Lieberman P, Simons F E R
Departments of Internal Medicine and Pediatrics (Divisions of Allergy and Immunology), University of Tennessee College of Medicine, Germantown, TN, USA.
Department of Pediatrics and Child Health and Department of Immunology, Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada.
Clin Exp Allergy. 2015 Aug;45(8):1288-95. doi: 10.1111/cea.12520.
Cardiovascular disease (CVD) increases the risk of severe or fatal anaphylaxis, and some medications for CVD treatment can exacerbate anaphylaxis. The aim of this article is to review the effect of anaphylaxis on the heart, the potential impact of medications for CVD on anaphylaxis and anaphylaxis treatment, and the cardiovascular effects of epinephrine. The therapeutic dilemmas arising from these issues are also discussed and management strategies proposed. PubMed searches were performed for the years 1990-2014 inclusive, using terms such as angiotensin-converting enzyme (ACE) inhibitors, adrenaline, allergic myocardial infarction, anaphylaxis, angiotensin-receptor blockers (ARBs), beta-adrenergic blockers, epinephrine, and Kounis syndrome. Literature analysis indicated that: cardiac mast cells are key constituents of atherosclerotic plaques; mast cell mediators play an important role in acute coronary syndrome (ACS); patients with CVD are at increased risk of developing severe or fatal anaphylaxis; and medications for CVD treatment, including beta-adrenergic blockers and ACE inhibitors, potentially exacerbate anaphylaxis or make it more difficult to treat. Epinephrine increases myocardial contractility, decreases the duration of systole relative to diastole, and enhances coronary blood flow. Its transient adverse effects include pallor, tremor, anxiety, and palpitations. Serious adverse effects (including ventricular arrhythmias and hypertension) are rare, and are significantly more likely after intravenous injection than after intramuscular injection. Epinephrine is life-saving in anaphylaxis; second-line medications (including antihistamines and glucocorticoids) are not. In CVD patients (especially those with ACS), the decision to administer epinephrine for anaphylaxis can be difficult, and its benefits and potential harms need to be carefully considered. Concerns about potential adverse effects need to be weighed against concerns about possible death from untreated anaphylaxis, but there is no absolute contraindication to epinephrine injection in anaphylaxis.
心血管疾病（CVD）会增加严重或致命性过敏反应的风险，一些用于治疗CVD的药物可能会加重过敏反应。本文旨在综述过敏反应对心脏的影响、用于治疗CVD的药物对过敏反应及其治疗的潜在影响，以及肾上腺素的心血管效应。还讨论了由这些问题引发的治疗困境并提出了管理策略。我们在PubMed上检索了1990年至2014年（含）期间的文献，使用了诸如血管紧张素转换酶（ACE）抑制剂、肾上腺素、过敏性心肌梗死、过敏反应、血管紧张素受体阻滞剂（ARB）、β-肾上腺素能阻滞剂、肾上腺素和库尼斯综合征等术语。文献分析表明：心脏肥大细胞是动脉粥样硬化斑块的关键组成部分；肥大细胞介质在急性冠状动脉综合征（ACS）中起重要作用；患有CVD的患者发生严重或致命性过敏反应的风险增加；用于治疗CVD的药物，包括β-肾上腺素能阻滞剂和ACE抑制剂，可能会加重过敏反应或使其更难治疗。肾上腺素可增加心肌收缩力，相对于舒张期缩短收缩期持续时间，并增强冠状动脉血流。其短暂的不良反应包括面色苍白、震颤、焦虑和心悸。严重不良反应（包括室性心律失常和高血压）很少见，静脉注射后比肌肉注射后更易发生。肾上腺素在过敏反应中可挽救生命；二线药物（包括抗组胺药和糖皮质激素）则不然。对于CVD患者（尤其是ACS患者），决定是否使用肾上腺素治疗过敏反应可能很困难，需要仔细考虑其益处和潜在危害。对潜在不良反应的担忧需要与未治疗的过敏反应可能导致死亡的担忧相权衡，但在过敏反应中注射肾上腺素没有绝对禁忌证。
