Bonsai-induced coronary artery spasm.

To the Editor,

I have read the article by İnci et al. (1) entitled “Bonsai-induced Kounis Syndrome in a young male patient” with great interest, which was published in Anatol J Cardiol 2015, 15: 952-3. The authors presented an unusual form of acute coronary syndrome, which developed following the synthetic cannabinoid “Bonsai” use. I would like highlight some points regarding this article.

Although there are no definite diagnostic criteria to differentiate prinzmetal angina from Kounis syndrome, systemic allergic reactions associated with acute myocardial ischemia in a patient should suggest that the patient has Kounis syndrome (2). Are there any signs and symptoms of systemic allergic reactions such as generalized erythema or urticarial rashes in the patient? Also, after clinical stabilization, additional allergy tests, including skin prick test, may be helpful for diagnosis.

I also would like to highlight a specific point in the treatment of the abovementioned patient. In the cases where type 1 Kounis syndrome progresses to acute myocardial infarction with increased cardiac enzymes and troponins, anti-allergic treatment, including administration of H1 and H2 blockers together with corticosteroids combined with classical treatment of acute coronary syndromes, is recommended (3). Also, in patients with non-ST-elevation acute coronary syndromes, dual antiplatelet therapy with aspirin and clopidogrel has been recommended for 1 year over aspirin alone, irrespective of the revascularization strategy and stent type according to the current guidelines (4). However, the utilization of aspirin is controversial because of the underlying anaphylactic reaction in Kounis syndrome. Acetylsalicylic acid can cause allergic reactions and induce anaphylaxis; therefore, the safety of aspirin use in patients with Kounis syndrome is unknown (5). I would like to kindly ask the authors whether there is any specific reason for the treatment of aspirin in this case?

In conclusion, because the use of synthetic cannabinoid is gradually increasing in our country, rapid diagnosis and appropriate treatment in these patients has great importance because of the complex and complicated course of acute coronary syndromes associated with allergic reactions.