respiratory emergency

Pulmonary Embolism Severity Index (PESI) -- Full Version

Full PESI score predicts 30-day mortality in acute pulmonary embolism. Classifies patients into 5 risk classes (I-V) based on age, sex, cancer, heart failure, COPD, heart rate, systolic BP, respiratory rate, temperature, mental status, and O2 saturation. Risk Class I-II (very low/low) may be suitable for outpatient treatment with DOAC. Validated in 11,000+ patients. Note: simplified PESI (sPESI) also available in this app.

Patient age (years) -- age is added directly to the score*(years)

Sex*

Cancer (history of or active cancer)*

Heart failure (known chronic heart failure)*

Chronic lung disease (COPD, asthma, pulmonary fibrosis)*

Heart rate above 110 bpm*

Systolic blood pressure below 100 mmHg*

Respiratory rate at or above 30/min*

Temperature below 36 degrees Celsius*

Altered mental status (disorientation, lethargy, stupor, or coma)*

SpO2 below 90% on room air*

Score interpretation

PESI Class I -- Very Low Risk (30-day mortality 1.1%) 0–65

PESI Class I (at or below 65) -- very low 30-day PE mortality

→ Outpatient treatment appropriate if: no hypoxia, no bilateral DVT, no renal impairment, patient can take oral medications, adequate support at home (per Hestia criteria); start DOAC immediately (rivaroxaban 15 mg BD x 21 days then 20 mg OD, or apixaban 10 mg BD x 7 days then 5 mg BD, or edoxaban after 5-10 days parenteral, or dabigatran after 5-10 days parenteral); ensure patient has written instructions on anticoagulation duration and signs of worsening; GP follow-up within 1 week; consider Hestia checklist before discharge.

PESI Class II -- Low Risk (30-day mortality 3.1%) 66–85

PESI Class II (66-85) -- low 30-day mortality; consider outpatient treatment with caution

→ Consider outpatient treatment vs short inpatient stay (24-48 hours); if Hestia criteria met and no right heart strain on ECG/echo: discharge with DOAC; if hospitalised: parenteral anticoagulation (LMWH or fondaparinux) then transition to DOAC or warfarin; ensure echocardiography if troponin elevated or clinical deterioration; follow-up respiratory outpatient within 2-4 weeks; provoked vs unprovoked PE assessment for anticoagulation duration.

PESI Class III -- Intermediate Risk (30-day mortality 6.5%) 86–105

PESI Class III (86-105) -- intermediate risk; inpatient monitoring required

→ Hospitalise; anticoagulation: LMWH (enoxaparin 1 mg/kg BD SC, or dalteparin weight-based) initially, transition to DOAC when clinically stable; monitor troponin, BNP/NT-proBNP, and echo for right heart strain (if RV dysfunction: upgrade to PESI IV management); respiratory physician or medicine consultant review; monitor oxygen saturation; VTE team input; consider CT pulmonary angiogram if not already done; assess for underlying cause (thrombophilia, malignancy if unprovoked PE); anticoagulation duration depends on provoked vs unprovoked classification.

PESI Class IV -- High Risk (30-day mortality 13.1%) 106–125

PESI Class IV (106-125) -- high risk; inpatient management with close monitoring

→ Hospital admission; HDU or closely monitored medical ward; assess for haemodynamic instability (SBP below 90, HR above 100): if haemodynamically unstable -- consider systemic thrombolysis (alteplase 100 mg IV over 2 hours) or surgical embolectomy or catheter-directed therapy; anticoagulation: IV UFH preferred (bolus 80 units/kg then 18 units/kg/hr, titrate to APTT 60-100 seconds) if thrombolysis candidate; if haemodynamically stable: LMWH; echocardiography urgently; troponin and BNP; PE response team (PERT) activation if available; escalate to ICU if deteriorating.

PESI Class V -- Very High Risk (30-day mortality 24.5%) ≥ 126

PESI Class V (above 125) -- very high risk; urgent multidisciplinary escalation

→ ICU admission; PE response team (PERT) activation urgently; IV UFH immediately (bolus 80 units/kg then 18 units/kg/hr, monitor APTT 60-100 seconds); haemodynamic support: vasopressors (noradrenaline) if shock; if massive PE with haemodynamic collapse: systemic thrombolysis is life-saving (alteplase 10 mg IV bolus then 90 mg over 2 hours -- contraindicated if recent surgery within 10 days, stroke, active bleeding); if thrombolysis contraindicated or failed: catheter-directed therapy (CDT) or surgical embolectomy at specialist centre; ECMO if refractory cardiac arrest; RV support; multi-organ monitoring; involve cardiothoracics early.

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

References

Aujesky D et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med. 2005;172(8):1041-1046.
Konstantinides SV et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2020;41(4):543-603.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Drugs

Pathways

Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.

Score interpretation

References

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