Acute Pulmonary Embolism — Risk Stratification & Treatment Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Hemodynamically unstable?
   Is the patient hemodynamically unstable? (After confirmed/highly suspected PE, stratify by early mortality risk. High-risk = hemodynamic instability (SBP <90 or a drop ≥40 mmHg from baseline for ≥15 min, needing vasopressors, shock). Anticoagulate all patients early (unless contraindicated).)
   • High-risk (unstable) → High-risk → reperfusion
   • Stable → Not high-risk · re-stratify
2. [End] High-risk → reperfusion
   High-risk PE (shock/hypotension): systemic thrombolysis (preferred reperfusion if no contraindication, e.g. alteplase) + anticoagulation (unfractionated heparin preferred); if thrombolysis is contraindicated/fails → catheter-directed or surgical embolectomy. Circulatory support (cautious fluids, norepinephrine, ECMO if needed).
3. [Decision] Not high-risk · re-stratify
   Not high-risk: re-stratify by PESI/sPESI + RV function + cardiac biomarkers? (In non-high-risk patients, use PESI (class I–II) or sPESI (0) to identify low risk; RV dysfunction (echo/CT) and troponin/BNP define the intermediate subgroups.)
   • Low-risk (PESI I–II/sPESI 0, no RV involvement) → Low-risk
   • Intermediate (RV dysfunction and/or raised biomarkers) → Intermediate-risk
4. [End] Low-risk
   PESI I–II or sPESI 0, no RV dysfunction and normal biomarkers: anticoagulation alone (usually a DOAC); early discharge / outpatient treatment may be considered. Give return advice.
5. [End] Intermediate-risk
   Inpatient anticoagulation (DOAC, or LMWH → DOAC). Intermediate-high risk (both RV dysfunction and raised biomarkers) needs close monitoring; do not routinely give full-dose thrombolysis (bleeding risk, PEITHO); give rescue thrombolysis or catheter-directed therapy the moment hemodynamics deteriorate. Intermediate-low risk: inpatient monitoring and anticoagulation.

Source guidelines & references

• 2019 ESC Guidelines on the diagnosis and management of acute pulmonary embolism (with ERS)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

Other pathways