronary events has been demonstrated. The hypothesis is based on the existence of a much higher degree of mast cell degranulation at plaque erosion or rupture sites compared with at the adjacent areas or even more distant segments in post-acute myocardial infarction of non-allergic etiology. Although mast cell activation, differentiation, and mediator release takes days or weeks, the mast cell degranulation may occur just before any acute coronary event, further resulting in coronary artery vasoconstriction and atheromatous plaque rupture. It seems that medications and natural molecules stabilizing the mast cell membrane as well as monoclonal antibodies protecting the mast cell surface can emerge as novel therapeutic modalities for acute coronary and cerebrovascular event prevention.
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Affiliation(s)
- Nicholas G. Kounis
- Department of Cardiology, Patras University School of Medicine, Patras, Greece
| | - Ioanna Koniari
- Electrophysiology and Device Department University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Dimitrios Velissaris
- Department of Internal Medicine, Patras University School of Medicine, Patras, Greece
| | - George Tzanis
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Via Madonna di Genova, Cotignola RA, Italy
| | - George Hahalis
- Department of Cardiology, Patras University School of Medicine, Patras, Greece
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