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.

Keywords: intermediate-risk pulmonary embolism; right ventricular dysfunction; risk stratification; thrombolytic therapy.

Figure 1

Computed tomography angiography findings consistent with right ventricular dysfunction [32]. (A) CTA chest: Axial image at the level of the mitral valve. Solid arrow demonstrating enlargement of the right ventricle compared to the left ventricular cavity. Dashed arrow highlights the deviation of the interventricular septum towards the left ventricle. (B) Transthoracic ECHO (same patient): shortened pulmonary ejection acceleration time (AcT) with a “notched” midsystolic velocity deceleration in the RV outflow track (white arrow). (C) Transthoracic ECHO (same patient): demonstrating tricuspid regurgitation (TR) peak systolic gradient (TRPG) of less than 60 mm Hg (42.7 mm Hg), consistent with the proposed 60/60 sign.

Figure 2

Decision–making in management of intermediate–risk pulmonary embolism.