Management of Pulmonary Embolism Based on PESI Guidelines

Risk Stratification Tools

The Pulmonary Embolism Severity Index (PESI) was derived and validated using a cohort of 15,752 patients with confirmed pulmonary embolism, and classifies patients into five risk classes (I-V) based on 30-day mortality risk 1
PESI classes I (very low risk) and II (low risk) had 30-day mortality rates of ≤1.6% and 3.6%, respectively, demonstrating excellent discriminatory power with area under the ROC curve of 0.77-0.87 1
The simplified PESI (sPESI) consists of six variables with binary scoring (0 or 1 point for each variable), and a score of zero classifies patients as low risk, with low-risk patients (sPESI=0) having 30-day mortality of 1.0-1.1% 3

Patients with confirmed pulmonary embolism should be risk-stratified using the PESI or simplified PESI (sPESI) to determine appropriate management setting, with low-risk patients (PESI class I/II or sPESI 0) eligible for outpatient treatment when additional exclusion criteria are met 1, 2
Low-risk patients (PESI I/II or sPESI=0) without exclusion criteria should be offered outpatient management, while intermediate-risk patients (PESI III or higher) should be considered for inpatient management, and high-risk patients (hemodynamically unstable) require inpatient management with consideration of thrombolysis 2, 5, 6

Outpatients with confirmed pulmonary embolism should receive either low molecular weight heparin (LMWH) and dabigatran, LMWH and edoxaban, or a single-drug regimen (apixaban or rivaroxaban) 5

A robust pathway for follow-up and monitoring must exist for outpatient management, and patients with suspected pulmonary embolism should ideally undergo same-day investigation 1, 5
All patients considered for outpatient management should be reviewed by a consultant or appropriate senior clinician before discharge, and pregnant and postpartum women require consultant review and discussion with maternity services prior to discharge 5