Prognostic stratification of pulmonary embolism: what does it change from 2014 European Society of Cardiology guidelines?

Luca Masotti, Giancarlo Landini, Gianni Lorenzini, Irene Chiti, Grazia Panigada



Prognostic stratification is of utmost importance for clinical management of acute pulmonary embolism (PE). Clinical presentation, echocardiography and biomarkers represented the key points on which recommendations of European Society of Cardiology (ESC) released in 2008 were based. In fact, in 2008 the ESC prognostic model suggested to divide acute PE in high risk, heamodynamically unstable, based on presentation with shock or hypotension, and non high risk, haemodynamically stable. The non high risk PE was divided in intermediate rand low risk PE based on echocardiographic
and biomarkers signs of right heart dysfunction (RHD) and myocardial damage. This approach was not an academic speculation but permitted to define the early mortality risk (>15% in high risk, 3-15% in intermediate risk, <1% in low risk) and bring the most appropriate treatment. Over the years it became clear that co-morbidity influenced the early mortality risk and may define better the low mortality risk. Practical clinical scores, such as the Pulmonary Embolism Severity Index, PESI, in its original or simplified version, demonstrated to have high prognostic power to identify high (early mortality risk over 10%) and low risk (early mortality risk ≤ 1%) patients. Furthermore, it has become clear that the combination of ESC prognostic model, based on haemodynamics, and clinical prognostic scores may improve the prognostic stratification of acute PE, especially for patients with intermediate risk in whom the range of early mortality risk is wide The latest version of ESC recommendations on management of acute PE released in August 2014 go toward this direction and suggest to divide the non high risk PE in low or intermediate risk taking in account the PESI score. In this review we describe the prognostic strategy of acute PE suggested from the latest version of ESC recommendations.


Pulmonary embolism; Prognosis; Severity index; Guidelines

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  • Masotti L. Tromboembolia polmonare acuta. Dalla fisiopatologia al follow-up. Torino, SEEd: 2009
  • Masotti L, Righini M, Vuilleumier N, et al. Prognostic stratification of acute pulmonary embolism: focus on clinical aspects, imaging, and biomarkers. Vasc Health Risk Manag 2009; 5: 567-75;
  • Sanchez O, Trinquart L, Colombet I, et al. Prognostic value of right ventricular dysfunction in patients with haemodynamically stable pulmonary embolism: a systematic review. Eur Heart J 2008; 29: 1569-77;
  • Torbicki A, Perrier A, Konstantinides S, et al.; ESC Committee for Practice Guidelines (CPG). Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008; 29: 2276-315;
  • Konstantinides S, Torbicki A, Agnelli G et al.; Authors/Task Force Members. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)Endorsed by the European Respiratory Society (ERS). Eur Heart J 2014 [Epub ahead of print];
  • Becattini C, Casazza F, Forgione C, et al. Acute pulmonary embolism: external validation of an integrated risk stratification model. Chest 2013; 144: 1539-45;
  • Masotti L, Pieralli F, Panigada G, et al. Characteristics and clinical management of acute pulmonary embolism in real world: findings from TUSCAN-PE Study. Ital J Med 2014 [Epub ahead of print];
  • Aujesky D, Hughes R, Jiménez D. Short-term prognosis of pulmonary embolism. J Thromb Haemost 2009; 7 Suppl 1: 318-21;
  • Zondag W, Hiddinga BI, Crobach MJ, et al.; Hestia Study Investigators. Hestia criteria can discriminate high- from low-risk patients with pulmonary embolism. Eur Respir J 2013; 41: 588-92;
  • Jiménez D, Yusen RD, Otero R, et al. Prognostic models for selecting patients with acute pulmonary embolism for initial outpatient therapy. Chest 2007; 132: 24-30;
  • Aujesky D, Perrier A, Roy PM, et al. Validation of a clinical prognostic model to identify low-risk patients with pulmonary embolism. J Intern Med 2007; 261: 597-604;
  • Jiménez D, Aujesky D, Moores L, et al.; RIETE Investigators. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 2010; 170: 1383-9;
  • Uresandi F, Otero R, Cayuela A, et al. A clinical prediction rule for identifying short-term risk of adverse events in patients with pulmonary thromboembolism. Arch Bronconeumol 2007; 43: 617-22;
  • Paiva LV, Providencia RC, Barra SN, et al. Cardiovascular risk assessment of pulmonary embolism with the GRACE risk score. Am J Cardiol 2013; 111: 425-31;
  • Barra S, Paiva L, Providência R, et al. LR-PED rule: low risk pulmonary embolism decision rule - a new decision score for low risk pulmonary embolism. Thromb Res 2012; 130: 327-33;
  • Zhou XY, Ben SQ, Chen HL, et al. The prognostic value of pulmonary embolism severity index in acute pulmonary embolism: a meta-analysis. Respir Res 2012; 13: 111;
  • Piran S, Le Gal G, Wells PS, et al. Outpatient treatment of symptomatic pulmonary embolism: a systematic review and meta-analysis. Thromb Res 2013; 132: 515-9;
  • Singanayagam A, Scally C, Al-Khairalla MZ, et al. Are biomarkers additive to pulmonary embolism severity index for severity assessment in normotensive patients with acute pulmonary embolism? QJM 2011; 104: 125-31;
  • Moores L, Aujesky D, Jiménez D, et al. Pulmonary Embolism Severity Index and troponin testing for the selection of low-risk patients with acute symptomatic pulmonary embolism. J Thromb Haemost 2010; 8: 517-22;
  • Sanchez O, Trinquart L, Planquette B, et al. Echocardiography and pulmonary embolism severity index have independent prognostic roles in pulmonary embolism. Eur Respir J 2013; 42: 681-8;
  • Lankeit M, Gómez V, Wagner C, et al.; Instituto Ramón y Cajal de Investigación Sanitaria Pulmonary Embolism Study Group. A strategy combining imaging and laboratory biomarkers in comparison with a simplified clinical score for risk stratification of patients with acute pulmonary embolism. Chest 2012; 141: 916-22;
  • Ozsu S, Ozlu T, Sentürk A, et al.; TUPEG Study Investigators. Combination and comparison of two models in prognosis of pulmonary embolism: results from TUrkey Pulmonary Embolism Group (TUPEG) study. Thromb Res 2014; 133: 1006-10;


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