Score interpretation

Class I — Very Low Risk (~1% mortality) 0–65

PESI Class I (≤ 65): Very low 30-day mortality. Outpatient treatment may be appropriate.

→ Consider outpatient DOAC (rivaroxaban or apixaban) if no contraindications, good social support, and Hestia criteria negative. Follow-up within 24–48 hours.

Class II — Low Risk (~3.5% mortality) 66–85

PESI Class II (66–85): Low 30-day mortality. Short admission or close outpatient follow-up.

→ Short admission for observation vs outpatient with safety-netting. Apply Hestia criteria. DOAC therapy (rivaroxaban/apixaban preferred).

Class III — Moderate Risk (~7% mortality) 86–105

PESI Class III (86–105): Moderate 30-day mortality. Inpatient admission required.

→ Admit. Anticoagulation: LMWH bridge or DOAC. Monitor haemodynamics. Troponin and BNP to further risk stratify. Echo if haemodynamically unstable.

Class IV — High Risk (~11% mortality) 106–125

PESI Class IV (106–125): High 30-day mortality.

→ Admit — consider HDU. Assess right heart strain (Echo, BNP, troponin). Respiratory/haematology consult. LMWH or UFH if haemodynamically unstable.

Class V — Very High Risk (~25% mortality) ≥ 126

PESI Class V (> 125): Very high 30-day mortality.

→ ICU-level care. Haemodynamic resuscitation. Consider systemic thrombolysis if massive PE with haemodynamic compromise. Surgical/interventional embolectomy if thrombolysis contraindicated.

Interpretation bands for the PESI. Apply clinical judgement and local guidance.

Pulmonary Embolism Severity Index (PESI)

Score interpretation

References

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