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Pulmonary Embolism Risk Stratification (ESC/ERS 2019)

Pulmonary Embolism Risk Stratification (ESC/ERS 2019): Suspected acute PE → Adults only. Pregnancy: use a pregnancy PE pathway → Haemodynamically unstab...

Pathway Overview

28 steps

Algorithm Steps

28 total

  1. 01Start

    Suspected acute PE

    Clinical suspicion of acute pulmonary embolism in an adult

  2. 02Warning

    Adults only. Pregnancy: use a pregnancy PE pathway

    This pathway is for non-pregnant adults (18 years or older).

    • Pregnant or up to 6 weeks post-partum: tests and drugs differ (no DOAC); get obstetric and senior advice
    • Under 18: get paediatric specialist advice
    • Cardiac arrest: follow adult ALS; consider thrombolysis for suspected PE
  3. 03Decision

    Haemodynamically unstable?

    Cardiac arrest; or obstructive shock (SBP <90 mmHg or vasopressor needed, with end-organ hypoperfusion); or SBP <90 mmHg or a fall of 40 mmHg or more for >15 min, not due to arrhythmia, hypovolaemia or sepsis

  4. If Yes
    1. 04Action

      Unstable: IV UFH bolus now; bedside echo (TTE); CTPA if immediately available

      Start IV UFH with a weight-adjusted bolus without waiting for imaging (dose: local heparin protocol). Active bleeding or suspected aortic dissection: senior decision before heparin. Known or past HIT: no heparin; use a non-heparin anticoagulant (haematology advice). Look for RV dysfunction (RV/LV ratio >1.0). Do not delay care for tests the patient cannot tolerate.

      • RV dysfunction and CTPA not feasible: treat as high-risk PE
      • CTPA feasible: PE on CTPA confirms high-risk PE
      • No RV dysfunction on TTE, or CTPA negative: PE is unlikely to be the cause of shock
    2. 05Decision

      Unstable: high-risk PE confirmed (RV dysfunction on TTE or PE on CTPA)?

    3. If Yes
      1. 06Warning

        RV failure in high-risk PE: small fluid bolus only; avoid intubation if possible

        Fluid only if CVP is low-normal: 500 mL or less over 15-30 min. Large fluid volumes worsen RV failure. Hypotension: noradrenaline and/or dobutamine.

        • Induction and intubation can cause collapse: prefer high-flow nasal oxygen or NIV
        • If intubation is needed: avoid induction drugs that cause hypotension; apply PEEP with caution
        • Refractory shock or cardiac arrest: consider VA-ECMO with surgical or catheter treatment
      2. 07Warning

        High-risk PE: continue IV unfractionated heparin and plan reperfusion

        Continue IV UFH (if not yet given: weight-adjusted bolus now). Not LMWH or a DOAC at this stage. Call the senior team (ICU, PE team if available).

        • UFH dose and aPTT target: see local heparin protocol
        • Primary reperfusion is recommended: systemic thrombolysis unless contraindicated
        • Oxygen if SaO2 <90%
      3. 08Warning

        Before thrombolysis: check contraindications

        Relative contraindications need a senior decision on bleeding risk against benefit.

        • Absolute: haemorrhagic or unknown-cause stroke; ischaemic stroke <6 months; CNS tumour; major trauma, surgery or head injury <3 weeks
        • Absolute: bleeding disorder; active bleeding
        • Relative: TIA <6 months; oral anticoagulant; pregnancy or 1st week post-partum; non-compressible puncture; traumatic CPR; SBP >180 mmHg; advanced liver disease; endocarditis; active peptic ulcer
      4. 09Decision

        Thrombolysis contraindicated, or bleeding risk judged too high?

      5. If Yes
        1. 10Action

          Lysis contraindicated or failed: surgical embolectomy or catheter treatment

          Where expertise and resources are on site. If not available: discuss urgent transfer with the PE team or cardiothoracic centre.

          • Continue UFH
          • Refractory shock or cardiac arrest: consider VA-ECMO with the procedure
        2. 11Action

          High-risk PE, stable after reperfusion: continue anticoagulation

          Continue UFH. When haemodynamically stable, change from parenteral to oral anticoagulation (next step).

        3. 12Action

          Anticoagulant: DOAC preferred; not in APS, severe kidney impairment or pregnancy

          Eligible patients: apixaban, rivaroxaban, dabigatran or edoxaban (edoxaban is not TGA-registered in Australia) in preference to warfarin. Parenteral start: LMWH or fondaparinux rather than UFH, except high-risk PE, CrCl 30 mL/min or less (no fondaparinux) or severe obesity: use UFH. Active cancer: LMWH, or edoxaban, rivaroxaban or apixaban; GI cancer: LMWH preferred; genitourinary cancer: DOAC with caution (bleeding).

          • No DOAC: antiphospholipid syndrome, pregnancy or breastfeeding, CrCl <15 mL/min (dabigatran: CrCl <30 mL/min; apixaban in Australia: CrCl <25 mL/min)
          • Dabigatran and edoxaban: start after at least 5 days of parenteral anticoagulation
          • Warfarin: overlap with parenteral anticoagulant for at least 5 days and until INR 2.0-3.0 on 2 consecutive days
          • Check drug interactions and doses in the product information
        4. 13Outcome

          Anticoagulate for at least 3 months; review at 3-6 months

          At 3 months decide to stop or extend anticoagulation (recurrence risk vs bleeding risk). Persistent breathlessness: assess for CTEPH.

        If No
        1. 14Action

          No contraindication: systemic thrombolysis with alteplase

          Adult alteplase (1 mg/mL after reconstitution): 100 mg IV over 2 hours.

          • Adult 65 kg or more: 10 mg IV bolus over 1-2 min, then 90 mg IV over 2 hours
          • Adult under 65 kg: 10 mg IV bolus over 1-2 min, then infusion to a total of no more than 1.5 mg/kg over 2 hours
          • Heparin during and after alteplase: follow local protocol
          • Cardiac arrest (adult): 0.6 mg/kg IV over 15 min, maximum 50 mg (accelerated regimen, off-label); continue CPR for at least 60-90 min
        2. 15Decision

          After thrombolysis: still unstable or deteriorating?

          Yes: surgical embolectomy or catheter treatment (step 'Lysis contraindicated or failed'). No: continue anticoagulation (step 'High-risk PE, stable after reperfusion').

        3. If Yes
          1. Path rejoins step 10Shared downstream outcome
          If No
          1. Path rejoins step 11Shared downstream outcome
      If No
      1. 16Outcome

        Unstable, PE not confirmed: search for another cause of shock

        No RV dysfunction on TTE, or CTPA negative. Consider tamponade, aortic dissection, acute MI, hypovolaemia and sepsis. Do not give thrombolysis. Review the heparin started for suspected PE.

    If No
    1. 17Warning

      Stable: check bleeding risk and kidney function before any anticoagulant

      Applies to the first dose, including anticoagulation started while tests are in progress. Known or past HIT: no heparin or LMWH; use a non-heparin anticoagulant (haematology advice).

      • Active major bleeding or absolute contraindication (for example recent intracranial haemorrhage): do not anticoagulate
      • Get senior and haematology advice; consider an IVC filter
      • CrCl 30 mL/min or less or severe obesity: use UFH; no fondaparinux; LMWH only with adjusted dose
    2. 18Action

      Stable: confirm PE (clinical probability, D-dimer, CTPA)

      Assess clinical probability with clinical judgement or a rule (Wells or revised Geneva). CTPA not suitable (contrast allergy, severe kidney impairment): V/Q scan.

      • Low or intermediate probability (or PE unlikely): D-dimer (over 50 years: age-adjusted cut-off can be used). Negative: no treatment. Positive: CTPA
      • High probability (or PE likely): CTPA. Do not use D-dimer
      • High or intermediate probability: start anticoagulation while tests are in progress
      • PE confirmed: segmental or more proximal PE on CTPA at intermediate or high probability. Low probability or single subsegmental defect: review with radiologist; consider further tests
    3. 19Decision

      Stable: PE confirmed on imaging?

    4. If Yes
      1. 20Action

        Stable, PE confirmed: calculate sPESI (1 point each)

        Simplified PE Severity Index, 1 point each: (1) age >80 years; (2) cancer; (3) chronic heart failure or chronic lung disease; (4) heart rate 110/min or more; (5) SBP <100 mmHg; (6) SaO2 <90%.

      2. 21Decision

        sPESI 1 or more?

      3. If Yes
        1. 22Action

          Intermediate risk: assess RV (TTE or CTPA) and troponin

          sPESI 1 or more, or sPESI 0 with RV dysfunction or raised troponin. Admit to hospital.

        2. 23Decision

          Intermediate risk: RV dysfunction AND raised troponin?

        3. If Yes
          1. 24Warning

            Intermediate-high risk: admit, monitor closely, have rescue reperfusion ready

            Anticoagulate: LMWH for the first 2-3 days (UFH if CrCl 30 mL/min or less or severe obesity); change to oral only when stable. No routine primary thrombolysis.

            • Becomes unstable: rescue thrombolysis
            • Lysis contraindicated or failed: surgical embolectomy or catheter-directed treatment
            • Use a monitored bed
          2. Path rejoins step 12Shared downstream outcome
          If No
          1. 25Action

            Intermediate-low risk: admit to ward and anticoagulate

            Only one (or neither) of RV dysfunction and raised troponin. No thrombolysis. Watch for deterioration.

          2. Path rejoins step 12Shared downstream outcome
        If No
        1. 26Decision

          sPESI 0: RV dysfunction (TTE or CTPA) or raised troponin found?

          At sPESI 0, consider RV assessment (TTE or CTPA) or troponin. If abnormal: intermediate risk, not low risk.

        2. If Yes
          1. Path rejoins step 22Shared downstream outcome
          If No
          1. 27Action

            Low risk (sPESI 0, no RV or troponin abnormality): consider early discharge

            Early discharge and home treatment only if no Hestia exclusion criteria and outpatient care and anticoagulation can be provided.

            • Not for home: needs oxygen or IV pain relief, active bleeding or high bleeding risk, CrCl <30 mL/min, severe liver impairment, pregnancy, HIT, PE diagnosed while on anticoagulation, or medical or social reason to stay
            • Arrange early review
            • Patient education: bleeding and recurrence symptoms
          2. Path rejoins step 12Shared downstream outcome
      If No
      1. 28Outcome

        Stable, PE not confirmed: no anticoagulation for PE

        Negative D-dimer (low or intermediate probability) or negative CTPA. High probability with negative CTPA: consider further tests. Look for another cause.

Guideline Source

2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism (with ERS)

DOI: 10.1093/eurheartj/ehz405View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Heparin, vasopressor and DOAC doses are not given: use local protocols and the Australian product information
  • Based on ESC 2019 risk classes; the 2026 AHA/ACC acute PE guideline uses clinical categories A-E
  • Not for pregnancy, post-partum or children
  • Cancer-associated PE: first-line drug choice only; duration and extended anticoagulation decisions not covered

Contraindicated Populations

pediatricpregnancy

Applicable Regions

EUUSAU

AU: Alteplase (Actilyse) is TGA-registered for acute massive PE: 100 mg IV over 2 h (10 mg bolus, then 90 mg); under 65 kg, total no more than 1.5 mg/kg. Edoxaban is not TGA-registered: use apixaban, rivaroxaban or dabigatran. Australian PI contraindicates apixaban at CrCl <25 mL/min. Emergency: 000.

EU: ESC/ERS 2019 acute PE guideline (still the current ESC PE guideline in 2026).

US: 2026 AHA/ACC multisociety acute PE guideline uses clinical categories A-E and allows earlier catheter-directed therapy in selected patients; core steps are similar.

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Pulmonary Embolism Risk Stratification (ESC/ERS 2019)?

The Pulmonary Embolism Risk Stratification (ESC/ERS 2019) is a diagnostic clinical algorithm for Cardiology. It provides a structured decision tree to guide clinical decision-making, based on 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism (with ERS).

What guideline is the Pulmonary Embolism Risk Stratification (ESC/ERS 2019) based on?

This algorithm is based on 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism (with ERS) (DOI: 10.1093/eurheartj/ehz405).

What are the limitations of the Pulmonary Embolism Risk Stratification (ESC/ERS 2019)?

Known limitations include: Heparin, vasopressor and DOAC doses are not given: use local protocols and the Australian product information; Based on ESC 2019 risk classes; the 2026 AHA/ACC acute PE guideline uses clinical categories A-E; Not for pregnancy, post-partum or children; Cancer-associated PE: first-line drug choice only; duration and extended anticoagulation decisions not covered. Individual patient factors may require deviation from these recommendations.

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