key: cord-0765347-bt1m49go
authors: Camazón, Nuria Vallejo; Teis, Albert; Membrive, María José Martínez; Llibre, Cinta; Bayés-Genís, Antoni; Mateu, Lourdes
title: Long COVID-19 and microvascular disease-related angina
date: 2021-10-28
journal: Rev Esp Cardiol (Engl Ed)
DOI: 10.1016/j.rec.2021.10.010
sha: 2ad865c64c66e11f3a7246ac6118875608d2788d
doc_id: 765347
cord_uid: bt1m49go

nan

Cardiac involvement has been widely described during the acute phase of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. However, many patients report persistent symptoms after recovery, a condition known as persistent or long-coronavirus disease 2019 (COVID-19) syndrome. In some series, chest pain has been described in ~20% of patients with long-COVID-19 syndrome, 1 but the mechanisms for these symptoms have not been adequately explored. Some of these patients have angina-like chest pain. Adenosine stress perfusion cardiac magnetic resonance (CMR) imaging is a useful noninvasive diagnostic tool for assessing myocardial perfusion and distinguishing epicardial from microvascular impairment according to perfusion patterns. 2 CMR could play a role in the evaluation of this syndrome. 3 We are currently performing a prospective observational study of patients with angina-like No pericardial effusion was noted in any of the patients. Two patients showed myocarditis-like late gadolinium enhancement. There were no findings of an ischemic pattern or pericardial enhancement. First-pass stress perfusion CMR showed a significant circumferential subendocardial perfusion defect in 5 patients (50%), highly suggestive of microvascular dysfunction (figure 1). In all patients, epicardial artery disease was ruled out by coronary CT angiography.

Recent studies have reported a high incidence of cardiac lesions detected by CMR in patients who recovered from severe forms of COVID-19 infection and have a high incidence of previous cardiovascular disease or risk factors. 4 However, long COVID-19 syndrome affects predominantly middle-aged women without cardiovascular risk factors and previous mild forms of disease. 1, 4 In our study, 27% of our patient evaluated in a long COVID-19 unit had chest pain, some of them suggestive of angina after careful evaluation and after exclusion of other conditions. The pathological mechanism underlying this condition is still unknown. One explanation could be microvascular dysfunction. Half of our initial patients showed a microvascular dysfunction pattern on adenosine stress perfusion CMR. The mechanisms of microvascular disease in COVID-19 include endothelial injury via angiotensin converting-enzyme 2, with endothelial dysfunction and microvascular inflammation and thrombosis. 5, 6 These first consecutive cases in this observational study strongly suggest that coronary microvascular ischemia is the underlying mechanism of angina-like persistent chest pain in patients who have recovered from COVID-19. As noted, the patients reported here are part of a broader study (ANGI-Covid) in which special CMR sequences for noninvasive quantification of myocardial perfusion and coronary flow reserve are also being studied and evaluated in these patients. Future work will have to elucidate the incidence and prevalence and compare these data with controls. However, at this point, we believe the results provided are of clinical importance.

Therapeutic strategies aiming to prevent or treat endothelial dysfunction in this scenario should be tested. 

The authors declare no conflict of interest related to this manuscript. 

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Bayés-Genís A. Persistent chest pain after recovery of COVID-19 : microvascular disease-related angina ?

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Physiopathology of cardiovascular disease in patients with COVID-19. Ischemia, thrombosis and heart failure