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Kounis syndrome is a hypersensitivity coronary disorder induced by exposure to several triggers; the most common are antibiotics, followed by insect bites.We reviewed the literature and identified 66 patients who experienced acute coronary syndrome after insect bites.The median age was 51 years, and 19.0% were women and only 12% had a history of allergy. The most involved insects were bee and wasp (86%) and the most frequent clinical manifestations were chest pain and anaphylaxis (36% and 29%, respectively). ST-segment elevation was the most common electrocardiographic finding (70%). There was a not negligible rate of complications (15%), with a possible increased arrhythmic burden in patients without significant coronary atherosclerosis.Acute coronary syndrome after insect bites is not so rare and it could have serious complications, with a possible increased arrhythmic burden in patients without significant coronary atherosclerosis.

A 79-year-old woman was admitted to our coronary care unit for non-ST-elevation myocardial infarction. Urgent left transradial coronary angiography showed mid-distal high-grade stenosis of the left circumflex coronary artery. During percutaneous coronary intervention, stent dislodgement from the balloon catheter occurred. Fortunately, the guidewire was left in place through the detached stent, but a loop snare failed to cross the proximal circumflex artery. A second wire was placed in parallel to the first one and the first wire was caught in the loop snare, which was pulled back and closed at the level of the stent. Then, we cautiously pulled the guiding catheter together with the stent as a whole unit out of the introducer.

Since Heberden's first description, stable angina has represented a challenge for the clinicians. Even the most recent guidelines seem ineffective to correctly identify patients who should be sent to cath labs. Still too many patients who undergo coronary angiography are found not to have significant lesions; moreover, its extensive use as the first diagnostic test leads to revascularizations with uncertain appropriateness and prognostic significance. These considerations underline the importance of noninvasive testing before sending patients to invasive coronary angiography. However, it is still debatable whether it is better to pursue anatomic evaluation of the coronary tree with the use of computed tomography or assessment of myocardial ischemia, a controversy which has not been resolved by recent trials comparing the two diagnostic modalities. A combined approach using both functional and anatomic testing may lead to a more careful risk stratification before invasive coronary angiography. The aim of this article is to discuss the most recent evidence in this field, and its application in clinical practice.