American Journal of Emergency Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Correspondence
A forgotten cause of acute coronary syndrome: Allergic myocardial infarction To the Editor, We have read with great interest the article by Ohlow et al [1] on “Acute coronary syndrome without critical epicardial coronary disease: prevalence, characteristics, and outcome” recently published in The American Journal of Emergency Medicine [1]. The authors described the outcome of patients with acute coronary syndrome without coronary stenosis and compared those with a consecutive series of patients with acute coronary syndrome requiring percutaneous coronary intervention. They found that 6% of patients with acute onset of chest pain and elevated markers of myocardial necrosis did not show significant coronary stenosis at angiography. Although a variety of diseases is described as the causes of the chest pain in the present study, we want to remind a forgotten cause of chest pain without coronary stenosis. Kounis syndrome (allergic angina or allergic myocardial infarction) is the coincidental occurrence of chest pain and allergic reactions accompanied by clinical and laboratory findings of classical angina pectoris caused by inflammatory mediators released during an allergic insult [2]. There are several factors that have been reported as capable of inducing Kounis syndrome such as several drugs, foods, insect stings, and other. The mechanism of Kounis syndrome is coronary artery spasm because of mast cells degranulation and the subsequent release of vasoactive mediators [2]. Three variants of Kounis syndrome have been described [3]. Type I occurs in patients with angiographically normal coronary arteries, and type II occurs in patients in whom concomitant atheromatous lesions are found. Type III variant includes patients with coronary artery stent thrombosis in whom aspirated thrombus specimens stained with hematoxylin-eosin and Giemsa demonstrate the presence of eosinophils and mast cells. The catheterization laboratory prevalence of Kounis syndrome is estimated as 0.002% [2]. Although nearly 400 cases with Kounis syndrome have been reported in the literature, we think that many of the cases are misdiagnosed or unreported [4,5]. We want to emphasize that emergency physicians should be aware of the allergic myocardial infarction. The diagnosis of this unique disease should be entertained when acute-onset chest pain is accompanied by allergic
symptoms, electrocardiographic changes, and elevated cardiac enzymes. All patients admitted to the emergency departments with chest pain and ST elevation on electrocardiography should be interrogated for allergic insults. Birdal Yildirim MD Department of Emergency Medicine, Faculty of Medicine Muğla Sıtkı Koçman University, Muğla, Turkey Corresponding author. Muğla Sıtkı Koçman Üniversitesi Tıp Fakültesi Orhaniye Mah. Haluk Özsoy Cad., 48000, Muğla, Turkey Tel.: +90 252 2115210 E-mail address: [email protected] Ibrahim Altun MD Volkan Dogan MD Mustafa Ozcan Soylu MD Murat Biteker MD Department of Cardiology, Faculty of Medicine Muğla Sıtkı Koçman University, Muğla, Turkey
http://dx.doi.org/10.1016/j.ajem.2015.04.060
References [1] Ohlow MA, Wong V, Brunelli M, von Korn H, Farah A, Memisevic N, et al. Acute coronary syndrome without critical epicardial coronary disease: prevalence, characteristics, and outcome. Am J Emerg Med 2015;33(2):150–4. [2] Biteker M. Current understanding of Kounis syndrome. Expert Rev Clin Immunol 2010;6(5):777–88. [3] Biteker M. A new classification of Kounis syndrome. Int J Cardiol 2010;145(3):553. [4] Biteker M, Duran NE, Biteker FS, Gündüz S, Gökdeniz T, Kaya H, et al. Kounis syndrome secondary to cefuroxime-axetil use in an octogenarian. J Am Geriatr Soc 2008;56(9):1757–8. [5] Biteker M, Duran NE, Biteker F, Civan HA, Gündüz S, Gökdeniz T, et al. Kounis syndrome: first series in Turkish patients. Anadolu Kardiyol Derg 2009;9(1):59–60.
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Yildirim B, et al, A forgotten cause of acute coronary syndrome: Allergic myocardial infarction, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.060
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Correspondence
A forgotten cause of acute coronary syndrome: Allergic myocardial infarction To the Editor, We have read with great interest the article by Ohlow et al [1] on “Acute coronary syndrome without critical epicardial coronary disease: prevalence, characteristics, and outcome” recently published in The American Journal of Emergency Medicine [1]. The authors described the outcome of patients with acute coronary syndrome without coronary stenosis and compared those with a consecutive series of patients with acute coronary syndrome requiring percutaneous coronary intervention. They found that 6% of patients with acute onset of chest pain and elevated markers of myocardial necrosis did not show significant coronary stenosis at angiography. Although a variety of diseases is described as the causes of the chest pain in the present study, we want to remind a forgotten cause of chest pain without coronary stenosis. Kounis syndrome (allergic angina or allergic myocardial infarction) is the coincidental occurrence of chest pain and allergic reactions accompanied by clinical and laboratory findings of classical angina pectoris caused by inflammatory mediators released during an allergic insult [2]. There are several factors that have been reported as capable of inducing Kounis syndrome such as several drugs, foods, insect stings, and other. The mechanism of Kounis syndrome is coronary artery spasm because of mast cells degranulation and the subsequent release of vasoactive mediators [2]. Three variants of Kounis syndrome have been described [3]. Type I occurs in patients with angiographically normal coronary arteries, and type II occurs in patients in whom concomitant atheromatous lesions are found. Type III variant includes patients with coronary artery stent thrombosis in whom aspirated thrombus specimens stained with hematoxylin-eosin and Giemsa demonstrate the presence of eosinophils and mast cells. The catheterization laboratory prevalence of Kounis syndrome is estimated as 0.002% [2]. Although nearly 400 cases with Kounis syndrome have been reported in the literature, we think that many of the cases are misdiagnosed or unreported [4,5]. We want to emphasize that emergency physicians should be aware of the allergic myocardial infarction. The diagnosis of this unique disease should be entertained when acute-onset chest pain is accompanied by allergic
symptoms, electrocardiographic changes, and elevated cardiac enzymes. All patients admitted to the emergency departments with chest pain and ST elevation on electrocardiography should be interrogated for allergic insults. Birdal Yildirim MD Department of Emergency Medicine, Faculty of Medicine Muğla Sıtkı Koçman University, Muğla, Turkey Corresponding author. Muğla Sıtkı Koçman Üniversitesi Tıp Fakültesi Orhaniye Mah. Haluk Özsoy Cad., 48000, Muğla, Turkey Tel.: +90 252 2115210 E-mail address: [email protected] Ibrahim Altun MD Volkan Dogan MD Mustafa Ozcan Soylu MD Murat Biteker MD Department of Cardiology, Faculty of Medicine Muğla Sıtkı Koçman University, Muğla, Turkey
http://dx.doi.org/10.1016/j.ajem.2015.04.060
References [1] Ohlow MA, Wong V, Brunelli M, von Korn H, Farah A, Memisevic N, et al. Acute coronary syndrome without critical epicardial coronary disease: prevalence, characteristics, and outcome. Am J Emerg Med 2015;33(2):150–4. [2] Biteker M. Current understanding of Kounis syndrome. Expert Rev Clin Immunol 2010;6(5):777–88. [3] Biteker M. A new classification of Kounis syndrome. Int J Cardiol 2010;145(3):553. [4] Biteker M, Duran NE, Biteker FS, Gündüz S, Gökdeniz T, Kaya H, et al. Kounis syndrome secondary to cefuroxime-axetil use in an octogenarian. J Am Geriatr Soc 2008;56(9):1757–8. [5] Biteker M, Duran NE, Biteker F, Civan HA, Gündüz S, Gökdeniz T, et al. Kounis syndrome: first series in Turkish patients. Anadolu Kardiyol Derg 2009;9(1):59–60.
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Yildirim B, et al, A forgotten cause of acute coronary syndrome: Allergic myocardial infarction, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.060
