European Heart Journal - Case Reports CARDIOVASCULAR FLASHLIGHT doi:10.1093/ehjcr/ytab105 Coronary Heart Disease Persistent chest pain after recovery of COVID-19: microvascular disease-related angina? Nuria Vallejo1*, Albert Teis 1 , Lourdes Mateu 2,3 , and Antoni Bayés-Genı́s1,3 1 Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Carretera de Canyet sn 08916 Badalona (Barcelona), Spain; 2Infectious Diseases Department, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet sn 08916 Badalona (Barcelona), Spain; and 3Universitat Autònoma de Barcelona, Campus de la UAB, Plaza Cı́vica, 08193 Bellaterra (Barcelona), Spain Received 18 January 2021; first decision 29 January 2021; accepted 8 March 2021 .. A 42-year-old woman, presented with fever, anosmia, and a positive .. A coronary computed tomography showed angiographically polymerase chain reaction for severe acute respiratory syndrome .. normal coronary arteries (Supplementary material online, Figure .. coronavirus 2. .. S2 and S3). One month later, she complained of oppressive chest pain .. An adenosine-stress cardiac magnetic resonance (CMR) scan was .. increasing on exertion suggestive of angina. She did not have previous .. performed (Figure 1) at a state of the art 1.5 T scanner (Philips Intera- .. symptoms or history of coronary artery disease. A 12-lead .. dStream). Left and right indexed ventricular volumes and function electrocardiogram demonstrated sinus rhythm with asymmetric .. were within normal ranges [indexed left ventricular end-diastolic vol- .. T-wave inversion in precordial anterior leads (Supplementary mater- .. ume: 79 mL/m2 (60–93 mL/m2); indexed right ventricular end- ial online, Figure S1). .. diastolic volume: 80 mL/m2 (60–87 mL/m2); left ventricular ejection Figure 1 Mid short-axis cine slices in (A) diastole and (B) systole. Myocardial native T1 mapping (C) and T2 mapping (D) showed normal values. First-pass stress perfusion magnetic resonance imaging (E) with a significant circumferential subendocardial perfusion defect (arrows). Rest perfusion magnetic resonance imaging (F). No late gadolinium enhancement was detected (G and H). * Corresponding author. Tel: þ34 934978915/934978863, Email: nvallejo73@hotmail.com Handling Editor: Luca Arcari VC The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 2 N. Vallejo et al. .. .. COVID-19 include endothelial injury with endothelial dysfunction .. and microvascular inflammation, and thrombosis.4,5 .. .. This case demonstrates that coronary microvascular ischaemia .. could be the mechanism of persistent chest pain in patients that have .. .. recovered from COVID-19. When obstructive coronary disease is .. .. excluded, functional non-invasive tests are recommended to rule out .. myocardial ischaemia. At present, the pattern of recovery, or the pre- .. .. ferred management of post-COVD-19 microvascular dysfunction .. remains unresolved. .. .. .. .. .. Supplementary material .. .. Supplementary material is available at European Heart Journal - Case .. Video 1 Stress and rest perfusion cardiac magnetic resonance .. Reports online. imaging. .. .. Consent: The authors confirm that written consent for submission .. .. and publication of this case report including images and associated .. text has been obtained from the patient in line with COPE guidelines. .. fraction 69% (57–75%); right ventricular ejection fraction: 68% (53– .. 76%)].1 Native MOLLI T1 mapping was performed (at mid- .. Conflict of interest: None declared. .. ventricular level2). Septal native T1 mapping was normal (1040 ms) .. Funding: A.B.G. was supported by grants from the Ministerio de .. (normal: 930–1056 ms). Ventricular GraSE T2 mapping was 54 ms .. Educación y Ciencia (SAF2014-59892), Fundació La MARATÓ de (normal: 46–58 ms) ruling out myocardial edema. A first-pass stress .. TV3 (201502, 201516), CIBER Cardiovascular (CB16/11/00403), and .. perfusion CMR showed a significant circumferential subendocardial .. AdvanceCat 2014. perfusion defect which highly suggested microvascular dysfunction .. .. (Figure 1E, arrows), with normal perfusion at rest (Figure 1F) (Video 1). .. References No late gadolinium enhancement was detected (Figure 1G and H). .. 1. Kawel-Boehm N, Maceira A, Valsangiacomo-Buechel ER, Vogel-Claussen J, .. Turkbey EB, Williams R et al. Normal values for cardiovascular magnetic reson- During the test, the patient presented the same angina she previously .. reported. .. ance in adults and children. J Cardiovasc Magn Reson 2015;17:29. .. 2. Gottbrecht M, Kramer CM, Salerno M. Native T1 and extracellular volume meas- Treatment with aspirin, statins, ranolazine, and nitrates was initially .. urements by cardiac MRI in healthy adults: a meta-analysis. Radiology 2019;290: prescribed. Nitrates were stopped because of bad clinical tolerance. .. 317–326. .. 3. Carfı̀ A, Bernabei R, Landi F; Gemelli Against COVID-19 Post-Acute Care Study Low doses of beta-blockers and calcium antagonist could be added. .. Group. Persistent symptoms in patients after acute COVID-19. JAMA 2020;324: She reported partial improvement of symptoms, without major car- .. .. 603–605. diovascular events during follow-up. .. 4. Varga Z, Flammer AJ, Steiger P, Haberecker M, Andermatt R, Zinkernagel AS et Some patients report persistent symptoms after recovering from .. al. Endothelial cell infection and endotheliitis in COVID-19. Lancet 2020;395: .. acute coronavirus disease 2019 (COVID-19). Chest pain is present in .. 5. 1417–1418. Lowenstein CJ, Solomon SD. Severe COVID-19 Is a microvascular disease. 20% of patients.3 Mechanisms of microvascular disease in .. Circulation 2020;142:1609–1611.