Evidence-based risk stratification of patients with acute pulmonary embolism: Communication from the ISTH SSC Subcommittee on Predictive and Diagnostic Variables in Thrombotic Disease.

Background Acute pulmonary embolism (PE) includes clinical presentations with a wide spectrum of severities, making risk stratification essential to guide the decision-making process in daily practice. However, international guidelines differ in definition of risk classes and consequent treatment recommendations.Objective To summarize high quality evidence supporting four key management decisions in acute PE: hospitalization, intensive care unit (ICU) admission, reperfusion therapy and discharge.Methods A multidisciplinary ISTH taskforce completed with international experts conducted a literature review focused on randomized trials and prospective management studies reporting hard clinical outcomes and assessed as having a low risk of bias, focused on any of the 4 management decisions detailed above.Results And Conclusions Available evidence supports the use of either the Hestia criteria or (s)PESI combined with clinical judgment to select PE patients for outpatient treatment. In contrast, no PE-specific evidence exists to guide ICU admission. Reperfusion therapy in hemodynamically unstable patients is supported by one small, randomized trial, while currently available high-quality evidence does not support routine reperfusion therapy in hemodynamically stable patients; therefore, hemodynamic instability remains the only established indication for reperfusion therapy to date. The decision to discharge a PE patient may be supported by the use of sPESI combined with clinical assessment of stability. All in all, substantial evidence gaps persist, underscoring the need for further research to inform clinical practice and future guidelines.