Kounis-Zavras syndrome presenting with ventricular arrhythmias and cardiogenic shock

In this case report we describe a case of the Kounis-Zavras syndrome (coincidental occurrence of chest pain and allergic reactions accompanied by clinical and laboratory findings of cardiac ischemia). A 34-year-old woman presented to the emergency unit with severe chest pain from 2 h. She reported a medical history of asthma. On arrival, her heart rate was 125 beats/min and her systolic blood pressure (SBP) was 70 mmHg. A repeated electrocardiogram displayed dynamic changes with ST-segment elevation in D1-aVL leads and ST-segment depression in infero-posterior leads. Two episodes of ventricular fibrillation were observed. The coronary artery angiography showed multivessel coronary vasospasms. Intracoronary nitroglycerin was used to alleviate the coronary vasospasms. Contemporaneously, the patient's husband came to the hospital reporting a history of ketorolac consumption some hours before the onset of the acute event for headache symptoms. This crucial information permitted us to suppose it was a case of allergic myocardial infarction during anaphylactic shock due to ketorolac. Betametasone, chlorphenamine, and ranitidine were administered and progressively a full recovery of SBP and of clinical status was observed. <Learning objective: Allergic myocardial infarction (Kounis-Zavras syndrome) is a complex acute coronary syndrome which requires rapid treatment decisions. Most of the information on this syndrome comes from case reports or small case series. It should be considered in young, healthy patients when they develop acute coronary syndrome after administration of potentially allergic agent. The treatment should both dilate coronary vessels and suppress the allergic reaction (steroids, antihistamines, fluid resuscitation, oxygen, nitrates, calcium channel blockers).>.