Atypical Presentations of Coronary Microvascular Dysfunction in Patients After COVID.

Coronary microvascular dysfunction is a recognized cause of angina without obstructive coronary disease, yet routine tests are often nondiagnostic. In this case series, we describe 3 previously active adults with persistent chest pain after SARS-CoV-2 infection who fulfilled the World Health Organization criteria for postacute sequelae. All 3 patients underwent invasive coronary angiography with coronary reactivity testing with coronary flow reserve (CFR). In all patients, the epicardial coronary arteries were angiographically normal, however CFR was significantly impaired (<2.0). Medical management was tailored and guideline-concordant, including the use of calcium-channel blockers, beta-blockers, long-acting nitrates, and graded exercise, with some improvement in symptoms. We contend that coronary microvascular dysfunction may be the etiology of post-COVID chest pain. An earlier CFR assessment may shorten diagnostic delays and improve quality of life.