P207 KOUNIS SYNDROME TYPE 2: A COLD CASE

Case Report

A 61–year–old man, smoker and family history of cardiovascular diseases, started oral antibiotic therapy with amoxicillin / clavulanic acid following the appearance of a dental abscess. About 30 minutes after taking the antibiotic, he complained of widespread erythema in the limbs, followed by intense itching and dyspnea. Upon arrival of the medical staff, IV cortisone and antihistamine therapy was performed with gradual and progressive resolution of the symptoms. Despite the doctors’ invitation, the patient refused access to the emergency room for fear of a possible hospital infection with SARS–CoV–2. Almost two months later, due to the onset of exertional dyspnea, he is persuaded to go to the hospital for further tests. The ECG showed signs of diffuse anterolateral necrosis (Figure 1). Echocardiography showed severe left ventricular dysfunction (FE 35%) with extensive akinesia of the mid–distal SIV, apex, and anterior mid–distal wall. Myocardiocytolysis indices were negative and allergy tests positive for beta–lactam antibiotics. Subsequently he underwent coronary angiography which showed proximal occlusion of an intermediate branch (Figure 2) treated with angioplasty and drug stent release. Cardiac MRI was then performed with evidence of a large area of ischemic necrosis (subendocardial / transmural) of the antero–septal, anterior and anterolateral wall with FE 35% (Figure 3).

Comment

Kounis syndrome is a clinical emergency characterized by the appearance of an acute coronary syndrome during an anaphylactic–type reaction. A correct diagnosis is of fundamental importance to limit the extent of myocardial damage as much as possible. In Kounis type 2, the mediators of the allergic reaction can cause not only vasospasm but also the activation of metalloproteases that induce the degradation of collagen with consequent rupture of pre–existing atheromatous plaques, as in our patient. Failure to perform an ECG during first aid leaves doubts about the possible allergic genesis of the episode, which however cannot be excluded with certainty. We have decided to report this clinical case to emphasize the importance of always taking into consideration the possibility of being compared with a case of Kounis when assisting a patient with an anaphylactic type reaction.

P189 DOAC: WHEN DRUG INTERACTIONS MAKE A DIFFERENCE

Introduction

Direct oral anticoagulants (DOACs), as substrates of cytochrome P450 and / or P–glycoprotein (P–gp), are susceptible to drug–drug interactions (DDI) by both inducers and inhibitors. Awareness of this aspect is essential when choosing a DOAC, to avoid exposing the patient to an increased risk of bleeding or cardioembolicism.

Description

We report the clinical case of a 41–year–old woman with a history of iron deficiency anemia and primary hypertrophic cardiomyopathy (HCM), who came to our emergency room for an episode of atrial fibrillation with high ventricular rate (HR 140 bpm), datable (<48h) and haemodynamically well tolerated. She was therefore subjected to pharmacological cardioversion with amiodarone, which was found to be effective. Subsequently, she was subjected to interrogation of the defibrillator (ICD), of which the patient was a carrier in primary prevention, with the finding of numerous episodes of AF, lasting up to several hours, paucisymptomatic. An antiarrhythmic prophylaxis with amiodarone and anticoagulant therapy with edoxaban was therefore recommended at discharge. In the following two months, in conjunction with the menstrual cycle, the patient had access to emergency room for metrorrhagia with the need for blood transfusion due to severe anemia (Hb 6 gr / dl). The gynecological tests were negative and she was entrusted to the cardiologist for the management of the therapy. Reassessed on an outpatient basis, given the impossibility of changing antiarrhythmic drugs, as amiodarone is the only molecule recommended for rhythm control in patients with this type of cardiomyopathy, and given the possible interaction between edoxaban and amiodarone (+ 40% plasma DOAC levels ), it was decided to shift to another DOAC: rivaroxaban 20 mg (less interference). In the following twelve months the patient no longer had acute anemia phenomena, the hemoglobin values remained stable and upon interrogation of the ICD device there were no arrhythmic events.

Comment

We have described this case to underline how the possible pharmacokinetic interactions between DOACs and antiarrhythmic drugs are of fundamental importance in daily clinical practice, especially when there are non–reversible causes that increase the risk of bleeding. In this case, the therapy shift vs a DOAC with a documented lower DDI interaction was found to be conclusive.

Maximizing the potency of oxaliplatin coated nanoparticles with folic acid for modulating tumor progression in colorectal cancer

One of the challenges of nanotechnology is to improve the efficacy of treatments for diseases, in order to reduce morbidity and mortality rates. Following this line of study, we made a nanoparticle formulation with a small size, uniform surfaces, and a satisfactory encapsulation coefficient as a target for colorectal cancer cells. The results of binding and uptake prove that using the target system with folic acid works: Using this system, cytotoxicity and cell death are increased when compared to using free oxaliplatin. The data show that the system maximized the efficiency of oxaliplatin in modulating tumor progression, increasing apoptosis and decreasing resistance to the drug. Thus, for the first time, our findings suggest that PLGA-PEG-FA increases the antitumor effectiveness of oxaliplatin by functioning as a facilitator of drug delivery in colorectal cancer.