Three cases of vasospastic angina that developed following the initiation of corticosteroid therapy

A practical guide to the management of immune thrombocytopenia co-existing with acute coronary syndrome

Introduction

Immune thrombocytopenia (ITP) management with co-existing acute coronary syndrome (ACS) remains challenging as it requires a clinically relevant balance between the risk and outcomes of thrombosis and the risk of bleeding. However, the literature evaluating the treatment approaches in this high-risk population is scarce.

Methods and Results

In this review, we aimed to summarize the available literature on the safety of ITP first- and second-line therapies to provide a practical guide on the management of ITP co-existing with ACS. We recommend holding antithrombotic therapy, including antiplatelet agents and anticoagulation, in severe thrombocytopenia with a platelet count < 30 × 109/L and using a single antiplatelet agent when the platelet count falls between 30 and 50 × 109/L. We provide a stepwise approach according to platelet count and response to initial therapy, starting with corticosteroids, with or without intravenous immunoglobulin (IVIG) with a dose limit of 35 g, followed by thrombopoietin receptor agonists (TPO-RAs) to a target platelet count of 200 × 109/L and then rituximab.

Conclusion

Our review may serve as a practical guide for clinicians in the management of ITP co-existing with ACS.

Life-threatening Vasospastic Angina Induced by Carteolol Eye Drops

Vasospastic angina (VSA) can be worsened by oral nonselective beta-blockers. Ophthalmic carteolol eye drops are nonselective beta-blockers and effective against glaucoma and ocular hypertension. Systemic effects of ophthalmic beta-blockers on VSA have not yet been reported. We herein report a case of VSA that developed after a patient started carteolol eye drops for ocular hypertension. Even though benidipine, a calcium channel blocker, was started, a VSA attack with incessant non-sustained ventricular tachycardia occurred. Once the carteolol eyedrops were discontinued, the VSA resolved. This case demonstrates that carteolol eye drops can induce life-threatening VSA.

Drug-Induced Kounis Syndrome: Latest Novelties

Kounis syndrome (KS) is defined by an acute coronary syndrome associated with hypersensitivity reactions, an under-diagnosed life-threatening medical emergency. Although multiple causes have been described, drugs constitute the most frequent cause. The purpose of this review is to update knowledge about drug-induced KS, to give guidelines on the correct diagnosis and treatment. This article reviews the literature on drug-induced KS from the last 5 years. Antibiotics and NSAIDs are the most frequently implicated drugs. In addition, data on pathophysiology, clinical presentation, diagnosis, and management are reviewed in detail. Highlight that there is a great deal of variability in the diagnosis and especially in the treatment of KS. This review provides a valuable selection of practical resources for all stakeholders to support effective care for KS, from a cardiologic and allergologic point of view. Future research should focus on developing validated, evidence-based, and patient-centered tools to improve the management of KS.

Non-ST-Segment Elevation Myocardial Infarction Shortly After Starting Steroid Replacement Therapy in a Patient With Adrenal Insufficiency

Adrenal insufficiency is a rare disorder that results from etiological factors affecting either the hypothalamic-pituitary axis or the adrenal gland itself. Studies have associated an inherently increased risk of cardiovascular events with this condition. It is treated with exogenous steroid supplementation. However, in recent years, there have been an increasing number of reports regarding the potential of steroid therapy to precipitate acute cardiac events. However, this risk is generally assumed to be dose-dependent and could be absent in patients receiving low-dose glucocorticoid treatment. We present a case of a 71-year-old woman who was admitted to our institution with bilateral lower limb swelling. Blood investigation revealed hypoalbuminemia and hyponatremia. Upon further evaluation she was diagnosed to have adrenal insufficiency and was started on hydrocortisone replacement therapy; however, the patient developed non-ST-segment elevation myocardial infarction (NSTEMI) and acute pulmonary edema a few days after starting steroid replacement therapy. Here, we discuss the possible association between hydrocortisone use and the development of acute cardiac events.

Delayed Acute Coronary Syndrome Caused by Multiple Bee Stings: A Rare Case of Kounis Syndrome

A 51-year-old female patient was admitted to our hospital for medical evaluation and treatment of a syncopal episode following multiple bee stings. The syncopal episode was attributed to an allergic reaction and the patient was treated with intravenous hydration and anti-histamines. Twenty-four hours later, the patient manifested an acute coronary syndrome with chest discomfort, electrocardiographic disorders, and myocardial enzyme motility (including troponin). Coronary angiography was performed without revealing pathological findings and she was diagnosed with Kounis syndrome type I. The management of the patient included administration of single antiplatelet therapy combined with a calcium channel blocker (CCB). The patient follow-up was uncomplicated. In patients with Kounis syndrome type I undergoing a normal coronary angiography, in the absence of specific guidelines, single antiplatelet therapy and CCB may be a reasonable approach.

Coronary spastic angina in a multiple myeloma patient treated with bortezomib, lenalidomide, and dexamethasone

Adverse cardiovascular events have been reported in patients with multiple myeloma. We present a case of coronary spastic angina during combination therapy with bortezomib, lenalidomide, and dexamethasone for multiple myeloma. A 70-year-old man, newly diagnosed with multiple myeloma, was admitted to our hospital at his fifth therapy cycle due to exertional chest pain. Coronary angiography revealed diffuse spasm in the left coronary artery, which normalized after intracoronary injection of nitroglycerin. Calcium channel blockers were effective in treating his coronary spastic angina and the patient resumed treatment for multiple myeloma. This case highlights the importance of being aware of the possibility of coronary spastic angina when combination therapy with bortezomib, lenalidomide, and dexamethasone is initiated.

<Learning objective: Combination therapy with bortezomib, lenalidomide, and dexamethasone has improved overall survival of multiple myeloma patients. However, these drugs can induce coronary spastic angina. Calcium channel blockers may be effective for coronary spastic angina and allow patients to continue multiple myeloma treatment.>

Dexamethasone Associated ST Elevation Myocardial Infarction Four Days after an Unremarkable Coronary Angiogram-Another Reason for Cautious Use of Steroids: A Case Report and Review of the Literature

Drug induced myocardial infarction is a known entity with different forms of steroids linked to coronary artery disease (CAD) either through promoting its traditional risk factors, inducing coronary spasm, or by other unidentified mechanisms. Dexamethasone is known to promote an atherogenic and hypercoagulable state. We report a case of a 75-year-old woman who had ST elevation myocardial infarction (STEMI) associated with dexamethasone use just 4 days following an angiogram showing minor luminal irregularities.

Foods, Drugs and Environmental Factors: Novel Kounis Syndrome Offenders

Kounis syndrome is hypersensitivity coronary disorder induced by various types of environmental exposures, drugs, conditions and stents. Allergic, hypersensitivity, anaphylactic and anaphylactoid reactions are associated with this syndrome. The disorder manifests as coronary spasms, acute myocardial infarction and stent thrombosis and affects the cerebral and mesenteric as well as coronary arteries. Importantly, its manifestations are broad and its etiology is continuously increasing. Recently, a variety of unusual etiologies have been reported including Anisakis simplex, scombroid syndrome, the use of Gelofusin or ultrasound contrast agents, kiwifruit, fly bites, and bee stings. Furthermore, losartan and the paradox of corticosteroid allergy have been implicated as possible causes. Although not rare, Kounis syndrome is infrequently diagnosed. Therefore, awareness of its etiology, manifestations and pathophysiology is important for providing the proper diagnosis and treatment and determining prognosis.