Risk Stratification and Management of Intermediate-Risk Acute Pulmonary Embolism

Abstract

Pulmonary embolism (PE) is the third most common cause of cardiovascular death and necessitates prompt, accurate risk assessment at initial diagnosis to guide treatment and reduce associated mortality. Intermediate-risk PE, defined as the presence of right ventricular (RV) dysfunction in the absence of hemodynamic compromise, carries a significant risk for adverse clinical outcomes and represents a unique diagnostic challenge. While small clinical trials have evaluated advanced treatment strategies beyond standard anticoagulation, such as thrombolytic or endovascular therapy, there remains continued debate on the optimal care for this patient population. Here, we review the most recent risk stratification models, highlighting differences between prediction scores and their limitations, and discuss the utility of serologic biomarkers and imaging modalities to detect right ventricular dysfunction. Additionally, we examine current treatment recommendations including anticoagulation strategies, use of thrombolytics at full and reduced doses, and utilization of invasive treatment options. Current knowledge gaps and ongoing studies are highlighted.

Management of Venous and Arterial Thrombosis

“…Its simplified form (sPESI) has limited specificity in predicting mortality among high-risk patients. Risk indicators for PE include serologic markers of right-ventricular dysfunction and myocardial injury, echocardiography, computed tomography pulmonary angiography (CTPA), and the evaluation of hemodynamic status via right-heart catheterization [14].…”

“…Systemic thrombolytic therapy reduces pulmonary arterial pressure and length of hospitalization [14]. In severe cases of iliofemoral DVT, catheter-directed thrombolytic systems and mechanical thrombectomy show promising results not only in terms of decreasing the risk of PE development and death but also in terms of ameliorating its later consequences [19].…”