p.21 抽出テキスト

............................................................................ diagnostic algorithm (Figure 4) and immediate referral for reperfusion treatment, as explained in section 7, and displayed in Figure 6 and Supplementary Data Figure 1. Testing for laboratory biomarkers such as cardiac troponins or natriuretic peptides is not necessary for immediate therapeutic decisions in patients with high-risk PE.

In the absence of haemodynamic instability at presentation, further risk stratification of PE is recommended, as it has implications for early discharge vs. hospitalization or monitoring of the patient (explained in section 7). Table 8 provides an overview of the clinical, imaging, and laboratory parameters used to distinguish intermediateand low-risk PE. The PESI is—in its original or simplified form—the most extensively validated and most broadly used clinical score to date, as it integrates baseline indicators of the severity of the acute PE episode with aggravating conditions and the comorbidity of the patient. Overall, a PESI of class III or an sPESI of 0 is a reliable predictor of low-risk PE. In addition to clinical parameters, patients in the intermediate-risk group who display evidence of both RV dysfunction (on echocardiography or CTPA) and elevated cardiac biomarker levels in the circulation (particularly a positive cardiac troponin test) are classified into the intermediate-high-risk category. As will be discussed in more detail in section 7, close monitoring is recommended in these cases to permit the early detection of haemodynamic decompensation or collapse, and consequently the need for rescue reperfusion therapy.179 Patients in whom the RV appears normal on echocardiography or CTPA, and/or who have normal cardiac biomarker levels, belong to the intermediate-low-risk category. As an alternative approach, use of further prognostic scores combining clinical, imaging, and laboratory parameters may be considered to semi-quantitatively assess the severity of the PE episode, and distinguish intermediate-high-risk and intermediate-low-risk PE. Supplementary Data Table 4 lists the scores most frequently investigated for this purpose in observational (cohort) studies; however, none of them has been used in RCTs to date.

A recent meta-analysis included 21 cohort studies with a total of 3295 patients with ‘low-risk’ PE based on a PESI of III or an sPESI of 0.234 Overall, 34% (95% CI 3039%) of them were reported to have signs of RV dysfunction on echocardiography or CTPA. Data on early mortality were provided in seven studies (1597 patients) and revealed an OR of 4.19 (95% CI 1.3912.58) for death from any cause in the presence of RV dysfunction; elevated cardiac troponin levels were associated with a comparable magnitude of risk elevation.234 Early all-cause mortality rates (1.8% for RV dysfunction and 3.8% for elevated troponin levels234) were in the lower range of those previously reported for patients with intermediate-risk PE.235 Until the clinical implications of such discrepancies are clarified, patients with signs of RV dysfunction or elevated cardiac biomarkers, despite a low PESI or an sPESI of 0, should be classified into the intermediate-low-risk category.

Table 8 Classification of pulmonary embolism severity and the risk of early (in-hospital or 30 day) death

Early mortality risk Indicators of risk

Haemodynamic

instabilitya Clinical parameters

of PE severity and/ or comorbidity: PESI class III–V or

sPESI ≥1 RV dysfunction on

TTE or CTPAb Elevated cardiac

troponin levelsc

High + (+)d + (+)

Intermediate Intermediate–high - +e + +

Intermediate–low - +e One (or none) positive Low - - - Assesment optional;

if assessed, negative ©ESC 2019

BP = blood pressure; CTPA = computed tomography pulmonary angiography; H-FABP = heart-type fatty acid-binding protein; NT-proBNP = N-terminal pro B-type natriuretic peptide; PE = pulmonary embolism; PESI = Pulmonary Embolism Severity Index; RV = right ventricular; sPESI = simplified Pulmonary Embolism Severity Index; TTE = transthoracic echocardiogram. aOne of the following clinical presentations (Table 4): cardiac arrest, obstructive shock (systolic BP <90 mmHg or vasopressors required to achieve a BP >_90 mmHg despite an adequate filling status, in combination with end-organ hypoperfusion), or persistent hypotension (systolic BP <90 mmHg or a systolic BP drop >_40 mmHg for >15 min, not caused by new-onset arrhythmia, hypovolaemia, or sepsis). bPrognostically relevant imaging (TTE or CTPA) findings in patients with acute PE, and the corresponding cut-off levels, are graphically presented in Figure 3, and their prognostic value is summarized in Supplementary Data Table 3. cElevation of further laboratory biomarkers, such as NT-proBNP >_600 ng/L, H-FABP >_6 ng/mL, or copeptin >_24 pmol/L, may provide additional prognostic information. These markers have been validated in cohort studies but they have not yet been used to guide treatment decisions in randomized controlled trials. dHaemodynamic instability, combined with PE confirmation on CTPA and/or evidence of RV dysfunction on TTE, is sufficient to classify a patient into the high-risk PE category. In these cases, neither calculation of the PESI nor measurement of troponins or other cardiac biomarkers is necessary. eSigns of RV dysfunction on TTE (or CTPA) or elevated cardiac biomarker levels may be present, despite a calculated PESI of III or an sPESI of 0.234 Until the implications of such discrepancies for the management of PE are fully understood, these patients should be classified into the intermediate-risk category. Downloaded from academic.oup.com/eurheartj/article/41/4/543/5556136 by guest on 07 October 2026