Kounis syndrome
Background
Acute coronary syndromes associated with mast cell activation (anaphylaxis or anaphylactoid reaction). Also known as Coronary hypersensitivity disorder.[1]
Clinical Features
- Stent thrombosis is the main manifestation of Kounis syndrome due to the mast cell infiltration of areas protected by drug-eluting stents[2]
Differential Diagnosis
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Elevated Troponin
True Positive
False (Non-CAD) Positives
- Pericarditis
- Myocarditis
- PE
- CHF
- Sepsis
- Dissection
- Arrhythmias
- CVA
- SAH
- Burns
- Renal failure
- Assume true positive until proven otherwise
- ESRD
- 86% elevated predialysis in troponin-T
- 6% elevated predialysis in troponin-I
- no difference in post-MI troponin-I clearance rate in ESRD vs. normal GFR
- Cardioversion
- Cardiotoxic medications
- Amyloidosis
- Rheumatoid Factor
- Heterophilic antibodies
- Apical ballooning syndrome
- Cardiac procedures (surgery, ablation, pacing, stenting)
- Extreme exertion
Evaluation
Intensity of treatment should be based on ACS likelihood
- ST-Elevation Myocardial Infarction (STEMI)
- Non ST-Elevation Myocardial Infarction (NSTEMI)
- Unstable Angina