Kounis syndrome

Background

Acute coronary syndromes associated with mast cell activation (anaphylaxis or anaphylactoid reaction). Also known as Coronary hypersensitivity disorder.

Differential Diagnosis

Chest pain

Critical

• Acute coronary syndromes (ACS)
  • STEMI
  • Non-STEMI
  • Unstable angina
• 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

• Occlusive myocardial infarction
  • STEMI
  • NSTEMI

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