Pulmonary Embolism Management Based on PESI Score

Risk Stratification and Treatment Approach

The European Society of Cardiology recommends that patients with confirmed pulmonary embolism and low PESI scores (Class I/II or sPESI=0) should be managed as outpatients with direct oral anticoagulants (apixaban or rivaroxaban), provided they meet exclusion criteria, while intermediate and high-risk patients require inpatient management with escalating intensity of monitoring and consideration of reperfusion therapy 1, 2, 3
The PESI score stratifies patients into five classes (I-V) with 30-day mortality rates of ≤1.6% for Class I and 3.6% for Class II, demonstrating excellent discriminatory power, and the simplified PESI (sPESI) uses six binary variables, with a score of 0 identifying low-risk patients with 30-day mortality of 1.0-1.1% 1, 3, 4

For low-risk PE patients (PESI Class I/II or sPESI=0), the American College of Chest Physicians recommends outpatient management with direct oral anticoagulants (apixaban or rivaroxaban) when exclusion criteria are absent, and mandatory exclusion criteria include physiologic instability, active bleeding or recent major bleeding risk, severe renal impairment, and social factors 2, 3, 5
For intermediate-risk PE patients (PESI Class III or Higher with sPESI ≥1), the European Society of Cardiology recommends inpatient management with further stratification based on right ventricular dysfunction and cardiac biomarkers, and treatment includes standard anticoagulation, close monitoring for clinical deterioration, and consideration of reperfusion therapy if hemodynamic decompensation occurs 1, 4, 6

The presence of right heart thrombi represents a critical exception where anatomic location significantly impacts prognosis, with mortality of 21% versus 11% without right heart thrombi, and thrombolytic therapy is the only treatment independently associated with decreased mortality in this subset 6
Concomitant DVT is an adverse prognostic factor independently associated with 30-day all-cause mortality (OR 1.9, 95% CI 1.5-2.4), indicating significant comorbidity 1, 4

The American College of Emergency Physicians recommends not relying solely on RV dilation on imaging to exclude patients from outpatient management, and measuring cardiac biomarkers (BNP/troponin) for additional risk stratification if RV dilation is present 2, 5
The European Society of Cardiology recommends not using routine bleeding risk scores beyond the exclusion criteria already outlined for patients deemed low-risk by PESI/sPESI, and not discharging patients without same-day anticoagulation 5