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New classification of Kounis Syndrome
International Journal of Cardiology 247 (2017) 14
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
New classification of Kounis Syndrome Mahmoud Abdelghany ⁎, Siddharth Shah, Rogin Subedi, Hani Kozman Department of Medicine, Division of Cardiology, State University of New York, Upstate Medical University, Syracuse, NY, USA
a r t i c l e
i n f o
Article history: Received 12 June 2017 Accepted 15 June 2017
Bitekar et al. raised an important point. A sub-analysis of our review [1] revealed 3 important facts. First: Kounis Syndrome type-III (KS-III) is far more common with drug eluting stents (DES), but it had also been reported with bare metal stents (BMS) [2]. This can be explained by the allergic reaction to the components of the DES; metal strut, polymer or the eluted drug itself. The associated antiplatelet therapy can also trigger the allergy [3]. Second: The left anterior descending (LAD) artery is the most affected in KS-III. Although the reason is unclear, the more tendency of using DES in the LAD stenosis may contribute to this observation. Third: ST is a more common cause of KS-III than ISR. With DES, the chronic local tissue inflammation may last for months-years and results in late/very late thrombosis. The newer DES avoid nickel and used chromium and cobalt alloy which might decrease the likelihood of allergic reaction [4]. ISR occurs more with BMS possibly secondary to metallic
DOI of original article: http://dx.doi.org/10.1016/j.ijcard.2017.06.002. ⁎ Corresponding author. E-mail address: [email protected] (M. Abdelghany).
http://dx.doi.org/10.1016/j.ijcard.2017.06.061 0167-5273/© 2017 Elsevier B.V. All rights reserved.
allergy causing vessel wall inflammation driving fibroblast growth and smooth muscle cell hyperplasia [5]. ST is serious with mortality rates of 20–40%. Management is achieved with thrombus aspiration and balloon angioplasty with restenting in 30–50% of cases. Although ISR is less serious, 20% of patients present with acute myocardial infarction. Management includes restenting with DES or angioplasty with drug-coated balloons [5]. Thus; it is reasonable to reclassify KS-III into a more common KS-IIIa: Allergic ST and a less common KS-IIIb: Allergic ISR. References [1] M. Abdelghany, R. Subedi, S. Shah, H. Kozman, Kounis syndrome: a review article on epidemiology, diagnostic findings, management and complications of allergic acute coronary syndrome, Int. J. Cardiol. 232 (2017) 1–4. [2] E. Venturini, L. Magni, N.G. Kounis, Amoxicillin-induced Kounis syndrome manifesting as late stent thrombosis, Int. J. Cardiol. 151 (1) (2011) e26–e28. [3] N.G. Kounis, G.N. Kounis, S.N. Kouni, et al., Allergic reactions following implantation of drug-eluting stents: a manifestation of Kounis syndrome? J. Am. Coll. Cardiol. 48 (3) (2006) 592–593. [4] N.G. Kounis, G. Almpanis, A. Mazarakis, Stent thrombosis and Kounis syndrome: who is guilty? J. Cardiovasc. Med. (Hagerstown) 12 (1) (2011) 71–72. [5] R.A. Byrne, M. Joner, A. Kastrati, Stent thrombosis and restenosis: what have we learned and where are we going? The Andreas Grüntzig Lecture ESC 2014, Eur. Heart J. 36 (47) (2015) 3320–3331.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
New classification of Kounis Syndrome Mahmoud Abdelghany ⁎, Siddharth Shah, Rogin Subedi, Hani Kozman Department of Medicine, Division of Cardiology, State University of New York, Upstate Medical University, Syracuse, NY, USA
a r t i c l e
i n f o
Article history: Received 12 June 2017 Accepted 15 June 2017
Bitekar et al. raised an important point. A sub-analysis of our review [1] revealed 3 important facts. First: Kounis Syndrome type-III (KS-III) is far more common with drug eluting stents (DES), but it had also been reported with bare metal stents (BMS) [2]. This can be explained by the allergic reaction to the components of the DES; metal strut, polymer or the eluted drug itself. The associated antiplatelet therapy can also trigger the allergy [3]. Second: The left anterior descending (LAD) artery is the most affected in KS-III. Although the reason is unclear, the more tendency of using DES in the LAD stenosis may contribute to this observation. Third: ST is a more common cause of KS-III than ISR. With DES, the chronic local tissue inflammation may last for months-years and results in late/very late thrombosis. The newer DES avoid nickel and used chromium and cobalt alloy which might decrease the likelihood of allergic reaction [4]. ISR occurs more with BMS possibly secondary to metallic
DOI of original article: http://dx.doi.org/10.1016/j.ijcard.2017.06.002. ⁎ Corresponding author. E-mail address: [email protected] (M. Abdelghany).
http://dx.doi.org/10.1016/j.ijcard.2017.06.061 0167-5273/© 2017 Elsevier B.V. All rights reserved.
allergy causing vessel wall inflammation driving fibroblast growth and smooth muscle cell hyperplasia [5]. ST is serious with mortality rates of 20–40%. Management is achieved with thrombus aspiration and balloon angioplasty with restenting in 30–50% of cases. Although ISR is less serious, 20% of patients present with acute myocardial infarction. Management includes restenting with DES or angioplasty with drug-coated balloons [5]. Thus; it is reasonable to reclassify KS-III into a more common KS-IIIa: Allergic ST and a less common KS-IIIb: Allergic ISR. References [1] M. Abdelghany, R. Subedi, S. Shah, H. Kozman, Kounis syndrome: a review article on epidemiology, diagnostic findings, management and complications of allergic acute coronary syndrome, Int. J. Cardiol. 232 (2017) 1–4. [2] E. Venturini, L. Magni, N.G. Kounis, Amoxicillin-induced Kounis syndrome manifesting as late stent thrombosis, Int. J. Cardiol. 151 (1) (2011) e26–e28. [3] N.G. Kounis, G.N. Kounis, S.N. Kouni, et al., Allergic reactions following implantation of drug-eluting stents: a manifestation of Kounis syndrome? J. Am. Coll. Cardiol. 48 (3) (2006) 592–593. [4] N.G. Kounis, G. Almpanis, A. Mazarakis, Stent thrombosis and Kounis syndrome: who is guilty? J. Cardiovasc. Med. (Hagerstown) 12 (1) (2011) 71–72. [5] R.A. Byrne, M. Joner, A. Kastrati, Stent thrombosis and restenosis: what have we learned and where are we going? The Andreas Grüntzig Lecture ESC 2014, Eur. Heart J. 36 (47) (2015) 3320–3331.