Vasoespasmo coronario en un niño alérgico al látex: síndrome de Kounis / Coronary vasospasm in a child allergic to latex: Kounis syndrome

El síndrome de Kounis consiste en la aparición simultánea de anafilaxia y síndrome coronario agudo. Se trata de una entidad poco descrita y que puede estar infradiagnosticada en pediatría. Es crucial, por su presentación variable, atípica e inesperada, y por sus posibles complicaciones graves (arritmias ventriculares, infarto de miocardio, muerte súbita), su reconocimiento y tratamiento precoz, dirigido a la revascularización del miocardio y al tratamiento de la reacción anafiláctica concomitante. Se presenta el caso de un varón de 11 años que, tras el contacto con látex, presentó una reacción anafiláctica asociada a vasoespasmo coronario, con recuperación rápida y completa con la administración de adrenalina intramuscular. El estudio cardiológico descartó patología coronaria como causa del evento. El estudio alergológico puso de manifiesto un síndrome de reactividad cruzada látex-frutas (kiwi y piña). Se diagnosticó síndrome de Kounis tipo i desencadenado por látex, y se recomendó evitar posibles factores desencadenantes.

Kounis syndrome consists of the simultaneous occurrence of anaphylaxis and acute coronary syndrome. It is a rare entity that may be underdiagnosed in paediatrics. The clinical presentation is variable, atypical and usually unexpected, and it carries possible serious complications such as ventricular arrhythmias, myocardial infarction and sudden death. Therefore, an early diagnosis and treatment for myocardial revascularization and the anaphylactic reaction are crucial. We report the case of an 11-year-old male who, after contact with latex, presented an anaphylactic reaction associated with coronary vasospasm, with rapid and complete recovery after administration of intramuscular adrenaline. The cardiological study ruled out coronary pathology as the cause of the event. The allergy study revealed a latex-fruit (kiwi and pineapple) cross-reactivity syndrome. The patient was diagnosed with type I Kounis syndrome triggered by latex, recommending the avoidance of possible triggers.

Position article and guidelines 2018 recommendations of the Brazilian Society of Rheumatology for the indication, interpretation and performance of nailfold capillaroscopy

Abstract Nailfold capillaroscopy (NFC) is a reproducible, simple, low-cost, and safe imaging technique used for morphological analysis of nail bed capillaries. It is considered to be extremely useful for the investigation of Raynaud's phenomenon and for the early diagnosis of systemic sclerosis (SSc). The capillaroscopic pattern typically associated with SSc, scleroderma ("SD") pattern, is characterized by dilated capillaries, microhemorrhages, avascular areas and/or capillary loss, and distortion of the capillary architecture. The aim of these recommendations is to provide orientation regarding the relevance of NFC, and to establish a consensus on the indications, nomenclature, the interpretation of NFC findings and the technical equipments that should be used. These recommendations were formulated based on a systematic literature review of studies included in the database MEDLINE (PubMed) without any time restriction.

Vasodilatory efficacy and impact of papaverine on endothelium in radial artery predilatation for cabg surgery: in search for optimal concentration

Abstract Objective: The aim of this study was to compare the efficacy of two different papaverine concentrations (0.5 mg/ml and 2 mg/ml) for vasospasm prevention and their impact on endothelium integrity. Methods: We have studied distal segments of radial arteries obtained by no-touch technique from coronary artery bypass graft (CABG) patients (n=10). The vasodilatory effect of papaverine (concentrations of 0.5 mg/ml and 2 mg/ml) was assessed in vitro, in isometric tension studies using ex vivo myography (organ bath technique) and arterial rings precontracted with potassium chloride (KCl) and phenylephrine. The impact of papaverine on endothelial integrity was studied by measurement of the percentage of vessel's circumference revealing CD34 endothelial marker. Results: 2 mg/ml papaverine concentration showed stronger vasodilatatory effect than 0.5 mg/ml, but it caused significantly higher endothelial damage. Response to KCl was 7.35±3.33 mN for vessels protected with papaverine 0.5 mg/ml and 2.66±1.96 mN when papaverine in concentration of 2 mg/ml was used. The histological examination revealed a significant difference in the presence of undamaged endothelium between vessels incubated in papaverine 0.5 mg/ml (72.86±9.3%) and 2 mg/ml (50.23±13.42%), P=0.002. Conclusion: Papaverine 2 mg/ml caused the higher endothelial damage. Concentration of 0.5 mg/ml caused better preservation of the endothelial lining.

Ergonovine Stress Echocardiography for the Diagnosis of Vasospastic Angina and Its Prognostic Implications in 3,094 Consecutive Patients

BACKGROUND AND OBJECTIVES: Ergonovine stress echocardiography (ErgECHO) has been proposed as a noninvasive tool for the diagnosis of coronary vasospasm. However, concern over the safety of ErgECHO remains. This study was undertaken to investigate the safety and prognostic value of ErgECHO in a large population. METHODS: We studied 3,094 consecutive patients from a single-center registry who underwent ErgECHO from November 2002 to June 2009. Medical records, echocardiographic data, and laboratory findings obtained from follow-up periods were analyzed. RESULTS: The overall positive rate of ErgECHO was 8.6%. No procedure-related mortality or myocardial infarction (MI) occurred. Nineteen patients (0.6%) had transient symptomatic complications during ErgECHO including one who was successfully resuscitated. Cumulative major adverse cardiac events (MACEs) occurred in 14.0% and 5.1% of the patients with positive and negative ErgECHO results, respectively (p 220 mg/dL, and positive ErgECHO result itself were independent factors associated with MACEs. CONCLUSIONS: ErgECHO can be performed safely by experienced physicians and its positive result may be an independent risk factor for long-term adverse outcomes. It may also be an alternative tool to invasive ergonovine-provoked coronary angiography for the diagnosis of vasospastic angina.

Coronary artery spasm as the probable cause of cardiac arrest immediately after the induction of spinal anesthesia: A case report

A 72-year-old man underwent spinal anesthesia for artificial urinary sphincter placement for urinary incontinence. After the block level was confirmed below T6, 1 g of cefotetan, which had not shown any reaction on skin test, was administered as a prophylactic antibiotic. The patient began complaining of chest discomfort and dyspnea shortly after injection. ST elevation appeared on the electrocardiogram and the patient's pulse could not be palpated. Accordingly, cardiopulmonary resuscitation was performed for 5 minutes; the patient recovered spontaneous circulation. The patient was diagnosed as experienced coronary artery spasm by coronary angiography with spasm test. Because coronary artery spasm can also develop in patients with no history of coronary artery disease and under spinal anesthesia, careful observation, suspicion of coronary artery spasm and prompt response to hemodynamic and electrocardiogram changes are necessary.

Multi-vessel intractable coronary spasm development in a patient with aborted sudden cardiac death: a case study with intravascular ultrasound findings / 영남의대학술지

Coronary spasm generally occurs in patients with minimal atherosclerotic plaque lesion, and it has a rather favorable prognosis. However, in some cases, coronary spasm may induce myocardial infarction and even sudden cardiac death (SCD). Here, we report a case in which multi-vessel intractable coronary vasospasm suddenly occurred in a diffuse atherosclerotic lesion after percutaneous coronary intervention (PCI) in a patient with aborted SCD. We identified the characteristics of the spasm portion in intravascular ultrasound (IVUS) images and conducted percutaneous cardiopulmonary bypass support-PCI with stenting as treatment. Intima and media thickening and a large attenuated plaque burden with rupture were identified in IVUS images at the obstructive spasm portion.

Coronary Artery Vasospasm

Coronary artery vasospasm (CVS) is an important mechanism of myocardial ischemia and produces any of the manifestations of coronary artery disease from silent myocardial ischemia, to effort-induced angina and variant angina, to acute coronary syndrome including myocardial infarction or sudden cardiac death. The pathogenesis, characteristic clinical features, diagnosis, and treatment of CVS are summarized. Emphasis is placed on correct diagnosis of CVS using pharmacological spasm provocation test, either during coronary angiography or with echocardiographic monitoring of ventricular wall motion. Current underutilization of pharmacologic provocative test at the time of coronary angiography cannot be justified, as there is no evidence supporting that the incidence of CVS is declining. Physicians' vigilance for objective documentation of CVS is necessary for appropriate management of patients with various clinical presentations of ischemic heart disease.

Miocardiopatía adrenérgica por discinesia apical transitoria como forma de presentación de feocromocitoma / Adrenergic cardiomyopathy by transient apical dyskinesia as a form of presentation of pheochromocytoma

La cardiomiopatia adrenérgica o síndrome de tako-tsubo o discinesia apical transitoria está caracterizada por una excesiva estimulación simpática, que induce a un vasoespasmo coronario, todo de carácter transitorio con recuperación de la contractilidad hasta la normalidad en las semanas posteriores al evento. Reportamos el caso de una paciente de 37 años que presentó sintomatología de síndrome coronario agudo, electrocardiogramas con ondas T negativas en cara anterior, elevación de enzimas cardíacas, severa discinesia apical transitoria, coronarias angiográficamente normales; el dosaje de catecolaminas urinarias elevadas motivo una resonancia magnética nuclear de abdomen que mostró una masa adrenal izquierda en el contexto clínico de un feocromocitoma.

Adrenergic cardiomyopathy or tako-tsubo syndrome or transient apical dyskinesia or apical ballooning is characterized by excessive sympathetic stimulation, which induces coronary vasospasm, all of a transient nature with recovery of contractility to normality in the weeks after the event. We present the case of a 37-year-old female patient presenting with acute coronary syndrome, electrocardiograms with negative T-waves on the anterior face, elevated cardiac enzymes, severe transient apical dyskinesia, angiographically normal coronary arteries. Elevated urinary catecholamine dosage resulted in an abdominal magnetic resonance imaging that showed a left adrenal mass in the clinical setting of a pheochromocytoma.

A cardiomiopatia adrenérgica por síndrome de tako-tsubo ou discinesia apical transitória é caracterizada por estimulação simpática excessiva que induz um vasoespasmo coronário, de natureza transitória com recuperação da função ventricular esquerda até a normalidade nas semanas após o evento. Apresentamos o caso de uma paciente de 37 anos de idade apresentava sintomas de uma síndrome coronária aguda, electrocardiogramas com ondas T negativas na face anterior, elevação das enzimas cardíacas, severa discinesia apical transitória, artérias coronárias angiograficamente normais. O dosagem da catecolaminas urinárias elevadas motivou a realização de uma de ressonância magnética nuclear do abdômen que mostrou uma massa adrenal esquerda no cenário clínico de um feocromocitoma.

Can documented coronary vasospasm be the smoking gun in settling the etiology of sudden cardiac death?

No abstract available.

Masked inherited primary arrhythmia syndromes in sudden cardiac death patients accompanied by coronary vasospasm

BACKGROUND/AIMS: Coronary vasospasms are one of the important causes of sudden cardiac death (SCD). Provocation of coronary vasospasms can be useful, though some results may lead to false positives, with patients potentially experiencing recurrent SCD despite appropriate medical treatments. We hypothesized that it is not coronary vasospasms but inherited primary arrhythmia syndromes (IPAS) that underlie the development of SCD. METHODS: We analyzed 74 consecutive patients (3.8%) who survived out-of-hospital cardiac arrest among 1,986 patients who had angiographically proven coronary vasospasms. Electrical abnormalities were evaluated in serial follow-up electrocardiograms (ECGs) during and after the index event for a 3.9 years median follow-up. Major clinical events were defined as the composite of death and recurrent SCD events. RESULTS: Forty five patients (60.8%) displayed electrocardiographic abnormalities suggesting IPAS: Brugada type patterns in six (8.2%), arrhythmogenic right ventricular dysplasia patterns in three (4.1%), long QT syndrome pattern in one (2.2%), and early repolarization in 38 (51.4%). Patients having major clinical events showed more frequent Brugada type patterns, early repolarization, and more diffuse multivessel coronary vasospasms. Brugada type pattern ECGs (adjusted hazard ratio [HR], 4.22; 95% confidence interval [CI], 1.16 to 15.99; p = 0.034), and early repolarization (HR, 2.97; 95% CI, 1.09 to 8.10; p = 0.034) were ultimately associated with an increased risk of mortality. CONCLUSIONS: Even though a number of aborted SCD survivors have coronary vasospasms, some also have IPAS, which has the potential to cause SCD. Therefore, meticulous evaluations and follow-ups for IPAS are required in those patients.

Impact of Diltiazem Alone versus Diltiazem with Nitrate on Five-Year Clinical Outcomes in Patients with Significant Coronary Artery Spasm

PURPOSE: Calcium channel blockers diltiazem and nitrate have been used as selective coronary vasodilators for patients with significant coronary artery spasm (CAS). However, no study has compared the efficacy of diltiazem alone versus diltiazem with nitrate for long-term clinical outcomes in patients with CAS. MATERIALS AND METHODS: A total of 2741 consecutive patients without significant coronary artery disease with positive CAS by acetylcholine (Ach) provocation test between November 2004 and May 2014 were enrolled. Significant CAS was defined as a narrowing of >70% by incremental intracoronary injection of 20, 50, and 100 µg of Ach into the left coronary artery. Patients were assigned to either the diltiazem group (n=842) or the dual group (diltiazem with nitrate, n=1899) at physician discretion. To adjust for potential confounders, a propensity score matching (PSM) analysis was performed using the logistic regression model. After PSM analysis, two well-balanced groups (811 pairs, n=1622, C-statistic=0.708) were generated. RESULTS: At 5 years, there were similar incidences in primary endpoints, including mortality, myocardial infarction, revascularization, and recurrent angina requiring repeat coronary angiography between the two groups. Diltiazem alone was not an independent predictor for major adverse cardiovascular events or recurrent angina requiring repeat coronary angiography. CONCLUSION: Despite the expected improvement of endothelial function and the relief of CAS, the combination of diltiazem and nitrate treatment was not superior to diltiazem alone in reducing mortality and cardiovascular events up to 5 years in patients with significant CAS.

Cardiac complications in a metamizole-induced type I Kounis syndrome / Complicações cardíacas em síndrome de Kounis tipo I induzida por metamizol

ABSTRACT Kounis syndrome is defined as the coincidental occurrence of allergic reaction and acute coronary syndrome secondary to vasospasm. Anti-inflammatory drugs are included as one of the multiple causes. Current data available about this syndrome come from case reports. We present the case of a patient who suffered Kounis syndrome with cardiogenic shock and asystole after intravenous infusion of Metamizole, and in which no lesions were observed in coronariography.

RESUMO A síndrome de Kounis é definida como a ocorrência concomitante de reação alérgica e síndrome coronariana aguda secundária ao vasoespasmo. Os medicamentos anti-inflamatórios estão incluídos como uma das múltiplas causas. Os dados atuais disponíveis sobre essa síndrome são provenientes de relatos de caso. Relatamos o caso de um paciente que apresentou síndrome de Kounis com choque cardiogênico e assistolia após infusão intravenosa de metamizol e no qual não foram observadas lesões na coronariografia.

Ventricular Tachycardia Associated Syncope in a Patient of Variant Angina without Chest Pain

A 68-year-old man was admitted for a syncope workup. After routine evaluation, he was diagnosed with syncope of an unknown cause and was discharged from the hospital. He was readmitted due to dizziness. On repeated Holter monitoring, polymorphic ventricular tachycardia was detected during syncope. We performed intracoronary ergonovine provocation test; severe coronary spasm was induced at 70% stenosis of the proximal left anterior descending artery. The patient was treated with percutaneous coronary intervention. We present a rare case of syncope induced by ventricular arrhythmia in a patient with variant angina without chest pain.

Ventricular Tachycardia Associated Syncope in a Patient of Variant Angina without Chest Pain

A 68-year-old man was admitted for a syncope workup. After routine evaluation, he was diagnosed with syncope of an unknown cause and was discharged from the hospital. He was readmitted due to dizziness. On repeated Holter monitoring, polymorphic ventricular tachycardia was detected during syncope. We performed intracoronary ergonovine provocation test; severe coronary spasm was induced at 70% stenosis of the proximal left anterior descending artery. The patient was treated with percutaneous coronary intervention. We present a rare case of syncope induced by ventricular arrhythmia in a patient with variant angina without chest pain.

Association between the Red Cell Distribution Width and Vasospastic Angina in Korean Patients

PURPOSE: The association between the red cell distribution width (RDW) and vasospastic angina (VSA) has not been elucidated. We investigated the association of the RDW with the incidence and angiographic subtypes of VSA in Korean patients. MATERIALS AND METHODS: A total of 460 patients who underwent intracoronary ergonovine provocation tests were consecutively enrolled and classified into two groups: the VSA group (n=147, 32.0%) and non-VSA group (n=313, 68.0%). The subjects were classified into 3 subgroups (tertiles) according to the baseline level of RDW assessed before the angiographic provocation test. RESULTS: The VSA group had a higher RDW than the non-VSA group (12.9±0.8% vs. 12.5±0.7%, p=0.013). The high RDW level demonstrated an independent association with the high incidence of VSA [second tertile: hazard ratio (HR) 1.96 (1.13-2.83), third tertile: HR 2.33 (1.22-3.47), all p<0.001]. Moreover, the highest RDW tertile level had a significant association with the prevalence of the mixed-type coronary spasm [HR 1.29 (1.03-1.59), p=0.037]. CONCLUSION: The high level of RDW was significantly associated with the prevalence of VSA and the high-risk angiographic subtype of coronary spasm, suggesting that a proactive clinical investigation for VSA could be valuable in Korean patients with an elevated RDW.

Recurrent Cardiac Arrest during a Nontransplant Operation Due to Variant Angina in a Liver Transplantation Patient / 대한이식학회지

We report a case of recurrent cardiac arrest during a nontransplant operation in a liver transplant recipient with prior cardiac arrest during liver transplantation. A 45-year-old man who experienced cardiac arrest for 17 minutes during the preanhepatic phase of liver transplantation–which was performed 34 months ago–did not survive the recurrent cardiac arrest during portal venoplasty. Variant angina was not suspected for the first cardiac arrest; however, myocardial infarction by coronary vasospasm was revealed to be the cause of the second cardiac arrest.