What is the sPESI score?

The simplified Pulmonary Embolism Severity Index (sPESI) is a validated 6-variable scoring tool used after confirmed pulmonary embolism to estimate 30-day mortality risk and guide care decisions. A score of 0 indicates low risk (~1.1% 30-day mortality); a score of 1 or more indicates elevated risk (~8.9% mortality) requiring inpatient care and further risk stratification.

What does sPESI score 0 mean for outpatient treatment?

sPESI 0 is the first criterion for outpatient PE treatment eligibility but is not sufficient alone. ESC 2019 PE Guidelines require: sPESI 0 + negative troponin + absence of RV dysfunction on imaging + no Hestia criteria + adequate social support and follow-up access. When all conditions are met, outpatient treatment with DOAC (rivaroxaban or apixaban) is safe and equivalent to inpatient care.

What are the sPESI criteria?

The 6 sPESI criteria are: (1) Age >80 years — 1 point; (2) Active cancer — 1 point; (3) Chronic cardiopulmonary disease (heart failure, COPD, or chronic lung disease) — 1 point; (4) Heart rate ≥110 bpm — 1 point; (5) Systolic BP <100 mmHg — 1 point; (6) SpO2 <90% on room air — 1 point. Total score 0–6; classified as low risk (0) or elevated risk (≥1).

When should sPESI be calculated?

sPESI is calculated after pulmonary embolism has been diagnosed or confirmed — typically after CT pulmonary angiography or V/Q scan confirms the diagnosis. It is a prognostic tool for confirmed PE, not a pre-diagnostic probability tool. Do not use sPESI to decide whether to perform CT-PA — use Wells PE, Revised Geneva Score, YEARS, or PERC rule for that purpose.

What is massive vs submassive PE and how does sPESI relate?

Massive PE is defined by hemodynamic instability (systolic BP <90 mmHg for ≥15 minutes or needing vasopressors/CPR). Submassive (intermediate-risk) PE has hemodynamic stability but evidence of RV dysfunction or troponin elevation. sPESI helps classify stable confirmed PE but does not directly define massive vs submassive PE — hemodynamic status is the primary determinant.

What anticoagulant should I use for PE treatment?

For most PE patients: apixaban (10 mg BID × 7 days, then 5 mg BID) or rivaroxaban (15 mg BID × 21 days, then 20 mg daily) are preferred — no parenteral bridging needed, proven non-inferior to LMWH/warfarin. For massive PE: unfractionated heparin (UFH) is preferred due to rapid reversibility before potential thrombolysis. For cancer-associated PE: LMWH or DOACs (apixaban/rivaroxaban based on trial data).

How is sPESI used in cancer patients with PE?

Cancer scores 1 point in sPESI, placing all cancer patients with PE in the ≥1 risk category. This means cancer patients with PE are always classified as elevated risk by sPESI and require inpatient evaluation. Echocardiography and troponin are needed to further classify risk and guide decisions about anticoagulation intensity, PERT involvement, or catheter-directed therapy.

What does RV dysfunction mean in PE and how does it affect management?

Right ventricular (RV) dysfunction in PE refers to RV pressure overload causing RV dilation, septal bowing, and potentially hemodynamic compromise. On CT-PA, RV/LV ratio >0.9 or >1.0 indicates RV strain. On echo, RV dilation, McConnell sign, or TAPSE <16 mm suggests RV dysfunction. RV dysfunction + troponin elevation = intermediate-high risk PE, which may warrant PERT activation, closer monitoring, and consideration of catheter-directed thrombolysis.

Online Medical Tools — sPESI Score

Printed on 9/2/2026

For informational purposes only. This is not medical advice.

Emergency

sPESI Score

The simplified Pulmonary Embolism Severity Index (sPESI) is a validated 6-variable risk tool for adults with confirmed pulmonary embolism. It classifies patients into low risk (score 0) versus higher risk (score 1 or more) for short-term mortality. It is commonly used to support decisions around outpatient management versus inpatient monitoring.

Formula: sPESI = 1 point each for: age >80, cancer history, chronic cardiopulmonary disease, HR ≥110, SBP <100, SpO2 <90.

Age > 80 years

History of Cancer

Chronic Cardiopulmonary Disease

Heart Rate ≥ 110 bpm

Systolic BP < 100 mmHg

SpO2 < 90%

Save your results with a free account

Keep a history of calculations, favorite tools, and access your dashboard anytime.

Create free account Sign in

How It Works

Score 6 binary variables at PE diagnosis

After pulmonary embolism is confirmed (by CT-PA or V/Q scan), score each of the 6 sPESI variables: age >80 years, active cancer, chronic cardiopulmonary disease (heart failure, COPD, or chronic lung disease), heart rate ≥110 bpm, systolic BP <100 mmHg, and SpO2 <90%. Each item present scores 1 point.

Sum the total score (0–6)

Add up the applicable points. The total sPESI score ranges from 0 to 6. Most patients will score in the 0–3 range. A score of 0 places the patient in the low-risk category; any score of 1 or more places the patient in the high-risk category for 30-day adverse outcomes.

Apply the risk classification and plan care level

sPESI 0 = low risk (30-day mortality ~1.1%) — consider eligibility for outpatient treatment if also troponin-negative and RV function normal. sPESI ≥1 = high risk (30-day mortality ~8.9%) — inpatient treatment required; obtain echocardiography to assess RV function; measure troponin and BNP to further classify intermediate vs high risk.

Who Uses the sPESI Score

PE Risk Stratification at Diagnosis

Emergency physicians, hospitalists, pulmonologists

sPESI is calculated immediately after PE diagnosis to classify patients into low-risk (sPESI 0) versus higher-risk (sPESI ≥1) categories. This guides the subsequent workup — whether to obtain echocardiography, troponin, or BNP — and determines appropriate care level (outpatient vs inpatient).

Outpatient PE Treatment Eligibility (with Additional Criteria)

Emergency physicians, anticoagulation clinics

sPESI 0 is a prerequisite for outpatient PE treatment consideration. Combined with negative troponin, absence of RV dysfunction on CT-PA or echo, no Hestia exclusion criteria, and access to reliable follow-up, sPESI 0 patients may be safely discharged with oral anticoagulation (rivaroxaban or apixaban).

Guiding Echocardiography Urgency

Emergency physicians, cardiologists

sPESI ≥1 identifies patients who require echocardiography to assess right ventricular (RV) function. RV dysfunction combined with elevated troponin (intermediate-high risk PE) may warrant escalation to catheter-directed thrombolysis or PERT consultation.

ICU vs Ward vs Discharge Decision

Hospitalists, intensivists, emergency medicine

sPESI combined with hemodynamic stability and biomarker data guides care-level decisions: sPESI 0 + stable + negative biomarkers = potential outpatient; sPESI ≥1 + stable + positive troponin = intermediate risk, admit to monitored ward; sPESI ≥1 + hemodynamically unstable = high risk, consider ICU and thrombolysis.

Clinical Trial Risk Stratification

Clinical researchers, trialists

sPESI is used as a stratification variable in major PE clinical trials to ensure balanced allocation between treatment arms. The binary low-risk/high-risk classification enables straightforward subgroup analysis.

Pro Tips

sPESI 0 alone is not sufficient for outpatient treatment

sPESI 0 is a necessary but not sufficient criterion for outpatient PE management. ESC 2019 Guidelines require: sPESI 0 + negative troponin + absence of RV dysfunction on imaging (CT-PA RV/LV ratio <1.0 or normal echo). Social factors (adequate home support, medication access, reliable follow-up within 48–72h) are also essential.

sPESI ≥1 = at minimum intermediate risk — obtain echocardiography

Any sPESI ≥1 places the patient in the intermediate risk category at minimum. The next step is echocardiography (or CT-PA RV assessment) and troponin measurement. Intermediate-high risk PE (sPESI ≥1 + RV dysfunction + elevated troponin) may benefit from catheter-directed thrombolysis.

Massive PE requires thrombolysis regardless of sPESI

Hemodynamically unstable PE (persistent SBP <90 mmHg or >40 mmHg drop, or shock) is classified as high-risk (massive) PE. These patients require thrombolysis consideration or surgical/catheter embolectomy regardless of sPESI score. Do not apply sPESI-based outpatient criteria to unstable patients.

Systemic thrombolysis for massive PE — large benefit but hemorrhagic stroke risk

Systemic thrombolysis (alteplase 100 mg over 2h) for confirmed massive PE results in rapid hemodynamic improvement (60–80% response rate) but carries hemorrhagic stroke risk of 1.5–2.0% and major bleeding 9.9%. Reserve systemic thrombolysis for truly hemodynamically unstable patients without contraindications.

Intermediate-high risk PE — consider catheter-directed thrombolysis

Intermediate-high risk PE (sPESI ≥1 + RV dysfunction + troponin elevation) represents a clinical dilemma. Catheter-directed thrombolysis (ultrasound-accelerated or standard) delivers drug directly to the clot at lower doses, reducing systemic bleeding risk compared to systemic thrombolysis. PERT activation at centers with this capability is appropriate.

Anticoagulation options for PE — DOAC preferred over warfarin

For most PE patients, direct oral anticoagulants (DOACs) are preferred over warfarin. Rivaroxaban and apixaban are approved for PE with no need for parenteral bridging. Rivaroxaban: 15 mg BID for 21 days, then 20 mg daily. Apixaban: 10 mg BID for 7 days, then 5 mg BID. DOACs have equivalent efficacy and lower major bleeding rates compared to warfarin.

Cancer-associated PE — LMWH traditionally preferred but DOACs increasingly used

In cancer-associated PE, low-molecular-weight heparin (LMWH) has historically been preferred due to unpredictable warfarin absorption in cancer patients. However, DOACs (especially apixaban and rivaroxaban) have shown non-inferior efficacy in the ADAM-VTE, CARAVAGGIO, and SELECT-D trials, with the tradeoff of slightly higher GI bleeding risk in some cancers.

sPESI 30-day mortality benchmarks

sPESI 0: 30-day all-cause mortality ~1.1% (Jiménez et al. 2010). sPESI ≥1: 30-day all-cause mortality ~8.9%. These benchmarks are from the derivation cohort; real-world values may vary based on population characteristics and institutional PE management practices.

Common Questions About Your Results

Evidence-Based Methodology

Simplified PESI (sPESI) published by Jiménez et al. (Arch Intern Med 2010). sPESI 0: 30-day mortality 1.1% vs 8.9% for sPESI ≥1. Validated in multiple prospective cohorts. ESC 2019 PE Guidelines (Konstantinides et al.) endorse sPESI as the primary clinical severity tool. sPESI 0 + negative troponin + normal RV permits outpatient treatment consideration per HESTIA and HOME-PE trials. Outpatient PE treatment safety: Aujesky et al. (Lancet 2011 — PESI validation for outpatient).

Clinical Content Trust

Last reviewed:: April 21, 2026
Guideline version:: General evidence framework v2026.04
Source set version:: Primary-source set v1

How to Interpret Your Result

An sPESI score of 0 identifies a lower-risk group with relatively low 30-day mortality. A score of 1 or more identifies higher-risk patients who generally require inpatient management and closer surveillance.

sPESI supports prognosis and disposition planning, but it does not replace full PE severity assessment, clinician judgment, or evaluation for right-heart strain.

When to Use This Tool

Use sPESI in adults with confirmed acute pulmonary embolism to support early risk stratification and disposition decisions (outpatient pathway versus inpatient monitoring).

It is particularly useful after diagnostic confirmation when planning level of care and discussing short-term prognosis.

Limitations

sPESI is a binary simplification and can miss nuances captured by broader assessments such as RV dysfunction, biomarkers, clot burden, and dynamic hemodynamics.

A low sPESI score does not by itself guarantee safe outpatient treatment; apply local PE pathway criteria, contraindications to anticoagulation, bleeding risk, and follow-up reliability.

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.

Sources

Jiménez D, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170(15):1383-1389.

Changelog

April 21, 2026 · trust-baseline
Clinical trust metadata enabled for this tool page with structured review/version fields.

Related Tools

Emergency

Wells Score (PE)

Calculate Wells Score for PE to estimate pretest probability and guide D-dimer testing versus direct CTPA for pulmonary embolism workup.

Open Emergency

PERC Rule

Use PERC (Pulmonary Embolism Rule-out Criteria) to rule out PE in low-risk patients without D-dimer or CT when all 8 criteria are negative.

Open Emergency

Shock Index

Calculate the Shock Index (HR/SBP ratio) for rapid hemodynamic assessment. Normal: 0.5–0.7. Score ≥1.0 indicates hemodynamic compromise; ≥1.4 indicates severe shock requiring immediate intervention.

Open Emergency

qSOFA Score

Calculate qSOFA bedside sepsis risk score. A score of 2 or more (altered mentation, RR ≥22, SBP ≤100) flags high-risk infection requiring urgent evaluation.

Open

Frequently Asked Questions

PESI (original) classifies PE into 5 risk classes (I–V) using 11 weighted variables. sPESI uses only 6 binary variables and provides a simpler binary classification (low risk = 0, elevated risk ≥1). Studies confirm sPESI and PESI provide similar prognostic accuracy. ESC 2019 guidelines endorse sPESI as the primary clinical severity tool due to its simplicity. Use PESI when more granular class-specific mortality estimates are needed.

sPESI is a prognostic score estimating 30-day mortality risk. Hestia is a practical exclusion checklist assessing specific contraindications to outpatient PE treatment (hemodynamic instability, bleeding risk, oxygen requirement, IV medication needs, renal/liver impairment, pregnancy, social factors). Both are needed for outpatient PE decision-making: sPESI 0 identifies low mortality risk; Hestia negative confirms no safety contraindications to discharge.

Online Medical Tools — sPESI Score

sPESI Score

How It Works

Score 6 binary variables at PE diagnosis

Sum the total score (0–6)

Apply the risk classification and plan care level

Who Uses the sPESI Score

PE Risk Stratification at Diagnosis

Outpatient PE Treatment Eligibility (with Additional Criteria)

Guiding Echocardiography Urgency

ICU vs Ward vs Discharge Decision

Clinical Trial Risk Stratification

Pro Tips

sPESI 0 alone is not sufficient for outpatient treatment

sPESI ≥1 = at minimum intermediate risk — obtain echocardiography

Massive PE requires thrombolysis regardless of sPESI

Systemic thrombolysis for massive PE — large benefit but hemorrhagic stroke risk

Intermediate-high risk PE — consider catheter-directed thrombolysis

Anticoagulation options for PE — DOAC preferred over warfarin

Cancer-associated PE — LMWH traditionally preferred but DOACs increasingly used

sPESI 30-day mortality benchmarks

Common Questions About Your Results

Evidence-Based Methodology

Clinical Content Trust

How to Interpret Your Result

When to Use This Tool

Limitations

Sources

Changelog

Related Tools

Wells Score (PE)

PERC Rule

Shock Index

qSOFA Score

Further Reading

A Complete Guide to Emergency Medicine: Decision Tools, Scoring Systems, and Clinical Protocols

Frequently Asked Questions