Effective risk stratification in pulmonary embolism: evaluating current tools and identifying research gaps

Currently, most international guidelines advocate for risk stratification of acute pulmonary embolism (PE) as a framework to guide treatment decisions. Key prognostic factors for patients with PE include clinical presentation, comorbidities, (imaging) biomarkers and haemodynamic status. The most widely used risk stratification algorithm, outlined in the 2019 European Society of Cardiology/European Respiratory Society guidelines, classifies patients with PE into high-risk (massive), (high or low) intermediate-risk (submassive) and low-risk (nonmassive) categories. It is well established that the risk of adverse outcomes, including mortality, increases with each escalating risk level. However, substantial variation remains among leading international guidelines regarding risk stratification and corresponding treatment recommendations. This inconsistency stems from a lack of grade/level 1A evidence (i.e. strong recommendation based on high-quality evidence) to guide treatment decisions for certain PE risk profiles. In the coming years, ongoing randomised trials comparing novel reperfusion strategies with the current standard of care may reshape risk stratification. If successful, the selection criteria for these studies could lay the foundation for improved risk categories.This review aims to provide a comprehensive summary of existing risk stratification algorithms and their associated treatment recommendations, identify knowledge gaps and outline future research priorities.