PE RISK STRATIFICATION 
 

We use 3 things:

1. Hemodynamics (blood pressure)

2. RV dysfunction (echo or CT)

3. Cardiac biomarkers (troponin, BNP)

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1. HIGH-RISK (MASSIVE PE) — Needs thrombolysis

Criteria:

• Hypotension (SBP < 90 for >15 min)
  OR

• Shock (lactate elevated, altered MS, cold extremities)

Imaging/Biomarkers:

• RV dilation (RV:LV > 1)

• Troponin ↑, BNP ↑

ICU Management:

• Heparin → Systemic thrombolysis (tPA)

• Consider ECMO or catheter thrombectomy

Mortality: 15–30%

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2. INTERMEDIATE-HIGH RISK PE

(Normotensive but BOTH RV dysfunction + positive biomarkers)

Criteria:

• Normal BP
  BUT

• RV dysfunction

  • Echo: RV dilation (RV/LV > 1), McConnell sign

  • CT: RV enlargement

• AND elevated biomarkers:

  • Troponin

  • BNP

This is the “worrisome” PE—watch closely.

ICU Management:

• Start anticoagulation

• Monitor closely in ICU (risk of collapse)

• Consider thrombolysis if:

  • Clinical deterioration

  • Rising cardiac enzymes

  • Worsening RV

Mortality: 5–10%

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3. INTERMEDIATE-LOW RISK PE

(Normotensive + either RV dysfunction OR biomarker elevation, but NOT both)

Either:

• RV dysfunction only
  OR

• Elevated troponin/BNP only

But not both.

Management:

• Anticoagulation

• Floor or step-down (may need telemetry)

• Monitor carefully but not usually ICU

Mortality: ~3–5%

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4. LOW-RISK PE

Criteria:

• Normal BP

• NO RV dysfunction

• NO elevated biomarkers

Often small peripheral PE.

Management:

• Outpatient therapy possible (depending on situation)

• DOAC preferred if stable

• No ICU needed

 Mortality: <1%

 

 

 QUICK VISUAL TABLE (SUPER HIGH-YIELD)

Risk Group	BP	RV dysfunction	Troponin/BNP	Mortality	Treatment
High (Massive)	Low BP/Shock	Yes/No	Yes/No	15–30%	Thrombolysis, ICU, ECMO
Intermediate-High	Normal	Yes	Yes	5–10%	ICU, consider lytics if worsening
Intermediate-Low	Normal	± (One positive)	± (One positive)	3–5%	Anticoagulation, telemetry
Low-Risk	Normal	No	No	<1%	Outpatient possible

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ICU PEARLS

• BP is the most important factor for “massive” PE.

• Intermediate-High is the group that may suddenly decompensate → monitor in ICU.

• Echo is critical — quickest way to identify RV dysfunction.

• Troponin elevations correlate with RV strain and worse prognosis.

• Thrombolysis is NOT routine in Intermediate-High unless patient deteriorates.

• LACTATE elevation is a bad prognostic sign regardless of category.

 

• a massive PE, don’t wait for CT if unstable — bedside echo + treat

• Heparin is preferred because easy to turn off if thrombolysis needed

• RV failure is the cause of death → treat RV, not just PE

• Use low tidal volumes + avoid high PEEP (high PEEP worsens RV failure)

• Watch for PFO (right-to-left shunt) in severe cases

• Lactate correlates with severity

• PE can cause obstructive shock → resembles tamponade physiology

 

Thrombolysis (Lytics)

Indication: MASSIVE PE

• Hypotension or shock

• Cardiac arrest from PE

Medication:

Alteplase (tPA)

• 100 mg IV over 2 hours

During arrest:

• 50 mg IV bolus, repeat once

Submassive PE

• Consider thrombolysis if worsening RV failure, rising troponin, or decompensation

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 Mechanical Thrombectomy / Catheter-Directed Thrombolysis

Use if:

• Absolute contraindication to systemic thrombolysis

• High bleeding risk

• Severe RV failure

• Persistent shock despite heparin

Examples:

• EKOS catheter

• Suction thrombectomy

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 ECMO (VA-ECMO)

Used for:

• Cardiac arrest from PE

• Severe obstructive shock

• Bridge to thrombectomy or recovery

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 Managing RV Failure in PE (CRITICAL FOR ICU)

Optimize preload

• Avoid excessive fluids

• Small bolus (250–500 mL) only if hypovolemic

• Overload worsens RV dilation and septal shift

Support contractility

• Dobutamine or Milrinone (but may drop BP)

• In severe shock → combine with norepinephrine

Reduce RV afterload

• Oxygen

• Correct acidosis

• Avoid hypoxia/hypercapnia

• Consider inhaled vasodilators:

  • Inhaled nitric oxide

  • Inhaled epoprostenol

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 When Not to Thrombolyse

Absolute contraindications:

• Active bleeding

• Recent brain or spinal surgery (3 months)

• Prior intracranial hemorrhage

• Ischemic stroke < 3 months

• Severe head trauma

Relative contraindications:

• Anticoagulated patients

• Recent surgery

• Severe uncontrolled hypertension (>180/110)

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