Version July 2025
| Early mortality risk | Indicators of risk | ||||
| Haemodynamic instability* | Clinical parameters of PE severity and/or comorbidty: PESI class III-V or sPESI ≥1 | RV dysfunction on TTE or CTPA | Elevated cardiac troponin levels¶ | ||
| HighΔ | + | (+)◊ | + | (+) | |
| Intermediate§ | Intermediate-high | – | +¥ | + | + |
| Intermediate-low | – | +¥ | One (or none) positive | ||
| Low | – | – | – | Assesment optional; if assessed, negative | |
AHA: American Heart Association; BP: blood pressure; CTPA: computed tomographic pulmonary angiography; ESC: European Society of Cardiology; H-FABP: heart-type fatty acid-binding protein; NT-proBNP: N-terminal pro B-type natriuretic peptide; PESI: Pulmonary Embolism Severity Index; RV: right ventricular; sPESI: simplified PESI; TTE: transthoracic echocardiography/echocardiogram.
* One of the following clinical presentations: cardiac arrest, obstructive shock (systolic BP <90 mmHg or vasopressors required to achieve a BP ≥90 mmHg despite an adequate filling status, in combination with end-organ hypoperfusion), or persistent hypotension (systolic BP <90 mmHg or a systolic BP drop ≥40 mmHg for >15 minutes, not caused by new-onset arrhythmia, hypovolaemia, or sepsis).
¶ Elevation of further laboratory biomarkers, such as NT-proBNP ≥600 ng/L, H-FABP ≥6 ng/mL, or copeptin ≥24 pmol/L, may provide additional prognostic information. These markers have been validated in cohort studies, but they have not yet been used to guide treatment decisions in randomized controlled trials.
Δ AHA uses the term "massive."
◊ Haemodynamic instability, combined with PE confirmation on CTPA and/or evidence of RV dysfunction on TTE, is sufficient to classify a patient into the high-risk PE category. In these cases, neither calculation of the PESI nor measurement of troponins or other cardiac biomarkers is necessary.
§ AHA uses the term "submassive" for all 'intermediate' cases.
¥ Signs of RV dysfunction on TTE (or CTPA) or elevated cardiac biomarker levels may be present, despite a calculated PESI of I to II or an sPESI of 0. Until the implications of such discrepancies for the management of PE are fully understood, these patients should be classified into the intermediate-risk category.