Composite Pulmonary Embolism Shock (CPES) Score
Identifies high-risk pulmonary embolism patients at risk for haemodynamic deterioration and cardiogenic shock requiring reperfusion (thrombolysis or embolectomy). Complements PESI and sPESI in intermediate-risk PE.
Score interpretation
CPES 0-2 -- low risk of haemodynamic deterioration; anticoagulation standard management
→ Therapeutic anticoagulation: LMWH (enoxaparin 1.5 mg/kg OD or 1 mg/kg BD); DOACs: rivaroxaban 15 mg BD x21 days then 20 mg OD (EINSTEIN-PE) or apixaban 10 mg BD x7 days then 5 mg BD (AMPLIFY); UFH if thrombolysis may be needed or renal impairment; risk-stratification echo and troponin; admit if intermediate-high risk (RV dysfunction + troponin); sPESI score for outpatient eligibility (sPESI 0 may be managed outpatient with DOAC).
CPES 3-4 -- intermediate risk; close haemodynamic monitoring and readiness for escalation
→ Admit to high-dependency or CCU monitoring; serial echo (repeat at 12-24 hours); serial troponin every 6 hours; haemodynamic monitoring: invasive arterial line if borderline BP; PESI/sPESI documentation; CT pulmonary angiography if not done; catheter-directed thrombolysis (CDT) consideration if RV strain worsening (PERFECT registry, OPTALYSE PE); if deteriorates to CPES >= 5: systemic thrombolysis or embolectomy; oxygen therapy; avoid sedation if possible (reduces preload/venous tone); vasopressor (noradrenaline) if MAP < 65 mmHg.
CPES >= 5 -- high risk; massive or submassive PE with haemodynamic compromise; reperfusion indicated
→ Systemic thrombolysis if haemodynamically unstable: alteplase 100 mg IV over 2 hours (or 0.6 mg/kg over 15 min in cardiac arrest); stop LMWH/DOAC before alteplase; restart UFH (without bolus) when aPTT < 80 seconds post-thrombolysis; surgical pulmonary embolectomy if thrombolysis contraindicated or failed (30-day mortality 20-25%); catheter-directed therapy (ultrasound-assisted CDT: EKOS catheter) if intermediate-high and thrombolysis relatively contraindicated; ICU level care; vasopressors: noradrenaline first-line; inhaled nitric oxide or prostacyclin for RV afterload reduction; avoid aggressive fluid administration (> 500 mL may worsen RV failure); ECMO as rescue if refractory; haematology review if thrombolytic relative contraindication.
Interpretation bands for the CPES Score. Apply clinical judgement and local guidance.
References
- Konstantinides SV et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2020;41(4):543-603.
- NICE NG158. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. NICE. 2020 (updated 2023).
Related
Curated clinical cross-links plus same-class fallbacks.
- Pulmonary Embolism Severity Index (PESI) · Pulmonary Embolism
- YEARS Algorithm for Pulmonary Embolism · Pulmonary Embolism
- Wells' Criteria for Pulmonary Embolism · Pulmonary Embolism
- Revised Geneva Score for Pulmonary Embolism · Pulmonary Embolism
- Bova Score for Pulmonary Embolism Complications · Pulmonary Embolism
- Pulmonary Embolism Severity Index (PESI) -- Full Version · Pulmonary Embolism
- Sildenafil · PDE5 Inhibitor — Pulmonary Arterial Hypertension
- Hydrocortisone (ICU — Stress Dosing) · Corticosteroid (ICU/Septic Shock)
- Nitric Oxide (Inhaled — iNO) · Selective Pulmonary Vasodilator
- Alteplase (STEMI Thrombolysis) · Thrombolytic / STEMI
- Streptokinase (STEMI Thrombolysis) · Thrombolytic / STEMI
- Noradrenaline (Cardiogenic Shock / Vasopressor) · Vasopressor / Cardiogenic Shock
- Acute Heart Failure · ESC 2021 Heart Failure Guidelines; NICE NG106
- NSTEMI / Unstable Angina · ESC 2020 NSTEMI Guidelines; NICE NG185
- New-Onset Atrial Fibrillation · ESC 2020 AF Guidelines; NICE NG196
- Hypertensive Emergency · ESC/ESH 2018 Hypertension Guidelines; NICE NG136
- Bradycardia Management · Resuscitation Council UK ABCDE; ESC 2021 Pacing Guidelines
- Ventricular Tachycardia / Fibrillation · Resuscitation Council UK ACLS; ESC 2022 Ventricular Arrhythmia Guidelines
Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.