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Dr. Mete ALPASLAN
Kounis Syndrome - Hypersensitivity-induced Coronary Syndrome
Definition
Kounis syndrome is defined as the concurrence of acute coronary syndromes with conditions associated
with mast cell activation.
The human heart can be the primary site and the target of anaphylaxis, resulting in the development of
Kounis syndrome.
However, Kounis syndrome is not and should be differentiated from hypersensitivity myocarditis.
There are 3 types of Kounis syndrome
Type 1: Patients with normal or nearly normal coronary arteries without predisposing factors for coronary
artery disease in whom acute allergic attacks can induce either coronary artery spasm alone without raised
cardiac enzymes and troponins or coronary artery spasm leading to acute myocardial infarction with
raised cardiac enzymes and troponins.
Type 2: Patients with culprit but quiescent pre-existing atheromatous disease in whom the acute allergic
attacks can induce either coronary artery spasm, or plaque erosion or rupture manifesting as
acute myocardial infarction.
Type 3: Coincidence of hypersensitivity reactions following implantation of drug eluting stents and stent
thrombosis.
The following ECG findings are seen more frequently in patients with Kounis Syndrome
Sinus bradycardia
Sinus tachycardia
Atrial fibrillation
Nodal rhythm
ST segment depression or elevation
T wave inversion or flattening
QRS widening
Prolonged QT interval
Ventricular arrhythmias (frequent ventricular premature beats,
ventricular bigeminy,
ventricular fibrillation)
References
Future Cardiol 2011;7:805-824.
Can J Cardiol 2002;18:508-511.
Int J Cardiol 2010;145:553.
ECG 1a. The ECG above belongs to a 13 years-old girl and was recorded minutes after an allergic reaction to
Rubella vaccination and 2 hours before sudden death. Sinus tachycardia, low voltage, ST elevation in AVL,
T wave flattening in V5 and T wave negativity in V6 with diminished R wave in V1-V4 leads are observed.
Coronary histology showed infiltration of coronary intima, media and adventitia by numerous eosinophils and mast cells.
Prof. Dr. Nicholas George Kounis has donated the above ECG to our website.
ECG 1b. The ECG above belongs to the same girl and was recorded 1 hour before sudden death. It shows sinus tachycardia,
low voltage, ST flattening in I, ST elevation in AVL, T inversion in V5-V6 with diminished R wave in V1-V3 leads.
Coronary histology showed infiltration of coronary intima, media and adventitia by numerous eosinophils and mast cells.
Prof. Dr. Nicholas George Kounis has donated the above ECG to our website.
ECG 2. The ECG above was recorded from a 33 years-old man who developed ST segment elevation after the use of
beta-lactam antibiotics.
Click here for a more detailed ECG
Figure 2. His coronary angiography next day showed normal coronary arteries.
The ECGs above have been used with the permission of Anatolian Journal of Cardiology and AVES Publishing.
Click here to read the relevant article by Abdullah Ulucay et al.
Kounis syndrome is defined as the concurrence of acute coronary syndromes with conditions associated
with mast cell activation.
The human heart can be the primary site and the target of anaphylaxis, resulting in the development of
Kounis syndrome.
However, Kounis syndrome is not and should be differentiated from hypersensitivity myocarditis.
There are 3 types of Kounis syndrome
Type 1: Patients with normal or nearly normal coronary arteries without predisposing factors for coronary
artery disease in whom acute allergic attacks can induce either coronary artery spasm alone without raised
cardiac enzymes and troponins or coronary artery spasm leading to acute myocardial infarction with
raised cardiac enzymes and troponins.
Type 2: Patients with culprit but quiescent pre-existing atheromatous disease in whom the acute allergic
attacks can induce either coronary artery spasm, or plaque erosion or rupture manifesting as
acute myocardial infarction.
Type 3: Coincidence of hypersensitivity reactions following implantation of drug eluting stents and stent
thrombosis.
The following ECG findings are seen more frequently in patients with Kounis Syndrome
Sinus bradycardia
Sinus tachycardia
Atrial fibrillation
Nodal rhythm
ST segment depression or elevation
T wave inversion or flattening
QRS widening
Prolonged QT interval
Ventricular arrhythmias (frequent ventricular premature beats,
ventricular bigeminy,
ventricular fibrillation)
References
Future Cardiol 2011;7:805-824.
Can J Cardiol 2002;18:508-511.
Int J Cardiol 2010;145:553.
ECG 1a. The ECG above belongs to a 13 years-old girl and was recorded minutes after an allergic reaction to
Rubella vaccination and 2 hours before sudden death. Sinus tachycardia, low voltage, ST elevation in AVL,
T wave flattening in V5 and T wave negativity in V6 with diminished R wave in V1-V4 leads are observed.
Coronary histology showed infiltration of coronary intima, media and adventitia by numerous eosinophils and mast cells.
Prof. Dr. Nicholas George Kounis has donated the above ECG to our website.
ECG 1b. The ECG above belongs to the same girl and was recorded 1 hour before sudden death. It shows sinus tachycardia,
low voltage, ST flattening in I, ST elevation in AVL, T inversion in V5-V6 with diminished R wave in V1-V3 leads.
Coronary histology showed infiltration of coronary intima, media and adventitia by numerous eosinophils and mast cells.
Prof. Dr. Nicholas George Kounis has donated the above ECG to our website.
ECG 2. The ECG above was recorded from a 33 years-old man who developed ST segment elevation after the use of
beta-lactam antibiotics.
Click here for a more detailed ECG
Figure 2. His coronary angiography next day showed normal coronary arteries.
The ECGs above have been used with the permission of Anatolian Journal of Cardiology and AVES Publishing.
Click here to read the relevant article by Abdullah Ulucay et al.