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......................................................................................................... In patients admitted to the emergency department with haemodynamic instability and suspicion of PE, a combination of venous ultrasound with cardiac ultrasound may further increase specificity. Conversely, an echocardiogram without signs of RV dysfunction and a normal venous ultrasound excluded PE with a high (96%) negative predictive value in one study.167

For further details on the diagnosis and management of DVT, the reader is referred to the joint consensus document of the ESC Working Groups of Aorta and Peripheral Vascular Diseases, and Pulmonary Circulation and Right Ventricular Function.1

4.12 Computed tomography venography

When using CTPA, it is possible to image the deep veins of the legs during the same acquisition.115 However, this approach has not been widely validated and the added value of venous imaging is limited.164 Moreover, using CT venography is associated with increased radiation doses.168

5 Assessment of pulmonary

embolism severity and the risk of early death

Risk stratification of patients with acute PE is mandatory for determining the appropriate therapeutic management approach. As described in section 3.3, initial risk stratification is based on clinical symptoms and signs of haemodynamic instability (Table 4), which indicate a high risk of early death. In the large remaining group of patients with PE who present without haemodynamic instability, further (advanced) risk stratification requires the assessment of two sets of prognostic criteria: (i) clinical, imaging, and laboratory indicators of PE severity, mostly related to the presence of RV dysfunction; and (ii) presence of comorbidity and any other aggravating conditions that may adversely affect early prognosis. 5.1 Clinical parameters of pulmonary

embolism severity Acute RV failure, defined as a rapidly progressive syndrome with systemic congestion resulting from impaired RV filling and/or reduced RV flow output,68 is a critical determinant of outcome in acute PE. Tachycardia, low systolic BP, respiratory insufficiency (tachypnoea and/or low SaO2), and syncope, alone or in combination, have been associated with an unfavourable short-term prognosis in acute PE.

5.2 Imaging of right ventricular size and

function 5.2.1 Echocardiography Echocardiographic parameters used to stratify the early risk of patients with PE are graphically presented in Figure 3, and their prognostic values are summarized in Supplementary Data Table 3. Of these, an RV/LV diameter ratio >_1.0 and a TAPSE <16 mm are the findings for which an association with unfavourable prognosis has most frequently been reported.148 Overall, evidence for RV dysfunction on echocardiography is found in >_25% of unselected patients with acute PE.145 Systematic reviews and meta-analyses have suggested that RV dysfunction on echocardiography is associated with an elevated risk of short-term mortality in patients who appear haemodynamically stable at presentation,180,181 but its overall positive predictive value for PE-related death was low (<10%) in a metaanalysis.180 This weakness is partly related to the fact that echocardiographic parameters have proved difficult to standardize.148,180 Nevertheless, echocardiographic assessment of the morphology and function of the RV is widely recognized as a valuable tool for the prognostic assessment of normotensive patients with acute PE in clinical practice. In addition to RV dysfunction, echocardiography can identify rightto-left shunt through a patent foramen ovale and the presence of right heart thrombi, both of which are associated with increased

V/Q SPECT V/Q SPECT may be considered for PE diagnosis.121,126128 IIbd B Lower-limb CUS It is recommended to accept the diagnosis of VTE (and PE) if a CUS shows a proximal DVT in a patient with clinical suspicion of PE.164,165 I A If CUS shows only a distal DVT, further testing should be considered to confirm PE.177 IIa B If a positive proximal CUS is used to confirm PE, assessment of PE severity should be considered to permit risk-adjusted management.178,179 IIa C MRA MRA is not recommended for ruling out PE.139,140 III A

CT = computed tomographic; CTPA = computed tomography pulmonary angiography/angiogram; CUS = compression ultrasonography; DVT = deep vein thrombosis; i.v. = intravenous; MRA = magnetic resonance angiography; PE = pulmonary embolism; SPECT = single-photon emission computed tomography; UFH = unfractionated heparin; V/Q = ventilation/perfusion (lung scintigraphy); VTE = venous thromboembolism. aClass of recommendation. bLevel of evidence. cD-dimer cut-off levels adapted to clinical probability according to the YEARS model (signs of DVT, haemoptysis, and whether an alternative diagnosis is less likely than PE) may be used. According to this model, PE is excluded in patients without clinical items and D-dimer levels <1000 mg/L, or in patients with one or more clinical items and D-dimer levels <500 mg/L.107 dLow level of recommendation in view of the limitations summarized in Table 5. Downloaded from academic.oup.com/eurheartj/article/41/4/543/5556136 by guest on 07 October 2026