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Printed on 7/19/2026
For informational purposes only. This is not medical advice.
The Pulmonary Embolism Severity Index (PESI) is a validated prognostic score for adults with confirmed acute PE. It combines demographics, comorbidities, and physiologic findings to stratify short-term mortality risk into five classes. PESI supports disposition planning and intensity-of-care decisions after PE diagnosis.
Formula: PESI = age + male sex(10) + cancer(30) + heart failure(10) + chronic lung disease(10) + pulse≥110(20) + SBP<100(30) + RR≥30(20) + temp<36(20) + altered mental status(60) + SpO2<90(20).
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Before scoring all 11 variables, apply the Class I screening: if the patient is under 50 years old, has no comorbidities (no cancer, heart failure, or chronic lung disease), has normal mental status, normal vital signs (HR <100, SBP ≥90, RR <30, temp 36–39.9°C), and SpO2 ≥90% — they qualify as Class I (lowest risk) and can be considered for outpatient care without full scoring.
For patients not meeting Class I criteria, score: age in years (direct points), male sex (+10), cancer (+30), heart failure (+10), chronic lung disease (+10), pulse ≥110 bpm (+20), systolic BP <100 mmHg (+30), respiratory rate ≥30/min (+20), temperature <36°C (+20), altered mental status (+60), SpO2 <90% (+20). Sum all applicable points.
Class I = <66 points (0.1–1.6% 30-day mortality); Class II = 66–85 points (~3.5%); Class III = 86–105 points (~7%); Class IV = 106–125 points (~11%); Class V = >125 points (~24%). Classes I–II generally support outpatient treatment consideration when other criteria are met; Classes III–V require inpatient care; Class V warrants high-acuity monitoring.
Hospitalists, emergency physicians, pulmonologists
When sPESI gives limited guidance (e.g., patient is exactly at the boundary), PESI provides more granular 5-class risk stratification. PESI Class III (intermediate) benefits from additional clinical analysis to decide between ward observation and outpatient discharge.
Emergency physicians, anticoagulation clinics
PESI Classes I–II (30-day mortality <3.5%) represent the clinical threshold below which outpatient treatment is evidence-based. Combined with Hestia criteria assessment, negative troponin, and normal RV function, Class I–II patients can be safely discharged with DOAC anticoagulation.
Hospitalists, palliative care, pulmonologists
PESI provides quantitative 30-day mortality estimates for each class that can be used in patient and family discussions about prognosis, goals of care, and treatment intensity in confirmed PE, especially in patients with Class IV–V risk.
Hospital quality teams, administrators
PESI class distribution can be tracked across admitted PE patients to assess appropriateness of hospitalization, ICU utilization, and treatment pathways. Institutions with high Class I–II admission rates may have opportunities to increase safe outpatient PE management.
Clinical researchers, PE registries
PESI is a standard variable in PE registries (e.g., RIETE, PEITHO) and clinical trials. Its 5-class system enables finer subgroup analysis than sPESI's binary classification, particularly for intermediate-risk PE subgroups.
PESI Class I and II patients have very low short-term mortality (0.1–3.5%). When combined with Hestia criteria (no exclusions), negative troponin, normal RV function on imaging, and adequate follow-up access, these patients can be safely managed as outpatients with DOAC. The Aujesky et al. randomized trial (Lancet 2011) validated outpatient PE treatment in Class I–II patients.
sPESI provides binary (low/elevated) classification. PESI provides 5 classes with distinct mortality estimates. When the clinical question involves prognostication or borderline outpatient eligibility, PESI's granularity is more informative. In routine clinical practice, sPESI is faster and equally valid for risk stratification.
PESI Class I and II typically correspond to sPESI 0 patients. Class III broadly corresponds to sPESI ≥1. This alignment allows cross-reference between the two tools, though individual patients may be classified differently due to the different variable weighting systems.
The altered mental status criterion carries the highest weight in PESI (60 points). A single point for this item can push a patient from Class I into Class III–IV territory. Always assess orientation to person, place, and time carefully and document the basis for this criterion.
Systolic BP <100 mmHg (30 points) is the second-highest weighted item in PESI. In combination with tachycardia and altered mental status, it can rapidly push patients to Class V. Hemodynamic instability in confirmed PE requires thrombolysis evaluation independent of PESI class.
Troponin (cardiac injury) and BNP/NT-proBNP (RV pressure overload) provide prognostic information independent of PESI class. PESI Class II patients with elevated troponin may warrant closer inpatient monitoring than PESI class alone suggests — this is why ESC guidelines integrate PESI/sPESI + biomarkers + RV imaging into the full risk stratification algorithm.
PESI was derived and validated for short-term (30-day) mortality prediction. Long-term outcomes in PE — including post-PE syndrome, CTEPH (chronic thromboembolic pulmonary hypertension), and recurrent VTE — are not captured in PESI and require separate follow-up assessment.
The Class I screening criteria allow rapid identification of the lowest-risk patients without performing full PESI calculation: age <50, no comorbidities, normal vitals, normal mental status, SpO2 ≥90%. If all criteria are met, the patient is automatically Class I — full scoring is unnecessary.
PESI developed and validated by Aujesky et al. (Am J Respir Crit Care Med 2005) from 15,531 PE patients. C-statistic 0.78 for 30-day mortality. Class I 30-day mortality 0.1-1.6%, Class V 10-24.5%. Randomized trial of outpatient vs inpatient PE management using PESI (Aujesky et al., Lancet 2011). ESC 2019 PE Guidelines endorse PESI and sPESI as clinical severity assessment tools. PESI and sPESI compared in Lankeit et al. (Chest 2011).
PESI classifies confirmed PE into five mortality-risk classes. Class I-II generally represent lower short-term risk, Class III intermediate risk, and Class IV-V higher risk. As class increases, closer monitoring and higher-intensity inpatient care become more likely.
PESI supports prognosis and disposition planning, but should be integrated with RV assessment, biomarkers, bleeding risk, and clinician judgment.
Use PESI in adults with confirmed acute pulmonary embolism to estimate 30-day mortality risk and guide level-of-care planning.
It is especially useful when deciding between outpatient pathway eligibility and standard inpatient management.
PESI estimates mortality risk but does not directly determine treatment strategy by itself. Some clinically important factors (for example clot burden, RV strain details, and evolving instability) are not captured in the score.
A low-risk class does not guarantee safe outpatient care; local pathway criteria, anticoagulation suitability, social support, and follow-up access remain essential.
For related assessments, see sPESI Score, Wells Score (PE) and PERC Rule.
Disclaimer: This tool is for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about your health.
April 21, 2026 · trust-baseline
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