STEMI Secondary to Bee Sting. A Case of Allergic Angina

Department

Cardiology

Document Type

Conference Proceeding

Publication Title

Journal of the American College of Cardiology

Conference Name

ACC.21

Conference Date

2021-05-15

Abstract

Background Kounis syndrome (KS) is the concurrence of acute coronary syndromes with conditions associated with mast cell activation

Case A 72-year-old female with past medical history of hypertension and bee sting allergy presented with a syncopal episode after being stung by a bee. She was given epinephrine by a family member (Epi pen-0.3 mg IM). After regaining consciousness, she complained of chest pain radiating to the neck, associated with shortness of breath and diaphoresis. The initial electrocardiogram showed 1 mm horizontal ST elevation (STE) in the inferior leads and diffuse ST depression across the lateral and precordial leads. She was hypotensive on presentation (BP 91/68 mmHg) and initial Troponin I was elevated 0.19 ng/mL (nl= < 0.10)

Decision-making Left heart catheterization showed mild non-obstructive coronary artery disease. Her troponin I trended down. Repeated EKG showed resolution of the STE. The patient's presentation can be explained by type I KS. KS was first reported in the 1950s. Ischemia is thought to be secondary to the degranulation of mast cells with subsequent release of inflammatory mediators. Histamine induces coronary vasoconstriction and activates platelets. Tryptase exerts both thrombotic and fibrinolytic properties. Systemic vasodilation and decreased venous return may lead to a depressed cardiac output. There are 3 described variants: Type I variant: coronary vasospasm in patients with normal coronaries; Type II variant: plaque erosion or rupture in patients with occult atheromatous plaque; and Type III variant: coronary artery stent thrombosis. Management should be directed to stabilize the anaphylactic reaction (IV steroids, H1- and H2-blockers) in addition to ACS protocol (Type II & III). Beta-blockers should be avoided due to potential unopposed alpha action. Epinephrine, which is the drug of choice and may save lives in anaphylaxis, may aggravate ischemia, but usually at higher doses.

Conclusion KS is a syndrome of non-thrombogenic and thrombogenic ACS, caused by environmental exposure to different allergens. Three variants have been described. Management needs to address both cardiac and allergic symptoms simultaneously.

First Page

2533

Volume

77

Issue

11

Publication Date

5-11-2021

Comments

Poster Contributions Saturday, May 15, 2021, 3:45 p.m.-4:30 p.m. Session Title: Complex Clinical Cases: FIT Ischemic Heart Disease 2 Abstract Category: FIT: Ischemic Heart Disease

Link to Full Text

Share

COinS