Recent advances in risk stratification and treatment of acute pulmonary embolism

Table 1 Comparison of risk stratification models and parameters in acute pulmonary embolism

Ref.	Risk model/marker	Clinical application	Clinical use	Statistical performance	Advantages	Limitations
Aujesky et al[23], 2005	PESI	30-day mortality	Risk stratification for 30-day mortality	95% sensitivity, 38% specificity (for PE mortality)[24]	Only clinical assessment	Multiple parameters, no assessment of RV strain, low specificity
Jiménez et al[25], 2010	sPESI	30-day mortality, 30-day recurrent VTE/PE or bleeding	Simpler alternative to PESI	96% sensitivity, 37% specificity (for PE mortality)[24]	Simple and fast	No assessment of RV strain, low specificity
Zondag et al[26], 2011	Hestia criteria	Low-risk patients identification	Determines eligibility for outpatient management	82% sensitivity, 56% specificity (low-risk identification)[27]	99% negative prognostic value, solid validation data	Only low-risk assessment
Bova et al[28], 2014	BOVA score	30-day clinical deterioration and mortality	Identifies patients who may need escalated care	AUROC = 0.73, 95%CI: 0.68-0.77 (PE complication prediction)	Incorporates RV dysfunction, separates normotensive PE SBP > 90 mmHg from > 100 mmHg	Requires imaging and blood tests
Vanni et al[29], 2013	Plasma lactate	Clinical deterioration and 30-day mortality	Helps identify normotensive shock	HR = 11.67; 95%CI: 3.32-41.03 (all cause 30-day mortality)	Identifies hypoperfusion, thus true hemodynamic impact	Used supplementary to enhance risk models, requires sequential ABG assessment
Otero et al[30], 2007	Shock index	30-day mortality	Used in risk stratification for hemodynamic instability	SI vs SBP < 90 mmHg; specificity: 86.3% vs 96.6%, sensitivity: 30.5% vs 7.9%	Improves hemodynamic assessment	Lower specificity compared to SBP < 90 mmHg, limited value in hypertensive patients
Grade Santos et al[31], 2022	NEWS score	Clinical deterioration and 30-day mortality	Used in hospitalized patients for early detection of worsening PE	Greater predictive power compared to PESI (OR = 1.35; 95%CI: 1.11-1.64, P = 0.003 vs OR = 1.02; 95%CI: 1.00-1.03, P = 0.03)	Already widely used and validated in various health systems	Not specific for PE
Meinel et al[32], 2015	RV/LV ratio (CTPA)	Mortality and adverse outcomes up to 6 months	Predicts PE outcomes by RV dysfunction assessment	All-cause mortality (OR = 2.5; 95%CI: 1.8-3.5)	Calculated from CTPA if echocardiography is not available	Requires imaging
Pruszczyk et al[33], 2014	TAPSE	30-day mortality or need for rescue thrombolysis	Predicts PE outcomes by RV dysfunction assessment	Better AUC compared to RV/LV ratio (0.91, 95%CI: 0.856-0.935; P = 0.0001 vs 0.638, 95%CI: 0.589-0.686; P = 0.001)	Single parameter compared to RV/LV	Requires echocardiography
Kiamanesh et al[34], 2022	TAPSE/PASP ratio (RV-PA uncoupling)	Adverse events in normotensive PE	Predicts PE outcomes by RV-PA uncoupling	For each 0.1 mm/mmHg decrease in TAPSE/PASP (adjust OR = 2.49, 95%CI: 1.46-4.24, P = 0.001)	Allows the assessment of the true hemodynamic impact of PE in RV function	Requires echocardiography, limited evidence in PE

PESI: Pulmonary embolism severity index; sPESI: Simplified pulmonary embolism severity index; NEWS: National Early Warning Score; TAPSE: Tricuspid annular plane systolic excursion; PE: Pulmonary embolism; VTE: Venous thromboembolism; TAPSE: Tricuspid annular plane systolic excursion; PASP: Pulmonary artery systolic pressure; RV: Right ventricle; RV/LV ratio: Right ventricular to left ventricular diameter ratio; PA: Pulmonary artery; OR: Odds ratio; HR: Hazard ratio; CI: Confidence interval; AUROC: Area under the receiver operating characteristic curve; CTPA: Computed tomography pulmonary angiogram; SBP: Systolic blood pressure.