Although infections are frequent in patients with pulmonary embolism (PE), its effect on adverse outcome risk remains unclear. We investigated the incidence and prognostic impact of infections requiring antibiotic treatment and of inflammatory biomarkers (C-reactive protein [CRP] and procalcitonin [PCT]) on in-hospital adverse outcomes (all-cause mortality or hemodynamic insufficiency) in 749 consecutive PE patients enrolled in a single-centre registry. Adverse outcomes occurred in 65 patients. Clinically relevant infections were observed in 46.3% of patients and there was an increased adverse outcome risk with an odds ratio (OR) of 3.12 (95% confidence interval [CI] 1.70–5.74), comparable to an increase in one risk class of the European Society of Cardiology (ESC) risk stratification algorithm (OR 3.45 [95% CI 2.24–5.30]). CRP > 124 mg/dL and PCT > 0.25 µg/L predicted patient outcome independent of other risk factors and were associated with respective ORs for an adverse outcome of 4.87 (95% CI 2.55–9.33) and 5.91 (95% CI 2.74–12.76). In conclusion, clinically relevant infections requiring antibiotic treatment were observed in almost half of patients with acute PE and carried a similar prognostic effect to an increase in one risk class of the ESC risk stratification algorithm. Furthermore, elevated levels of CRP and PCT seemed to be independent predictors of adverse outcome.

Background: While previous studies indicate an association between chest pain and favorable clinical outcomes in patients with pulmonary embolism (PE), the extent and underlying mechanisms of this effect remain inadequately defined. Methods: We investigated the prognostic value of chest pain with regard to in-hospital adverse outcomes and the association of chest pain with age and sex in consecutive patients with confirmed PE enrolled in a single-center registry between 2008 and 2019. Results: Of 858 patients (52% female) included in this study, 435 (51%) had chest pain at presentation. Chest pain was more prevalent in younger individuals aged 18–34 years (74%) compared to patients >34 years (46%). The prevalence of coronary artery disease (CAD) was similar in patients with and without chest pain (17.0% vs. 16.1%). Chest pain patients less frequently presented with elevated troponin levels (p < 0.001) or signs of right heart strain (RHS; p = 0.007) but more frequently exhibited imaging signs of pulmonary infarction (p = 0.001). Chest pain was associated with lower risk of adverse outcome (OR 0.35 [95% CI: 0.19–0.65]) and in-hospital mortality (OR 0.31 [95% CI: 0.13–0.74]). Multivariable models confirmed a prognostic effect independent of sex, comorbidities and results of risk stratification algorithms. Conclusions: In acute PE, chest pain is a favorable prognostic marker irrespective of sex. Chest pain patients are less likely to suffer from myocardial ischemia or show signs of RHS but more frequently show imaging signs of pulmonary infarction, suggesting pleuritic irritation rather than myocardial ischemia as the likely cause of pain.

Leiomyosarcoma of the inferior vena cava (IVC) is a rare malignant tumor that may extend into the right atrium and mimic a primary cardiac neoplasm. Because clinical presentation is often non-specific and depends on tumor location and extent, diagnosis may be delayed, particularly in acute settings with suboptimal imaging conditions. We report the case of a 33-year-old woman presenting with progressive dyspnea, ascites and peripheral edema consistent with right-sided heart failure. Initial contrast-enhanced computed tomography, performed to exclude pulmonary embolism, suggested a right atrial myxoma. However, stepwise multimodality imaging including transthoracic and transesophageal echocardiography, multiphasic computed tomography (CT), and cardiac magnetic resonance imaging (CMR) revealed a large intravascular mass originating from the IVC with contiguous extension in the right atrium, causing near-complete luminal obstruction of atrium and IVC. CMR was essential in establishing the diagnosis by demonstrating tumor continuity, tissue heterogeneity, and malignant enhancement patterns. Histopathological analysis confirmed a low-grade spindle cell leiomyosarcoma (G2, Ki-67 approximately 40%). Staging with multiphasic CT and magnetic resonance imaging of the brain excluded distant metastases. The patient was initiated on neoadjuvant chemotherapy with doxorubicin and ifosfamide with planned surgical resection. This case illustrates the importance of multimodality imaging, with CMR playing a central role, in distinguishing malignant intravascular tumors from benign intracardiac masses. Early diagnosis and a multidisciplinary approach are essential for optimal management.