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Acute coronary syndrome and anaphylaxis
Síndrome coronario agudo y anafilaxia
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Agulló-García, J.L. Cubero Saldaña, S. Ulloa-Levit, C. Colás Sanz" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Agulló-García" "email" => array:1 [ 0 => "aagullog@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.L." "apellidos" => "Cubero Saldaña" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "Ulloa-Levit" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "C." "apellidos" => "Colás Sanz" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Alergología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome coronario agudo y anafilaxia" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Kounis syndrome was described in 1991 by Kounis and Zavras as the simultaneous onset of acute coronary events and allergic anaphylactic or anaphylactoid reactions.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> There are 3<span class="elsevierStyleHsp" style=""></span>subtypes of this condition<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a>: type 1 Kounis syndrome in patients with no coronary artery disease, type 2 Kounis syndrome in patients with coronary artery disease and type 3 Kounis syndrome in patients with drug-eluting stent thrombosis. The diagnosis is eminently clinical<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a> and is based on objective signs and symptoms suggestive of an anaphylactic reaction and an acute coronary event occurring simultaneously.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3–5</span></a> Treatment is the specific one for acute coronary syndrome and anaphylaxis.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Our objective was to report the main characteristics of 10<span class="elsevierStyleHsp" style=""></span>patients diagnosed with Kounis syndrome in the past 8<span class="elsevierStyleHsp" style=""></span>years in our department.</p><p id="par0015" class="elsevierStylePara elsevierViewall">All of the patients were men, with a mean age of 57<span class="elsevierStyleHsp" style=""></span>years. Ninety percent of the patients had no history of allergies or heart conditions, and their most common triggers were food and drugs. The latency varied from immediate to 1<span class="elsevierStyleHsp" style=""></span>h. All patients presented symptoms of anaphylaxis or anaphylactic shock, regardless of the causal agent.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Tryptase in the acute phase was a determinant in 6<span class="elsevierStyleHsp" style=""></span>patients, with high tryptase levels in 5<span class="elsevierStyleHsp" style=""></span>patients (from 18.5 to 84.5<span class="elsevierStyleHsp" style=""></span>μg/L). In all cases, we observed electrocardiographic abnormalities in the ST segment and increased troponin levels. Coronary angiography was performed on 7<span class="elsevierStyleHsp" style=""></span>patients, 5 of whom had no significant angiographic lesions. One patient presented a lesion in the mid left anterior descending artery, and another presented thrombosis and restenosis of a previous stent. Two of the patients who did not undergo a coronary angiography had an echocardiogram that ruled out ischemic disease.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In terms of treatment, 70% of the patients were treated with intravenous antihistamines and corticosteroids, and only 1 patient was treated with adrenaline. Other treatments included fluid therapy, oxygen therapy, atropine and antiarrhythmic agents.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The prick tests were positive in 4<span class="elsevierStyleHsp" style=""></span>cases (nuts, amoxicillin and metamizole), and the specific IgE tests were positive in 3<span class="elsevierStyleHsp" style=""></span>cases (nuts and amoxicillin), taking into account that we did not have commercial extracts for all the suspected allergens. By measuring baseline tryptase levels (with levels <11.4<span class="elsevierStyleHsp" style=""></span>μg/L considered normal<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a>), we showed that the levels returned to normal after each acute episode in all cases. The recommended treatment for all patients was to avoid the allergen trigger, after which the patients remained asymptomatic.</p><p id="par0035" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the main characteristics of the reactions and the results of the tests.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">There were no differences in our patients in the clinical presentation with the various triggers. The tryptase measurement in the acute phase was of considerable usefulness for the subsequent diagnosis. In terms of treatment, it is worth noting that only one patient was treated with intramuscular adrenaline. This is a highly debated topic<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> because adrenaline is the treatment of choice for anaphylaxis<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,7,9,10</span></a> but has adverse effects that can worsen a ventricular function already compromised by ischemia.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9,10</span></a> However, adrenaline should be considered as a treatment in the most severe cases.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">We believe it is important for all specialties to understand this disease, because of the essential nature of the initial suspicion of Kounis syndrome when faced with patients with symptoms of anaphylaxis and acute coronary syndrome. An immediate diagnosis is crucial for quickly starting appropriate treatment.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Agulló-García A, Cubero Saldaña JL, Ulloa-Levit S, Colás Sanz C. Síndrome coronario agudo y anafilaxia. Rev Clin Esp. 2018;218:323–326.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: CAG, coronary angiography; ECG, electrocardiogram; LTP, lipid-transfer protein; LAD, left anterior descending; NP, not performed; PT, prick tests; Tn I, troponin I; Tn T ultraS, ultrasensitive troponin T.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age, years \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Allergen trigger \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Latency period, min \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Symptoms \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Allergological study \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cardiac tests \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diclofenac \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urticaria, dyspnea, dysphonia, chest pain, syncope \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- PT: negative<br>- Specific IgE: NP<br>- Total IgE: NP<br>- Tryptase: NP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- ECG: ST elevation, negative T wave<br>- Tn I: 1.2<span class="elsevierStyleHsp" style=""></span>ng/mL<br>- CAG: lesion in LAD mid and diagonal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Metamizole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Generalized erythema, hypotension, pruritus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- PT: negative<br>- Specific IgE: NP<br>- Total IgE: NP<br>- Tryptase: NP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- ECG: ST elevation<br>- Tn I: 0.46<span class="elsevierStyleHsp" style=""></span>ng/mL<br>- CAG: no significant angiographic lesions on the coronary arteries \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Moxifloxacin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urticaria, facial angioedema, dyspnea, hypotension, chest pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- PT: NP<br>- Specific IgE: NP<br>- Total IgE: NP<br>- Tryptase: NP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- ECG: ST elevation, ventricular tachycardia<br>- Tn I: NP<br>- CAG: late thrombosis and significant restenosis in the stent overlap area \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Almonds \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dizziness, epigastric pain, generalized erythema, bronchospasms, hypotension, syncope \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- PT: nuts, LTP and flour<br>- Specific IgE: almond 2.98<span class="elsevierStyleHsp" style=""></span>kU/L<br>- Total IgE: 228<span class="elsevierStyleHsp" style=""></span>IU/mL<br>- Tryptase: 10 μg/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- ECG: ST reduction<br>- Tn I: 0.12<span class="elsevierStyleHsp" style=""></span>ng/mL<br>- CAG: no significant angiographic lesions on the coronary arteries \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cefuroxime \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urticaria, dizziness, general discomfort, headaches, chest pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- PT: negative<br>- Specific IgE: penicillin G, penicillin V, ampicillin, amoxicillin, latex <0.1<span class="elsevierStyleHsp" style=""></span>kU/L<br>- Total IgE: 129<span class="elsevierStyleHsp" style=""></span>IU/mL<br>- Tryptase: NP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- ECG: ST reduction<br>- Tn I: 0.87<span class="elsevierStyleHsp" style=""></span>ng/mL<br>- CAG: NP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Amoxicillin-clavulanate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urticaria, general discomfort, abdominal pain, hypotension, chest pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- PT: negative<br>- Specific IgE (kU/L): penicillin G 1.85; penicillin V 1.83; ampicillin 0.81; amoxicillin 1.06<br>- Total IgE: 511<span class="elsevierStyleHsp" style=""></span>IU/mL<br>- Tryptase: 84.5 μg/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- ECG: ST elevation<br>- Tn I: 0.33<span class="elsevierStyleHsp" style=""></span>ng/mL<br>- CAG: NP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rabeprazole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urticaria, angioedema, general discomfort, hypotension, chest tightness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- PT: negative<br>- Specific IgE: NP<br>- Total IgE: 374<span class="elsevierStyleHsp" style=""></span>IU/mL<br>- Tryptase: 18.5 μg/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- ECG: ST reduction<br>- Tn I: 1.77<span class="elsevierStyleHsp" style=""></span>ng/mL<br>- CAG: no significant angiographic lesions on the coronary arteries \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Amoxicillin-clavulanate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">General discomfort, generalized pruritus, nausea, hypotension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- PT: amoxicillin<br>- Specific IgE: penicillin G, penicillin V, ampicillin, amoxicillin <0.1<span class="elsevierStyleHsp" style=""></span>kU/L<br>- Total IgE: 54.3<span class="elsevierStyleHsp" style=""></span>IU/mL<br>- Tryptase: 38.5 μg/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- ECG: ST reduction<br>- Tn I: 0.1<span class="elsevierStyleHsp" style=""></span>ng/mL<br>- CAG: no significant angiographic lesions on the coronary arteries \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Almonds \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Generalized erythema, abdominal pain, diarrhea, dyspnea, aphonia, hypotension, syncope \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- PT: hazelnut and LTP<br>- Specific IgE (kU/L): peanut 1.33; hazelnut 0.93; almond 0.64; LTP 2.89<br>- Total IgE: 145<span class="elsevierStyleHsp" style=""></span>IU/mL<br>- Tryptase: 43.9<span class="elsevierStyleHsp" style=""></span>μg/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- ECG: ST reduction<br>- TnT ultraS: 74<span class="elsevierStyleHsp" style=""></span>ng/L<br>- CAG: no significant angiographic lesions on the coronary arteries \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Metamizole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Immediate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palmar pruritus, general discomfort, bradycardia, hypotension, syncope \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- PT: metamizole<br>- Specific IgE: NP<br>- Total IgE: NP<br>- Tryptase: 25.3<span class="elsevierStyleHsp" style=""></span>μg/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- ECG: ST elevation<br>- Tn T ultraS: 21.22<span class="elsevierStyleHsp" style=""></span>ng/L<br>- CAG: NP \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1818491.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Only the allergens that were positive in the tests were included.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patient age, allergen trigger, main characteristics of the reaction, results of the allergological<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> and cardiac studies.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Histamine-induced coronary artery spasm: the concept of allergic angina" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N.G. 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| 2023 April | 1 | 0 | 1 |
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| 2018 June | 0 | 1 | 1 |
