Cardiology and Angiology: An International Journal

Spontaneous Lingual Hematoma Associated with Rivaroxaban Therapy: A Rare Life-threatening Bleeding Complication

Lamia Tlohi — 2026-10-26

Background: Spontaneous lingual haematoma is an uncommon but potentially life-threatening form of anticoagulant-associated bleeding because progressive tongue swelling may obstruct the upper airway. This report describes the presentation, assessment, treatment and short-term outcome of an elderly patient receiving rivaroxaban.

Case Presentation: An 80-year-old woman treated with rivaroxaban 20 mg daily for permanent atrial fibrillation presented after 3–4 days of progressive oral discomfort, lingual pain, dysphonia and dysphagia. Examination showed a tense, violaceous, enlarged tongue and extensive cervicothoracic ecchymoses. Haemoglobin was 4.9 g/dL, creatinine clearance was 25 mL/min and rivaroxaban-specific anti-factor Xa activity was 250 ng/mL; the exact times of the last dose and blood sampling were not documented. Rivaroxaban was discontinued, and the patient received four-factor prothrombin complex concentrate, tranexamic acid, dexamethasone, transfused blood products and supportive care. Flexible nasendoscopy confirmed a patent airway despite mild supraglottic swelling. Following multidisciplinary assessment, translingual traction and intensive airway surveillance were used without intubation or tracheostomy. Swelling regressed during a five-day admission. Anticoagulation was resumed with apixaban 2.5 mg twice daily after clinical stabilisation. No recurrent lingual bleeding or airway compromise was recorded at one week, one month or three months after discharge.

Conclusion: This case underscores the importance of recognising atypical bleeding, reassessing renal function and monitoring the airway in patients receiving direct oral anticoagulants. The conservative airway approach described here reflects an individual clinical decision and should not be generalised.

The Ankle–brachial Index in Peripheral Arterial Disease: A Critical Narrative Review of Diagnostic Performance, Prognostic Value and Contested Screening Roles

Ketan Vagholkar — 2026-10-15

Peripheral arterial disease is a common manifestation of systemic atherosclerosis that remains frequently unrecognised, partly because most affected people do not report classic intermittent claudication. The ankle–brachial index, the ratio of ankle to arm systolic pressure, has served for more than half a century as the principal non-invasive test for the condition and has acquired a second role as a marker of cardiovascular risk. Its apparent simplicity conceals unresolved questions about measurement standardisation, diagnostic sensitivity in people with diabetes or chronic kidney disease, the meaning of borderline and elevated values, and the value of population screening. This critical narrative review examined how far the evidence supports each of the diagnostic, prognostic, screening and limb-threat roles now assigned to the index. Peer-reviewed literature, clinical practice guidelines and consensus statements were identified through structured searching of international biomedical databases and scholarly indexes, supplemented by citation tracking, and were appraised thematically with attention to study design, reference standards, spectrum of participants and consistency of findings. The synthesis indicates that an index of 0.90 or lower is a highly specific marker of haemodynamically significant disease and a robust, reproducible predictor of cardiovascular events and mortality across diverse cohorts. Sensitivity is modest and deteriorates markedly where medial arterial calcification is common, so that a normal value cannot reliably exclude disease in diabetes, advanced kidney disease or older age. Calculation conventions, device type and operator training materially alter prevalence estimates, and the prognostic signal extends to borderline and non-compressible values, which current diagnostic categories treat inconsistently. Randomised evidence has not shown that screening asymptomatic populations with the index alone improves outcomes, and major guideline bodies therefore diverge. Toe pressures, waveform analysis and data-driven methods may complement the index, but their evidence base is still largely low in certainty. The index remains indispensable as a first-line, context-dependent test, provided that its limitations are acknowledged, its measurement is standardised, and a normal result in high-risk groups is followed by complementary testing. Pragmatic trials of targeted case-finding and diagnostic studies in under-represented populations are the most pressing research needs.

Gender Differences in the Clinical Presentation, Management, and Prognosis of Acute Coronary Syndrome: A Single-Center Observational Study

K. Elaakib — 2026-09-19

Gender differences in acute coronary syndrome (ACS) are widely recognised. Women may present with ACS at an older age and with a different cardiovascular risk profile, including higher prevalences of hypertension, diabetes, and renal insufficiency in many cohorts. They may also have differences in symptom presentation, coronary anatomy, management, and outcomes. The objective of this study was to compare, by sex, the clinical characteristics, cardiovascular risk factors, electrocardiographic findings, echocardiographic data, therapeutic management, and prognosis of patients admitted for ACS. We conducted a single-centre, retrospective, observational study including 94 patients hospitalised for ACS in the cardiology department of the Mohammed VI University Hospital in Marrakesh. Of the 94 patients included, 69 were men (73.4%) and 25 were women (26.6%). Women had a higher prevalence of hypertension and diabetes, whereas smoking was observed only among men. Mean left ventricular ejection fraction was similar between women and men. In-hospital mortality was 32.0% among women (8/25) and 7.2% among men (5/69), with an overall mortality of 13.8% (13/94). In multivariable logistic regression adjusted for age, diabetes, renal insufficiency, and left ventricular ejection fraction, female sex was associated with an odds ratio of 4.18 (95% CI, 1.14–15.37; p=0.032); however, given the small sample and limited number of events, this estimate should be considered exploratory. These findings should therefore be interpreted cautiously and viewed as hypothesis-generating rather than definitive evidence of an independent prognostic effect of sex.

Correlation between SYNTAX Score and Myocardial Ischemia as Assessed by SPECT Myocardial Perfusion Imaging in Patients Undergoing Coronary Interventions

Muneer Saif Abdulkhaleq Mohammed Alshameery — 2026-09-28

Coronary artery disease (CAD) is a major cardiovascular health problem. Myocardial perfusion imaging (MPI), especially single-photon emission computed tomography (SPECT), provides valuable diagnostic and prognostic information after percutaneous coronary intervention (PCI). The Synergy Between PCI with TAXUS and Cardiac Surgery (SYNTAX) score evaluates coronary lesion complexity and predicts ischaemic burden and outcomes after revascularisation. The objective was to determine the correlation of the SYNTAX score with myocardial ischaemia measured by SPECT MPI among patients undergoing coronary interventions.

This prospective study was conducted in 85 patients undergoing coronary interventions. Each participant underwent clinical and local cardiac examination, together with laboratory testing comprising complete blood count (CBC), urea, serum creatinine, creatinine clearance, prothrombin time (PT), international normalised ratio (INR), and lipid profile.

SYNTAX I was significantly associated with myocardial ischaemia parameters, whereas SYNTAX II (PCI) was associated with SSS, SRS, SDS, and TPD (all P < 0.05). EF showed inverse correlations with SYNTAX I and SYNTAX II (PCI), whereas LDL showed no significant association. Patients with DM had higher SYNTAX I scores and TPD than those without DM (P < 0.05). SSS, SRS, SDS, and TPD differed significantly across SYNTAX I groups, whereas only SSS and SRS differed across SYNTAX II (PCI) groups. No significant associations were observed for SYNTAX II (CABG), HTN, dyslipidaemia, or smoking (P > 0.05).

SYNTAX I correlated with MPI parameters, while higher coronary complexity was associated with diabetes and reduced EF, supporting combined anatomical and functional assessment in CAD.

Valvular Prosthesis Dysfunction: A Single-Center Experience of 77 Cases — Clinical, Echocardiographic, and Etiological Profiles

F. Haffane — 2026-10-12

Background: Prosthetic valve dysfunction is a clinically important complication of valve replacement, with potentially serious haemodynamic, thromboembolic and infectious consequences. Its assessment requires evaluation of the clinical presentation, prosthetic valve haemodynamics and underlying mechanisms.

Objective: To describe the clinical, echocardiographic and aetiological characteristics of patients with prosthetic valve dysfunction managed at Mohammed VI University Hospital Centre, Marrakech.

Methods: This retrospective, observational, single-centre study included 77 patients with suspected or confirmed prosthetic valve dysfunction. Clinical characteristics, echocardiographic findings, cinefluoroscopic assessments and aetiological investigations were reviewed using the available hospital records.

Results: The mean patient age was 54.1 ± 13.6 years, and 53.2% were women. Most patients were symptomatic, with 62.3% classified as New York Heart Association functional class III–IV. Ischaemic neurological events were documented in 26.0% of patients, while respiratory instability occurred in 14.3%. Transthoracic echocardiography demonstrated satisfactory prosthetic valve opening in 48 patients (62.3%). Left ventricular systolic dysfunction was identified in 23 patients, including eight with severe dysfunction. The mean systolic pulmonary artery pressure was 38.3 ± 10.9 mmHg. Haemolysis was identified in 28 patients (36.4%), prosthetic valve thrombosis in 17 (22.1%), pannus formation in 15 (19.5%) and infective endocarditis in nine (11.7%). Several mechanisms coexisted or remained difficult to differentiate.

Conclusion: Prosthetic valve dysfunction demonstrated heterogeneous clinical and aetiological characteristics. An integrated assessment using echocardiography and complementary imaging was important for identifying the underlying mechanisms and informing clinical management.

Incidence, Predictive Factors, and Outcomes of Ischemic High-degree Atrioventricular Block in Acute Coronary Syndrome: A Retrospective Observational Study

S. Oudadda — 2026-10-26

High-degree atrioventricular block (HD-AVB) is an uncommon but potentially life-threatening complication of acute coronary syndrome (ACS). Its occurrence is associated with increased haemodynamic instability and mortality. This study aimed to assess the incidence, clinical characteristics, predictive factors, and in-hospital prognosis of ischemic HD-AVB and to identify patients who may benefit from permanent pacing. We conducted a retrospective observational study in the Cardiology Department of the Mohammed VI University Hospital in Marrakesh over a 5-year period, from January 2021 to December 2025. All adult patients admitted with confirmed ACS presenting with complete or high-degree AV block were included. Among ACS admissions during the study period, the prevalence of HD-AVB was 4% (70 patients). The mean age was 65 years (range: 40–74), with a predominance of male patients. More than 80% of patients had modifiable cardiovascular risk factors, led by diabetes mellitus (41%). ST-segment elevation myocardial infarction (STEMI) was the primary clinical presentation, accounting for 85% of cases, whereas non-ST-segment elevation acute coronary syndrome (NSTEMI) was observed in 15% of patients. Among patients with STEMI, inferior wall involvement was markedly predominant (75% of STEMI cases). Complete AV block accounted for 90% of cases. Coronary angiography revealed significant right coronary artery lesions in 38% and three-vessel disease in 38%. Regarding management, 23% of patients recovered sinus rhythm spontaneously, while 46% required a temporary pacing lead and subsequently returned to sinus rhythm following revascularisation. An additional 16% ultimately required permanent DDD pacemaker implantation, while 15% of patients died during hospitalisation. Ischaemic HD-AVB predominantly complicates inferior STEMI and is usually transient. Temporary pacing is often required acutely, while permanent pacemakers remain limited to persistent blocks. Inferior STEMI was characterised by transient nodal ischemia with an 82.0% electrical recovery rate after revascularisation. Conversely, anterior STEMI carried a significantly higher incidence of cardiogenic shock and higher in-hospital mortality.

Functional Prosthetic Valve Dysfunction: An Underrecognized Cause of Elevated Transprosthetic Gradients

Haffane Fadwa — 2026-10-27

Background: Elevated transprosthetic gradients are commonly considered a sign of prosthetic valve obstruction. However, certain haemodynamic or physiological conditions may result in increased gradients despite a structurally normal prosthesis. Recognizing these functional abnormalities is essential to avoid misdiagnosis of prosthetic obstruction and inappropriate management.

Aims: To assess the frequency and principal clinical, echocardiographic and aetiological characteristics of functional prosthetic valve dysfunction associated with elevated transprosthetic gradients in a single-centre cohort.

Methodology: We conducted a retrospective single-centre study at the Department of Cardiology, Mohammed VI University Hospital, Marrakech, including 77 patients with prosthetic valve dysfunction. Clinical, transthoracic and transoesophageal echocardiographic data, together with laboratory data, were analysed. Functional prosthetic valve dysfunction was defined as elevated transprosthetic gradients in the absence of morphological evidence of prosthetic obstruction, with an identified haemodynamic or physiological condition explaining the increased gradients.

Results: Functional prosthetic valve dysfunction was identified in 9 of 77 patients (11.7%). The mean age was 55.9 ± 14.3 years, with a female predominance (66.7%). The main underlying conditions were severe anaemia in 4 patients (44.4%), hyperthyroidism in 2 patients (22.2%), patient–prosthesis mismatch in 2 patients (22.2%), and pregnancy in 1 patient (11.1%). All patients were symptomatic, with NYHA functional class II in 3 patients and class III in 6 patients. The mean transprosthetic gradient was 10.3 ± 1.6 mmHg across mitral prostheses and 30.3 ± 7.0 mmHg across aortic prostheses. No definitive morphological evidence of thrombus or pannus was identified in this subgroup.

Conclusion: Functional prosthetic valve dysfunction accounted for 11.7% of prosthetic valve dysfunctions in our series. Severe anaemia, hyperthyroidism, patient–prosthesis mismatch, and pregnancy were the main associated conditions. An elevated transprosthetic gradient should therefore not be interpreted in isolation as evidence of prosthetic obstruction. Its assessment should integrate transvalvular flow, Doppler parameters, the clinical context, and prosthetic valve morphology.