Pain Killers May Lead to Heart Failure

Kounis syndrome (KS) also known as allergic angina syndrome is characterized by acute coronary syndromes that are known to be triggered by allergic reactions (Type 1 hypersensitivity reactions) due to certain drug intake as reported in a case report at Japanese College of Cardiology, published in the Journal of Cardiology Cases by Elsevier. Allergic reactions may intensify as a result of drug intake, thereby driving to varied clinical conditions. Several drugs are known to be associated with Kounis syndrome, among which anti-inflammatory, anti-histaminic, and antibiotic drugs are the most frequently responsible agents.

In recent decades, NSAIDs (Non-steroidal anti-inflammatory drugs – commonly used in alleviating pain and inflammation) have been blamed for the development of acute coronary syndromes (ACS – sudden, reduced blood flow to the heart that may cause a heart attack), //referred to as Kounis syndrome. The syndrome was first described in 1991 by Kounis and Zavras.

Although the definite prevalence of the syndrome is not known, it may cause serious life-threatening cardiovascular events. There are two reported variants of this syndrome leading to heart attack, that occur as a result of vasoactive and inflammatory mediators due to hypersensitivity reaction:

• Type 1 – Vasospasm occurring in normal coronary arteries
• Type 2 – Atherosclerotic plaque rupture

Drug-Induced Heart Attack in Kounis Syndrome

The case report demonstrates the event of Type 2 Kounis syndrome that leads to acute anterior myocardial infarction (heart attack) followed by cardiac arrest (heart attack, heart failure). A healthy 49-year-old male was reported to develop the syndrome soon after intramuscular injection of diclofenac sodium.

Diclofenac sodium is a broadly used NSAID that may provoke allergic reactions, including heart failure in the present case. Earlier studies have also mentioned the effects of diclofenac in ACS.

The equivalence between two molecules, thromboxane A2 (vasoconstrictor) and prostacyclin (vasodilator) is essential for the control of normal circulation. As the NSAIDs alter this balance between thromboxane-prostacyclin equilibrium, it causes vasospasm (narrowing of the blood vessels – arteries) followed by the development of small platelet thrombi (blood clot). Thus, the anti-prostacyclin effects are the adverse reaction of NSAIDs.

Another supportive clinical feature apart from the abrupt onset of heart attack in Kounis syndrome is high levels of IgE (immunoglobulins E, a type of antibody)

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The study thereby highlights the incidence of Kounis syndrome due to diclofenac which is higher than reported. It is therefore suggested that the risk of myocardial infarction probability due to allergic reactions of these drugs must be kept in mind when prescribing.

Risks and Side Effects of NSAIDs

The risk factors include:

• People over 65 years old
• Pregnancy/breastfeeding
• Asthma
• Allergic reactions to NSAIDs
• Heart, liver, kidney ailments
• Hypertension and/or diabetes

Side effects include:

• Stomach pain/ stomach ulcers
• Diarrhea
• Headache
• Drowsiness
• Dizziness

References:

1. Kounis syndrome triggered by diclofenac sodium injection which leads to myocardial infarction and cardiac arrest: Caglar EmreCagliyan et al: https://doi.org/10.1016/j.jccase.2013.03.002
2. Interrelationships between prostacyclin and thromboxane A2 - ( https://pubmed.ncbi.nlm.nih.gov/6258879/)
3. Allergic acute coronary syndrome (Kounis syndrome) - ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462222/)
4. Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management - ( https://pubmed.ncbi.nlm.nih.gov/26966931/)

Source-Medindia