Kounis Syndrome treatment requires amelioration of both allergic and cardiovascular symptoms.
- Type I KS patients may only need treatment for allergic aspects without ever progressing to heart attack.
- Type II and III KS patients are recommended to follow acute coronary event protocol recommended by ACS.
| Treatment of allergic aspects of Kounis Syndrome | |||
| Drug class | Medication | Dosage | Notes |
| H1 inverse agonist | Diphenhydramine | 1-2 mg/kg
50mg IV is a frequent dosage used for mast cell patients experiencing anaphylaxis symptoms |
Can cause hypotension and decrease blood flow through coronary artery if given bolus; should be given slowly |
| H2 antagonist | Ranitidine | 1 mg/kg | |
| Famotidine | 40mg IV is a frequent dosage used for mast cell patients experiencing anaphylaxis symptoms | ||
| Corticosteroid | Methylprednisolone or other | Methylprednisolone 120 mg IV is a frequent dosage used for mast cell patients experiencing anaphylaxis symptoms | Corticosteroids are not used for immediate effect, but to prevent biphasic reactions.Corticosteroid treatment in active heart attack patients has not been found to be harmful.Corticosteroids were recommended as early as 2008 by Kounis for several reasons: inhibition of eicosanoid synthesis, decreasing amount of prostaglandins, leukotrienes and thromboxanes that can be made; reduction of inflammation by increasing death receptor CD95 on some cells; synthesis of annexins, proteins that modulate inflammatory cells and their actions
|
| Fluid support | IV fluids | Crystalloid normal saline; avoid colloid solution | Use with caution to avoid pulmonary edema |
| Epinephrine | Epinephrine | IM dose: 0.2-0.5mg every 5-15 minutes | Can contribute to myocardial ischemiaCan prolong the QTc interval
Can cause coronary vasospasm and arrhythmias, especially if given IV Glucagon is an alternative in patients for whom epinephrine is inappropriate |
| Treatment of coronary syndrome in Kounis Syndrome | |||
| Drug class | Medication | Dosage | Notes |
| Nitroglycerin | Nitroglycerin | Sublingual: 0.3-0.4 mg every five minutesIV: 5-10mcg/min, increased by 10 mcg/min every 5 minutes | Causes dilation of coronary vesselsIncreases bloodflow to counteract myocardial ischemia |
| Calcium channel blocker | Diltiazem, verapamil | Example ER dosing for verapamil: 80mg orally every eight hours, immediate release | Vasodilators |
| NSAID | Aspirin | 160-325 mg | Prevent clot formation |
| P2Y12 receptor inhibitor | Clopidogrel | 75mg daily | Taken with aspirin to prevent clot formation; some medical bodies recommend P2Y12 inhibitors with aspirin, while others recommend aspirin alone |
| Glycosaminoglycan | Heparin | IV: 5000 IU bolus, followed by infusion of heparin until PTT 1.5-2.5 above normal | Type III patientsHeparin may cause allergic reaction, especially in bolus |
| Opioid | Fentanyl | 1-2 mcg/kg | Drug of choice for pain management, causes small amount of mast cell degranulation, other opiates risk large scale degranulationDoes not affect cardiac output |
| N/A | Stent placement if vessel narrowed by atherosclerosis | N/A | |
Notes:
Beta blockers are contraindicated in Kounis Syndrome for the same reason they are contraindicated in mast cell patients – they block the action of epinephrine, which complicates treatment of anaphylaxis.
IV acetaminophen is generally well tolerated by mast cell patients but is not appropriate for Kounis Syndrome. Acetaminophen reduces cardiac output and systemic vascular resistance which can cause severe low blood pressure and aggravate cardiogenic shock.
References:
Kounis NG, et al. Kounis Syndrome (allergic angina and allergic myocardial infarction). In: Angina Pectoris: Etiology, Pathogenesis and Treatment 2008.
Lippi G, et al. Cardiac troponin I is increased in patients admitted to the emergency department with severe allergic reactions. A case-control study. International Journal of Cardiology 2015, 194: 68-69.
Kounis NG, et al. The heart and coronary arteries as primary target in severe allergic reactions: Cardiac troponins and the Kounis hypersensitivity-associated acute coronary syndrome. International Journal of Cardiology 2015, 198: 83-84.
Fassio F, et al. Kounis syndrome: a concise review with focus on management. European Journal of Internal Medicine 2016; 30:7-10.
Kounis Syndrome: Aspects on pathophysiology and management. European Journal of Internal Medicine 2016.
Kounis NG. Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management. Clin Chem Lab Med 2016
Kounis NG. Coronary hypersensitivity disorder: the Kounis Syndrome. Clinical Therapeutics 2013, 35 (5): 563-571.