Clinical Risk Assessment of Acute Intermediate-Risk Pulmonary Embolism Using Repeat Transthoracic Echocardiography

Current risk stratification algorithms for intermediate-risk pulmonary embolism (PE) inadequately identify patients who may benefit from escalated care interventions (ECIs) beyond anticoagulation and do not incorporate temporal assessments of right ventricular (RV) function.

To evaluate whether changes in tricuspid annular plane systolic excursion (TAPSE) on repeat transthoracic echocardiography (TTE) before ECIs are associated with clinical outcomes in acute intermediate-risk PE.

Acute intermediate-risk PE patients at a single quaternary care center were retrospectively identified. Inclusion required two or more TTE studies with TAPSE measurements before discharge or ECI initiation. Patients were stratified into worsening (ΔTAPSE < 0 mm) and stable/improving cohorts. The primary outcome was 30-day mortality. Secondary outcomes included 90-day mortality, intubation, ICU admission, vasopressor requirement, and ECIs.

Eighty-eight patients met inclusion criteria (38 worsening, 50 stable/improving). Worsening TAPSE was associated with a significantly increased risk of 30-day mortality (RR 5.26; p = 0.003), 90-day mortality (RR 3.01; p = 0.004), and intubation (RR 1.86; p = 0.010). In univariate logistic regression, each 1 mm increase in ΔTAPSE was associated with lower odds of 30-day mortality (OR 0.86; p = 0.005). Among 53 patients with initial TAPSE ≥16 mm, those with subsequent decline had significantly higher 30-day mortality (33.3% vs. 8.7%; p = 0.048).

Worsening RV function on repeat echocardiography was associated with short-term mortality in acute intermediate-risk PE, even with initially preserved cardiac function. Serial assessment of RV function may refine risk stratification, and the impact on patient triage and escalation decisions warrants prospective evaluation.