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Acute stent thrombosis due to Kounis syndrome
Acute stent thrombosis due to Kounis syndrome Elena Velasco, Elena D´ıaz, Pablo Avanzas, Jos´e M. Rub´ın PII: DOI: Reference:
S0167-5273(14)01866-X doi: 10.1016/j.ijcard.2014.09.146 IJCA 18922
To appear in:
International Journal of Cardiology
Received date: Accepted date:
16 September 2014 27 September 2014
Please cite this article as: Velasco Elena, D´ıaz Elena, Avanzas Pablo, Rub´ın Jos´e M., Acute stent thrombosis due to Kounis syndrome, International Journal of Cardiology (2014), doi: 10.1016/j.ijcard.2014.09.146
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT TITLE: Acute stent thrombosis due to Kounis syndrome. AUTHORS: Elena Velasco1
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Elena Díaz1 Pablo Avanzas1
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José M Rubín1
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1.Hospital Universitario Central de Asturias – Department of Cardiology.
CORRESPONDING AUTHOR.
D
Elena Velasco
MA
Avd. Hospital Central de Asturias sn 33011 Oviedo – Spain.
TE
Hospital Universitario Central de Asturias Email: [email protected]
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Tlf: (0034) 660225828
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Adress: Hospital Universitario Central de Asturias. Department of Cardiology. Avd/ Hospital Central de Asturias sn. 33011 Oviedo. Spain.
ACCEPTED MANUSCRIPT Dear editor, A 66 year old man with no known allergies and medical history of hypertension and
T
hypercolesterolemia correctly treated, was admitted to our hospital complaining of chest
IP
pain. His electrocardiogram (EKG) showed ST elevation in inferior leads (Figure 1A).
SC R
An emergent coronariography showed a critical lesion of the distal right coronary artery (RCA) (Figure 2A) that was considered the culprit lesion, as well as severe stenoses in
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the 1st diagonal branch and the circumflex arteries. Primary angioplasty was performed, and two bare metal stents were implanted in the RCA (Figure 2B). He was evolving
MA
well, until 72 hours after admission, when, while eating a kiwi, he complained of bizarre taste, itching, and shortness of breath. At examination he had tongue and facial
D
swelling, and stridor, all suggestive of angioedema. Oxygen saturation dropped to 94%
TE
and arterial pressure to 80/40. With the suspicion of anaphylactic reaction –probably caused by not known allergy to Kiwi- intravenous corticoids, antihystaminics, i.v. fluids
CE P
and oxygen therapy were administrated, with initial rapid improvement of the symptoms, but new onset of thoracic pain. Serial EKGs showed progressive and
AC
persistent ST elevation in the same leads as at admission (Figure 1C). Emergent coronariography showed thrombosis of the stent implanted in the distal RCA (Figure 2C), and a drug eluting stent was implanted (Figure 2D). A stress echocardiogram performed 5 days after this new event showed inferior wall hypocinesia with preserved ejection fraction, and no inducible ischemia, so no further revascularization was indicated. He was discharged with the usual medication –dual antiplatelet therapy, betablockers, ACE inhibitors, statins and nitrates- and sent to the allergology testing clinic. Allergy to Kiwi was confirmed by specific IgE levels elevated in plasma. The concurrence of an allergic reaction and acute coronary syndrome is known as Kounis syndrome (KS) and was first described in 1991 by Kounis and Zavras. [1]
ACCEPTED MANUSCRIPT The real incidence is not well known and most of the data in the literature comes from case reports and small series. Several different triggers have been described, including
T
drugs (antibiotics, analgesics...), insect stings, venoms (jellyfish, snakes…), systemic
IP
diseases as mastocitoses and food allergies (seafood, kiwi...) [2,3].
SC R
Two groups were initially described. Type I KS, referring to patients with angiographically normal coronary arteries, and type II KS including those with a pre-
NU
existing coronary lesion[1,2]. The proposed physiopathology differs from one form to another. In type I KS, the release of allergic mediators is thought to cause coronary
MA
vasospasm. In type II variant, quiescent atherosclerotic plaques may rupture causing native coronary or stent thrombosis. Mast cells, known to be abundant in the
D
atherosclerotic plaque, would be activated by the allergic insult, releasing histamine and
TE
proteases –tryptase and chimase- among other substances, leading to plaque rupture [2,3]. Also, it has been proposed, that the hemodynamic stress induced by an
CE P
anaphylactic reaction could play a role in type II KS by exacerbating the pre-existing disease [3]. Lately, a type III has been described, comprising patients with late or very
AC
late farmacoactive stent thrombosis [2]. In those patients, an inflammatory reaction developing over a few days or weeks, due to hypersensivity to the compound of nickel alloys, eluted drugs and polymers present in the stent are thought to be the triggers. This theory is supported by the finding of inflammatory infiltrates with eosinophils, macrophages and mast cells within the thrombus obtained in animal models and in patients that have died after late farmacoactive stent thrombosis [4]. Some cases of acute farmacoactive stent thrombosis have been described as well, usually in predisposed patients with history of atopy, asthma or other related conditions [5]. The case we present is consistent with a type II KS. After systematic review of the literature, we have found many case reports of native coronary artery or late stent
ACCEPTED MANUSCRIPT thrombosis, and even a recent publication of a bypass graft occlusion due to an allergic reaction [6], but to our knowledge, this is the first case of an acute bare metal stent
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MA
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SC R
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thrombosis due to KS.
ACCEPTED MANUSCRIPT LEGEND TO FIGURES Figure 1: EKG sequence. A: EKG at admission shows acute inferior wall STEMI. B:
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during anaphylactic reaction. D: EKG at discharge.
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EKG 48h post primary angioplasty, evolving inferior myocardial infarction. C: EKG
Figure 2. A: Critical lesion in distal RCA (arrow). B: RCA after stent implantation. C:
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stent thrombosis (arrow shows the thrombosed stent). D: final result.
ACCEPTED MANUSCRIPT REFERENCES 1. N.G. Kounis, G.M. Zavras, Histamine-induced coronary spasm: the concept of
IP
T
allergic angina, Br J Clin Pract. 45 (1991) 121-128. 2. P. Cepada Rico, E. Palencia Herejon, MM. Rodriguez Agurregabiria MM, Kounis
SC R
síndrome, Med Intensiva. 36 (2012) 358-364.
3. F. Fassio, F. Almerigogna, Kounys syndrome (allergic acute coronary syndrome):
NU
different views in allergologic and cardiologic literature, Intern Emerg Med. 7
MA
(2012) 489-495.
4. N. G. Kounis, S. A. Kounis, Kounis hypersensivity coronary syndrome is associated
D
with presence of older thrombus in patients with late and very late stent
TE
thrombosis, J Cardiol. 60 (2012) 338.
CE P
5. G. Almpanis, A. Mazarakis, G. Tsigkas, C. Koutsojannis, G. N. Kounis, N. G. Kounis, Acute stent thrombosis and athopy: Implicacions for Kounis syndrome, Int J Cardiol. 145 (2010) 398-400.
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6. K. Dazy, D. Walters, C. Holland, J. Baldwin, Anaphylaxis mediated myocardial infarction in a coronary graft: a new variant of Kounis syndrome (a case report). Int J Cardiol 168 (2013) 84-85.
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D
MA
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SC R
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ACCEPTED MANUSCRIPT
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Figure 1
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ACCEPTED MANUSCRIPT
Figure 2
S0167-5273(14)01866-X doi: 10.1016/j.ijcard.2014.09.146 IJCA 18922
To appear in:
International Journal of Cardiology
Received date: Accepted date:
16 September 2014 27 September 2014
Please cite this article as: Velasco Elena, D´ıaz Elena, Avanzas Pablo, Rub´ın Jos´e M., Acute stent thrombosis due to Kounis syndrome, International Journal of Cardiology (2014), doi: 10.1016/j.ijcard.2014.09.146
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT TITLE: Acute stent thrombosis due to Kounis syndrome. AUTHORS: Elena Velasco1
IP
T
Elena Díaz1 Pablo Avanzas1
SC R
José M Rubín1
NU
1.Hospital Universitario Central de Asturias – Department of Cardiology.
CORRESPONDING AUTHOR.
D
Elena Velasco
MA
Avd. Hospital Central de Asturias sn 33011 Oviedo – Spain.
TE
Hospital Universitario Central de Asturias Email: [email protected]
CE P
Tlf: (0034) 660225828
AC
Adress: Hospital Universitario Central de Asturias. Department of Cardiology. Avd/ Hospital Central de Asturias sn. 33011 Oviedo. Spain.
ACCEPTED MANUSCRIPT Dear editor, A 66 year old man with no known allergies and medical history of hypertension and
T
hypercolesterolemia correctly treated, was admitted to our hospital complaining of chest
IP
pain. His electrocardiogram (EKG) showed ST elevation in inferior leads (Figure 1A).
SC R
An emergent coronariography showed a critical lesion of the distal right coronary artery (RCA) (Figure 2A) that was considered the culprit lesion, as well as severe stenoses in
NU
the 1st diagonal branch and the circumflex arteries. Primary angioplasty was performed, and two bare metal stents were implanted in the RCA (Figure 2B). He was evolving
MA
well, until 72 hours after admission, when, while eating a kiwi, he complained of bizarre taste, itching, and shortness of breath. At examination he had tongue and facial
D
swelling, and stridor, all suggestive of angioedema. Oxygen saturation dropped to 94%
TE
and arterial pressure to 80/40. With the suspicion of anaphylactic reaction –probably caused by not known allergy to Kiwi- intravenous corticoids, antihystaminics, i.v. fluids
CE P
and oxygen therapy were administrated, with initial rapid improvement of the symptoms, but new onset of thoracic pain. Serial EKGs showed progressive and
AC
persistent ST elevation in the same leads as at admission (Figure 1C). Emergent coronariography showed thrombosis of the stent implanted in the distal RCA (Figure 2C), and a drug eluting stent was implanted (Figure 2D). A stress echocardiogram performed 5 days after this new event showed inferior wall hypocinesia with preserved ejection fraction, and no inducible ischemia, so no further revascularization was indicated. He was discharged with the usual medication –dual antiplatelet therapy, betablockers, ACE inhibitors, statins and nitrates- and sent to the allergology testing clinic. Allergy to Kiwi was confirmed by specific IgE levels elevated in plasma. The concurrence of an allergic reaction and acute coronary syndrome is known as Kounis syndrome (KS) and was first described in 1991 by Kounis and Zavras. [1]
ACCEPTED MANUSCRIPT The real incidence is not well known and most of the data in the literature comes from case reports and small series. Several different triggers have been described, including
T
drugs (antibiotics, analgesics...), insect stings, venoms (jellyfish, snakes…), systemic
IP
diseases as mastocitoses and food allergies (seafood, kiwi...) [2,3].
SC R
Two groups were initially described. Type I KS, referring to patients with angiographically normal coronary arteries, and type II KS including those with a pre-
NU
existing coronary lesion[1,2]. The proposed physiopathology differs from one form to another. In type I KS, the release of allergic mediators is thought to cause coronary
MA
vasospasm. In type II variant, quiescent atherosclerotic plaques may rupture causing native coronary or stent thrombosis. Mast cells, known to be abundant in the
D
atherosclerotic plaque, would be activated by the allergic insult, releasing histamine and
TE
proteases –tryptase and chimase- among other substances, leading to plaque rupture [2,3]. Also, it has been proposed, that the hemodynamic stress induced by an
CE P
anaphylactic reaction could play a role in type II KS by exacerbating the pre-existing disease [3]. Lately, a type III has been described, comprising patients with late or very
AC
late farmacoactive stent thrombosis [2]. In those patients, an inflammatory reaction developing over a few days or weeks, due to hypersensivity to the compound of nickel alloys, eluted drugs and polymers present in the stent are thought to be the triggers. This theory is supported by the finding of inflammatory infiltrates with eosinophils, macrophages and mast cells within the thrombus obtained in animal models and in patients that have died after late farmacoactive stent thrombosis [4]. Some cases of acute farmacoactive stent thrombosis have been described as well, usually in predisposed patients with history of atopy, asthma or other related conditions [5]. The case we present is consistent with a type II KS. After systematic review of the literature, we have found many case reports of native coronary artery or late stent
ACCEPTED MANUSCRIPT thrombosis, and even a recent publication of a bypass graft occlusion due to an allergic reaction [6], but to our knowledge, this is the first case of an acute bare metal stent
AC
CE P
TE
D
MA
NU
SC R
IP
T
thrombosis due to KS.
ACCEPTED MANUSCRIPT LEGEND TO FIGURES Figure 1: EKG sequence. A: EKG at admission shows acute inferior wall STEMI. B:
IP
SC R
during anaphylactic reaction. D: EKG at discharge.
T
EKG 48h post primary angioplasty, evolving inferior myocardial infarction. C: EKG
Figure 2. A: Critical lesion in distal RCA (arrow). B: RCA after stent implantation. C:
AC
CE P
TE
D
MA
NU
stent thrombosis (arrow shows the thrombosed stent). D: final result.
ACCEPTED MANUSCRIPT REFERENCES 1. N.G. Kounis, G.M. Zavras, Histamine-induced coronary spasm: the concept of
IP
T
allergic angina, Br J Clin Pract. 45 (1991) 121-128. 2. P. Cepada Rico, E. Palencia Herejon, MM. Rodriguez Agurregabiria MM, Kounis
SC R
síndrome, Med Intensiva. 36 (2012) 358-364.
3. F. Fassio, F. Almerigogna, Kounys syndrome (allergic acute coronary syndrome):
NU
different views in allergologic and cardiologic literature, Intern Emerg Med. 7
MA
(2012) 489-495.
4. N. G. Kounis, S. A. Kounis, Kounis hypersensivity coronary syndrome is associated
D
with presence of older thrombus in patients with late and very late stent
TE
thrombosis, J Cardiol. 60 (2012) 338.
CE P
5. G. Almpanis, A. Mazarakis, G. Tsigkas, C. Koutsojannis, G. N. Kounis, N. G. Kounis, Acute stent thrombosis and athopy: Implicacions for Kounis syndrome, Int J Cardiol. 145 (2010) 398-400.
AC
6. K. Dazy, D. Walters, C. Holland, J. Baldwin, Anaphylaxis mediated myocardial infarction in a coronary graft: a new variant of Kounis syndrome (a case report). Int J Cardiol 168 (2013) 84-85.
TE
D
MA
NU
SC R
IP
T
ACCEPTED MANUSCRIPT
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Figure 1
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ACCEPTED MANUSCRIPT
Figure 2