Epinephrine can aggravate ischemia and worsen coronary vasospasm
. Thus, sulfite free epinephrine is preferable to be given intramuscularly at doses 0.2-0.5 mg (1:1000).
Acute coronary syndrome secondary to allergic coronary vasospasm
(Kounis syndrome): A case series, follow-up and literature review.
(3,4) Therefore, adrenaline should be used cautiously due to the theoretical risk of worsening coronary vasospasm
and myocardial ischemia through the alpha receptor effect.
described that coronary vasospasm
with thyrotoxicosis presented with a higher incidence of acute myocardial infarction and angiographically had normal coronary arteries and were more spontaneous, diffuse, involving the left main vessel, and medically intractable compared to those without thyrotoxicosis .
The most common electrocardiographic changes are related to repolarization, consequent to the fast progression of ischemia during the coronary vasospasm
. In 50% of the cases, the first change is a high and symmetrical T-wave which is accompanied by a slight increase of the QT interval, while a negative U-wave will sometimes be seen, followed by a gradual increase of the ST segment, its duration being a few minutes; it coincides with the anginal episode, associated as it is with very high R-waves and severely diminished or absent S-waves followed by the normalization of both the T-wave and the ST-segment.
1C--E), without cine wall motion abnormalities at left ventricular angiography; during the procedure, neither coronary vasospasm
nor embolization were documented.
These inflammatory mediators ultimately lead to coronary vasospasm
, increased cardiac contractility and heart rate, increased platelet aggregation, and increased plaque disruption.
Possible mechanisms of myocardial ischemia include imbalance in blood pressure and coronary vasospasm
caused by the combination of sympathetic excitation and release of catecholamines induced by scorpion venom and the direct effect of the toxin on the myocardium .
The other mechanism is myocardial ischemia caused by coronary vasospasm
due to release of vasoactive, inflammatory, and thrombogenic peptides and amine constituents (histamine, serotonin, bradykinin, leukotrienes, and thromboxane) .
Clinical presentation Site of tumor Publication Coronary vasospasm
Liver metastases of [16, 17] unknown origin Carcinoid tumor,  originated from ileum Systemic vasoconstriction Pulmonary NET  Catecholamine producing Ileal NET  GEP NET with diffuse  liver metastases Table 3: Hormone levels in blood and urine.
Comparison of serum levels of inflammatory markers in patients with coronary vasospasm
without significant fixed coronary artery disease versus patients with stable angina pectoris and acute coronary syndromes with significant fixed coronary artery disease.
Khat increases the catecholamine release, heart rate, and blood pressure, and induces coronary vasospasm
. The effect ofkhat on the myocardium could be explained by its vasomotor effect on the coronary vessels; however, its direct effect on the myocardium still needs further elaboration.