Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism

Short-term mortality prediction in acute pulmonary embolism: Radiomics values of skeletal muscle and intramuscular adipose tissue

BACKGROUND

Acute pulmonary embolism (APE) is a potentially life-threatening disorder, emphasizing the importance of accurate risk stratification and survival prognosis. The exploration of imaging biomarkers that can reflect patient survival holds the potential to further enhance the stratification of APE patients, enabling personalized treatment and early intervention. Therefore, in this study, we develop computed tomography pulmonary angiography (CTPA) radiomic signatures for the prognosis of 7- and 30-day all-cause mortality in patients with APE.

METHODS

Diagnostic CTPA images from 829 patients with APE were collected. Two hundred thirty-four features from each skeletal muscle (SM), intramuscular adipose tissue (IMAT) and both tissues combined (SM + IMAT) were calculated at the level of thoracic vertebra 12. Radiomic signatures were derived using 10 times repeated three-fold cross-validation on the training data for SM, IMAT and SM + IMAT for predicting 7- and 30-day mortality independently. The performance of the radiomic signatures was then evaluated on held-out test data and compared with the simplified pulmonary embolism severity index (sPESI) score, a well-established biomarker for risk stratification in APE. Predictive accuracy was assessed by the area under the receiver operating characteristic curve (AUC) with a 95% confidence interval (CI), sensitivity and specificity.

RESULTS

The radiomic signatures based on IMAT and a combination of SM and IMAT (SM + IMAT) achieved moderate performance for the prediction of 30-day mortality on test data (IMAT: AUC = 0.68, 95% CI [0.57-0.78], sensitivity = 0.57, specificity = 0.73; SM + IMAT: AUC = 0.70, 95% CI [0.60-0.79], sensitivity = 0.74, specificity = 0.54). Radiomic signatures developed for predicting 7-day all-cause mortality showed overall low performance. The clinical signature, that is, sPESI, achieved slightly better performance in terms of AUC on test data compared with the radiomic signatures for the prediction of both 7- and 30-day mortality on the test data (7 days: AUC = 0.73, 95% CI [0.67-0.79], sensitivity = 0.92, specificity = 0.16; 30 days: AUC = 0.74, 95% CI [0.66-0.82], sensitivity = 0.97, specificity = 0.16).

CONCLUSIONS

We developed and tested radiomic signatures for predicting 7- and 30-day all-cause mortality in APE using a multicentric retrospective dataset. The present multicentre work shows that radiomics parameters extracted from SM and IMAT can predict 30-day all-cause mortality in patients with APE.

Clinical Presentation and Risk Stratification of Pulmonary Embolism

Pulmonary embolism (PE) presents with a spectrum of symptoms, ranging from asymptomatic cases to life-threatening events. Common symptoms include sudden dyspnea, chest pain, limb swelling, syncope, and hemoptysis. Clinical presentation varies based on thrombus burden, demographics, and time to presentation. Diagnostic evaluation involves assessing symptoms, physical examination findings, and utilizing laboratory tests, including D-dimer. Risk stratification using tools like Wells score, Pulmonary Embolism Severity Index, and Hestia criteria aids in determining the severity of PE. PE is categorized based on hemodynamic status, temporal patterns, and anatomic locations of emboli to guide in making treatment decisions. Risk stratification plays a crucial role in directing management strategies, with elderly and comorbid individuals at higher risk. Early identification and appropriate risk stratification are essential for effective management of PE. As we delve into this review article, we aim to enhance the knowledge base surrounding PE, contributing to improved patient outcomes through informed decision-making in clinical practice.

The BNP to Albumin Ratio and Heart Rate in Stroke Complicating Atrial Fibrillation

Heart rate is still a controversial and unclear factor of stroke risk in atrial fibrillation. Indices combining parameters are more accurate predictors than single parameters. This article assessed the association of the BNP-to-albumin ratio (BAR), with the risk of stroke, and evaluated the relationship between heart rate and stroke risk. Data were retrospectively collected from the Zhongnan Hospital electronic records. Binary logistic regression assessed the association between BAR and the prediction of acute stroke in atrial fibrillation. Spearman's correlation analysis evaluated the correlation between heart rate and BAR. The specificity and sensitivity of the BAR index were determined by ROC curve analysis. A total of 197 participants were involved, including 119 cases and 78 controls. The mean BAR was significantly higher for cases than for controls P = 0.00 while the difference in mean heart rate did not reach statistical significance P = 0.08. Using binary logistic analysis, BAR was a significant predictor of stroke in AF, OR = 1.67 95%CI [1.09-2.55] P = 0.018. The correlation between BAR and heart rate was significant, the correlation coefficient was r = 0.15 P = 0.03. ROC curve analysis showed that at a cut-off value of 2.01*10-9 g/L 93% of patients with a BAR of less than 2.01 did not have an acute stroke and only the 60% with a BAR greater than 2.01 experienced an acute stroke. It's been suggested that the BNP to albumin ratio and heart rate could be used to estimate the risk of stroke among hospitalized atrial fibrillation patients, thus contributing to the implementation of appropriate measures.

Comparison of the efficacy and safety of rivaroxaban and low-molecular-weight heparin in Chinese lung cancer patients with nonhigh-risk pulmonary embolism

BACKGROUND

Data that guide selection of differing anticoagulant regimens for specific cancer-associated venous thromboembolism (VTE) are lacking. We aimed to compare the efficacy and safety of rivaroxaban and low-molecular-weight heparin (LMWH) against nonhigh-risk pulmonary embolism (PE) in Chinese lung cancer patients.

METHODS

Four hundred forty-six Chinese lung cancer patients with nonhigh-risk PE who initiated treatment with rivaroxaban or LMWH were identified from Zhongshan Hospital database from 2016 to 2020. The primary outcomes were the composite event of VTE recurrence or major bleeding, and all-cause mortality. The secondary outcomes were VTE recurrence, major bleeding and clinically relevant non-major bleeding (CRNMB). Propensity score matching was used to balance baseline covariates. We conducted sensitivity analysis by stabilized inverse probability of treatment weighting and competing risk analysis by a Fine and Gray subdistribution hazard model.

RESULTS

In propensity score-matched cohorts, rivaroxaban was similar to LMWH in the risks of the composite outcome (hazard ratio (HR), 0.73; 95% confidence interval (CI), 0.45-1.21; P = 0.22), VTE recurrence (HR, 0.69; 95% CI, 0.36-1.34; P = 0.28), major bleeding (HR, 0.79; 95% CI, 0.37-1.68; P = 0.54) and CRNMB (HR, 1.13; 95% CI, 0.62-2.09; P = 0.69). All-cause mortality was significantly lower in rivaroxaban group than LMWH group (HR, 0.52; 95% CI, 0.36-0.75; P < 0.001). The primary and secondary outcomes favored rivaroxaban over LMWH in all the subgroups expect for central PE and intermediate-risk PE. The sensitivity analysis yielded similar results, and competing risk analysis was in accordance with the primary findings.

CONCLUSIONS

Rivaroxaban might be a promising alternative to LMWH as initial treatment for nonhigh-risk PE in lung cancer patients.

Risks, diagnosis, and management of recurrent cancer-associated thrombosis (CAT): a narrative review

This paper aims to provide a narrative review of the risks, diagnosis, and management of recurrent venous thromboembolism (VTE) in cancer patients. There is an established association between cancer and VTE, with cancer being a major risk factor for VTE. A history of VTE, short duration of oral anticoagulation, and a proximal DVT are all associated with increased risk for recurrent VTE. Studies have shown that certain cancers (e.g., metastatic genitourinary, lung, and colorectal cancers) are associated with recurrent VTE. Published literature shows that cancer is prothrombotic, and various mechanisms have been postulated as pathways for increased thrombogenesis and hence recurrent VTE in cancer. The symptoms, signs, laboratory information, and imaging results for the diagnosis of recurrent VTE are similar to those of an initial VTE. Management of recurrent VTE involves using low molecular weight heparin (LMWH) or a direct oral anticoagulant (DOAC). Vitamin K antagonists (VKA) or inferior vena cava (IVC) filters are less commonly used.

Acute pulmonary embolism multimodality imaging prior to endovascular therapy

The manuscript discusses the application of CT pulmonary angiography, ventilation–perfusion scan, and magnetic resonance angiography to detect acute pulmonary embolism and to plan endovascular therapy. CT pulmonary angiography offers high accuracy, speed of acquisition, and widespread availability when applied to acute pulmonary embolism detection. This imaging modality also aids the planning of endovascular therapy by visualizing the number and distribution of emboli, determining ideal intra-procedural catheter position for treatment, and signs of right heart strain. Ventilation–perfusion scan and magnetic resonance angiography with and without contrast enhancement can also aid in the detection and pre-procedural planning of endovascular therapy in patients who are not candidates for CT pulmonary angiography.

Longitudinal increases in blood biomarkers of inflammation or cardiovascular disease and the incidence of venous thromboembolism

Essentials Inflammatory and cardiac diseases are associated with increased venous thromboembolism (VTE) risk. Our prospective study assessed rise in inflammatory or cardiac biomarkers and VTE risk. A greater 6-year rise in N-terminal natriuretic peptide is associated with increased VTE incidence. Volume overload or impending cardiac disease may contribute to VTE occurrence.

SUMMARY

Background We previously showed that participants in the population-based Atherosclerosis Risk in Communities (ARIC) cohort with elevated levels of blood biomarkers of inflammation or cardiac disease were at increased risk of venous thromboembolism (VTE). Objective We hypothesized that ARIC participants with larger 6-year increases in the levels of three biomarkers - C-reactive protein (CRP), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and troponin T - would also have an increased subsequent risk of VTE. Methods We measured changes in the levels of these biomarkers in 9844 participants from 1990-1992 to 1996-1998, and then identified VTEs through 2015. Results A greater 6-year rise in the level of NT-proBNP, but not in that of CRP or troponin T, was significantly associated with increased VTE incidence over a median of 17.6 years of follow-up. After adjustment for other VTE risk factors, those whose NT-proBNP level rose from < 100 pg mL-1 to ≥ 100 pg mL-1 had a hazard ratio for VTE of 1.44 (95% confidence interval [CI] 1.15-1.80), as compared with the reference group with an NT-proBNP level of < 100 pg mL-1 at both times. This hazard ratio was slightly higher (1.66, 95% CI 1.19-2.31) during the first 10 years of follow-up, but was attenuated (1.24, 95% CI 0.99-1.56) after adjustment for prevalent and incident coronary heart disease, heart failure, and atrial fibrillation. Conclusions The two most likely explanations for our results are that: (i) an increasing NT-proBNP level reflects increasing subclinical volume overload and potentially increased venous stasis or subclinical PE that had gone unrecognized over time; or (ii) an increasing NT-proBNP level is a risk marker for impending cardiac disease that places patients at risk of VTE.

Association of elevated NTproBNP with recurrent thromboembolic events after acute pulmonary embolism

INTRODUCTION

N-Terminal Pro-Brain Natriuretic Peptide (NTproBNP) is a predictor of adverse short-term clinical outcomes in patients with acute pulmonary embolism (APE), but its long-term prognostic value remains largely undefined. The aim of this study was to assess the value of plasma NTproBNP with regard to recurrent venous thromboembolism (VTE).

MATERIALS AND METHODS

NTproBNP levels were measured in 224 consecutive patients with the first episode of acute pulmonary embolism occurring from January 2005 through October 2010. Patients were categorized into two groups by NTproBNP reference range. Follow-ups were performed at 3, 6, and 12months and yearly thereafter. The primary end point was symptomatic, recurrent fatal or nonfatal VTE.

RESULTS

NTproBNP was elevated in 158 (70.5%) patients and not elevated in 66 (29.5%) patients. After a mean follow-up period of 31.0±19.4months, patients with elevated NTproBNP showed an increased risk of recurrent VTE (20 patients, 12.7%) compared to those without elevated NTproBNP (only 1 patient, 1.5%) (P=0.009). Of the 7 deaths related to pulmonary embolism, 6 occurred in patients with elevated NTproBNP compared to patients with normal NTproBNP (1 of 7 deaths). In a multivariate analysis stratified by oral anticoagulant treatment duration, elevated NTproBNP was an independent predictor of recurrent VTE (hazard ratio, 9.32; P=0.02).

CONCLUSIONS

Elevated NTproBNP is associated with recurrent VTE in acute pulmonary embolism patients.

Are biomarkers additive to pulmonary embolism severity index for severity assessment in normotensive patients with acute pulmonary embolism?

BACKGROUND

Biomarkers and clinical prediction rules have been proposed for severity assessment in acute pulmonary embolism (PE).

AIM

The aim of this study was to compare biomarkers with the PE Severity Index (PESI), a validated scoring system for predicting 30-day mortality and to determine if addition of biomarkers to PESI would improve its predictive accuracy.

STUDY DESIGN AND METHODS

We conducted a retrospective analysis of normotensive patients admitted with PE confirmed by CT pulmonary angiogram, to three teaching hospitals between January 2005 and July 2007. All patients had admission levels of D-dimer and Troponin I and calculation of PESI score on admission. The outcome of interest was 30-day mortality.

RESULTS

There were 411 patients included in the study. Patients who died had higher levels of D-dimer (median 2947 ng/ml vs. 1464 ng/ml; P=0.02), Troponin (57.1% positive vs. 13.8%; P<0.0001) and higher PESI scores [median 109 vs. 83; P<0.0001], compared to survivors. PESI had superior accuracy for predicting 30-day mortality than a combination of Troponin and D-dimer (AUC 0.80 vs. 0.75). Addition of Troponin to PESI further improved the predictive value of the score (AUC 0.85 for vs. AUC 0.80 for PESI alone).

CONCLUSION

Biomarkers and clinical prediction rules predict outcome in acute PE. Addition of troponin to the PESI scoring system improves the predictive value for 30-day mortality and may be useful for guiding initial management of patients presenting with PE.

Association between the Pulmonary Embolism Severity Index (PESI) and short-term clinical deterioration

The Pulmonary Embolism Severity Index (PESI) has been shown to predict 30 and 90 day mortality after PE. However, whether the PESI predicts patients who will be free of clinically adverse outcomes during a typical hospitalisation is not known. Retrospective analysis of Emergency Department patients with PE from May 2006 to April 2008. We compiled demographics, data to calculate the PESI and a composite outcome. Patients were considered to have a negative PESI if they were in category I or II (≤85 points). Patients were considered to have the composite outcome if, within five days of diagnosis, they: A) had recurrent PE; B) developed a new cardiac dysrhythmia; C) required advanced cardiac life support; D) required respiratory support; E) required vasopressors; F) received thrombolysis; G) had major bleeding; H) returned to the ED; I) died. We enrolled 245 patients with PE. Of these, 115 (47%) were male, 204 (83%) were white. The mean age was 57 ± 17 years. The PESI identified 109 (44%) as low risk and 136 (56%) as high risk. Sixty-one (26%) patients had the outcome, of whom nine (14%) were characterised as low risk by the PESI. Test characteristics were: sensitivity 86% (95% confidence interval [CI]: 75%-93%), specificity 55% (95% CI: 47%-62%), NPV 63% (95% CI: 55%-70%), PPV 40% (95% CI: 31%-49%), LR(+) 1.9 (95% CI: 1.57-2.30) and LR(-) 0.26 (95% CI: 0.14-0.48). Of the patients who had an adverse clinical event or required a hospital-based intervention within the first five days after PE diagnosis, 14% were categorised by the PESI as safe for discharge [corrected] .

Risk stratification of normotensive patients with acute symptomatic pulmonary embolism

Treatment guidelines recommend strong consideration of thrombolysis in patients with acute symptomatic pulmonary embolism (PE) that present with arterial hypotension or shock because of the high risk of death in this setting. For haemodynamically stable patients with PE, the categorization of risk for subgroups may assist with decision-making regarding PE therapy. Clinical models [e.g. Pulmonary Embolism Severity Index (PESI)] may accurately identify those at low risk of overall death in the first 3 months after the diagnosis of PE, and such patients might benefit from an abbreviated hospital stay or outpatient therapy. Though some evidence suggests that a subset of high-risk normotensive patients with PE may have a reasonable risk to benefit ratio for thrombolytic therapy, single markers of right ventricular dysfunction (e.g. echocardiography, spiral computed tomography, or brain natriuretic peptide testing) and myocardial injury (e.g. cardiac troponin T or I testing) have an insufficient positive predictive value for PE-specific mortality to drive decision-making toward such therapy. Recommendations for outpatient treatment or thrombolytic therapy for patients with PE necessitate further development of prognostic models and conduct of clinical trials that assess various treatment strategies.

Delay and misdiagnosis in sub-massive and non-massive acute pulmonary embolism

BACKGROUND

There is limited information about the extent and clinical importance of the delay in the diagnosis of acute pulmonary embolism.

PATIENTS AND METHODS

Between 1998 and 2009, all consecutive patients diagnosed of acute pulmonary embolism from a registry of a single department were evaluated. We recorded the start or shift in symptoms as the beginning of pulmonary embolism and the mistaken diagnosis for which the patients had been treated. We evaluated the factors associated with the delay and misdiagnosis and their relation with mortality.

RESULTS

Overall 375 patients were evaluated. Median age was 75 years, interquartile range (IQR) 15, and female 186 (49%). Median delay was 6 (IQR 12) days. Median Wells score was 4.5 (IQR 3). Delay in diagnosis was longer than 6 days in 50% (95% CI 44-55) of patients, longer than 14 days in 25% (95% CI 21-30) and longer than 21 days in 10% (95% CI 7-13). Misdiagnosis occurred in 50% (95% CI 44-55) of patients. Higher age, more days of delay and the absence of syncope or sudden onset dyspnea were factors associated with misdiagnosis. Follow-up was carried out in 331 patients during a median of 31 (IQR 45) months. 36% (95% CI 33-43) of patients died [median 8 (IQR 29) months]. Higher age, misdiagnosis and a history of cancer were factors associated with mortality. Days of delay were not associated with mortality.

CONCLUSIONS

Delay and misdiagnosis of pulmonary embolism is frequent. Elderly patients and the absence of syncope or sudden onset dyspnea favour the misdiagnosis. Delay in diagnosis does not participate in mortality.

Prognostic stratification of acute pulmonary embolism: focus on clinical aspects, imaging, and biomarkers

Pulmonary embolism (PE) represents a common disease in emergency medicine and guidelines for diagnosis and treatment have had wide diffusion. However, PE morbidity and mortality remain high, especially when associated to hemodynamic instability or right ventricular dysfunction. Prognostic stratification to identify high risk patients needing to receive more aggressive pharmacological and closer monitoring is of utmost importance. Modern guidelines for management of acute PE are based on risk stratification using either clinical, radiological, or laboratory findings. This article reviews the modern treatment of acute PE, which is customized upon patient prognosis. Accordingly the current risk stratification tools described in the literature such as clinical scores, echocardiography, helical computer tomography, and biomarkers will be reviewed.

Advanced treatment strategies for acute pulmonary embolism, including thrombolysis and embolectomy

The optimal treatment strategy for acute pulmonary embolism relies upon a multidisciplinary team that rapidly assesses available data, performs additional testing if necessary, weighs treatment options, and recommends an appropriate therapeutic plan to the patient and family. Round-the-clock availability is imperative. Centers that specialize in pulmonary embolism management offer a wide range of therapeutic options. Hospitals with more limited facilities should establish pulmonary embolism patient referral and transfer contingency plans that can be activated at a moment's notice. Management options include anticoagulation alone, thrombolysis plus anticoagulation, insertion of an inferior vena caval filter, catheter embolectomy, or surgical embolectomy. The decision-making process requires accurate risk stratification, which is comprised of several crucial components: clinical evaluation that includes history and physical examination, biomarker measurement especially of troponin, as well as assessment of right ventricular size and function based upon chest CT scanning and echocardiography. The 'old school' approach of declaring a benign prognosis based solely upon the presence of normal systemic arterial pressure can delay advanced therapy until after the onset of irreversible cardiogenic shock. We have now formulated a more contemporary, comprehensive, and multifaceted strategy to prognosticate. Our 'new approach' uses advanced treatment strategies in addition to anticoagulation for those pulmonary embolism patients deemed to be at high risk for a poor outcome.

Risk stratification and outcomes in hemodynamically stable patients with acute pulmonary embolism: a prospective, multicentre, cohort study with three months of follow-up

BACKGROUND

The role of risk stratification in normotensive patients with acute pulmonary embolism (PE) is still unclear.

OBJECTIVES

We evaluated, in these patients, the usefulness of six prognostic markers for predicting in-hospital adverse events related to PE and 3-month mortality.

PATIENTS/METHODS

Two hundred and one consecutive patients with confirmed acute PE and normal blood pressure, who were administered conventional anticoagulation, were recruited in a multicentre prospective cohort study with 3 months of follow-up. At baseline, they received a comprehensive risk-evaluation including echocardiographic assessment of right ventricular dysfunction, determination of troponin I, brain natriuretic peptide and D-dimer, arterial blood gas analysis and a clinical score. Primary outcome of the study was PE-related in-hospital death or clinical deterioration. Secondary outcomes were in-hospital and 3-month all-cause mortality.

RESULTS

The primary outcome occurred in one patient (0.5%), who died from PE during hospitalization. The in-hospital and 3-month all-cause mortality were 2% and 9%, respectively. None of the prognostic markers was predictive of the primary outcome. Clinical score, troponin I and hypoxemia predicted in-hospital all-cause mortality (P = 0.02, 0.01 and < 0.01, respectively). Clinical score (HR, 4.7; 95% CI, 1.9-12.0), D-dimer (4.8; 1.4-16.3), hypoxemia (5.7; 2.1-15.1) and troponin I (7.5; 2.5-22.7) were predictors of 3-month all-cause mortality on univariate analysis. On multivariate analysis clinical score and troponin I remained independently predictive.

CONCLUSIONS

We did not find prognostic markers useful as predictors of in-hospital PE-related adverse events. Clinical score, troponin I and hypoxemia predicted in-hospital all-cause mortality. Clinical score and troponin I independently predicted 3-month all-cause mortality.

B-type natriuretic peptide in acute pulmonary embolism

Myocardial stretch leads to the natriuretic peptides release in acute or chronic left ventricular dysfunction. However, there is an accumulating evidence that B-type natriuretic peptide (BNP) and its N-terminal fragment (NT-proBNP) may originate from right ventricle and their concentrations are elevated in patients with acute pulmonary embolism (APE) especially when resulting in right ventricular dysfunction (RVD). Recently it is underlined that severity assessment of APE as well as the risk stratification and therapy selection is based both on patients' hemodynamic status and markers of myocardial injury and RVD. BNP and NT-proBNP are helpful in identifying patients with RVD in APE, emerging as an adjunctive tool to echocardiography. Elevated BNP or NT-proBNP levels are also significant predictors of death and/or complicated clinical course in APE.

Persistent NT-proBNP elevation in acute pulmonary embolism predicts early death

AIMS

Low levels of brain natriuretic peptides on admission identify low-risk patients with acute pulmonary embolism (APE) through their high NPV for mortality. However, increased natriuretic peptide values on admission are less helpful for identifying high-risk patients due to their low PPV. The aim of the study was to test whether the PPV for mortality can be improved by performing serial NT-proBNP measurements on admission, at 12 h, and at 24 h.

METHODS AND RESULTS

We prospectively included 113 consecutive patients with APE (mean age 63+/-18 years), of whom 10 had clinically massive APE. Thirty-day mortality was 15% (95% CI: 8%-22%). In survivors, median NT-proBNP levels decreased within 24 h from 1895 ng/L (range: 16-33,340) to 1007 ng/L (range: 9-33,243) (p<0.001). In non-survivors, median NT-proBNP levels at baseline (11,491 ng/L, range: 618-60,958) remained elevated at 24 h (8139 ng/L, range: 35-70,018; p=NS). The 30-day mortality rate in the group of 18 patients with NT-proBNP >7500 ng/L and less than 50% decrease of NT-proBNP within 24 h was 61% (95% CI: 39%-84%). PPV and NPV of NT-proBNP >7500 ng/L on admission and less than 50% decrease of NT-proBNP within 24 h were 61% and 94%, respectively.

CONCLUSION

Persistent elevation of plasma NT-proBNP levels within 24 h after APE diagnosis indicates ongoing right ventricular dysfunction with a poor prognosis. These critically ill patients may be candidates for rapid aggressive intervention, including thrombolysis, catheter thrombectomy, or surgical embolectomy.

Acute pulmonary embolism: risk stratification in the emergency department

Pulmonary embolism is a common disease associated with a high mortality rate. Death due to pulmonary embolism occurs more commonly in undiagnosed patients before hospital admission or during the initial in-hospital stay. Thus, mortality could be reduced by prompt diagnosis, early prognostic stratification and more intensive treatment in patients with adverse prognosis. Mortality is particularly high in patients with pulmonary embolism presenting with arterial hypotension or cardiogenic shock. In patients with pulmonary embolism and normal blood pressure, a number of clinical features and objective findings have been associated with a high risk of adverse in-hospital outcome. Advanced age and concomitant cardiopulmonary disease are clinical risk factors for in-hospital mortality. The Bburden of thromboembolism, as assessed by lung scan or spiral CT, and right ventricle overload, as assessed by echocardiography and probably spiral CT, have been claimed to be risk factors for in-hospital mortality. Elevated serum levels of troponins have been shown to be associated with right ventricular overload and adverse in-hospital outcomes in patients with pulmonary embolism. Despite the currently available evidence, no definite prognostic value can be assigned to any of the individual risk factors or cluster of them. Large prospective trials should be carried out to validate individual risk factors or clusters of risk factors able to identify patients with acute pulmonary embolism at high risk for in-hospital mortality. These patients could afford the trade-off of an increased risk of side effects related to a more aggressive treatment, such as thrombolysis or surgical or interventional procedures.