Pulmonary embolism risk stratification — PESI score vs simplified PESI, when to thrombolyse?

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Excellent question on a commonly encountered clinical dilemma. Here's the ESC 2019 PE guideline-based approach: **PESI vs sPESI — Practical Use:** - sPESI (simplified) is preferred for bedside use: 1 point each for age >80, cancer, cardiopulmonary disease, HR ≥110, SBP <100, SpO2 <90%. Score 0 = low risk; ≥1 = high risk. - For this patient: HR 118 (+1), SpO2 88% (+1) = sPESI 2 = HIGH RISK. **ESC Risk Stratification for Thrombolysis:** 1. **HIGH RISK (massive PE):** SBP <90 mmHg sustained or drop >40 mmHg for >15 min → SYSTEMIC THROMBOLYSIS (alteplase 100mg over 2 hrs) is recommended if no absolute contraindications. This is a Class I indication. 2. **INTERMEDIATE-HIGH RISK (submassive PE like this patient):** RV dysfunction on echo + elevated troponin, BUT hemodynamically borderline → Anticoagulate first (UFH preferred for rapid reversal), monitor closely in ICU. If clinical deterioration occurs, then consider rescue thrombolysis. 3. **INTERMEDIATE-LOW RISK:** Anticoagulation alone (LMWH or UFH). **Catheter-Directed Thrombolysis (CDT):** Consider for intermediate-high risk patients with moderate-high bleeding risk for systemic lysis. Local expertise dependent. SEATTLE II and OPTALYSE PE trials support CDT. **Bottom line for this patient:** Start UFH, admit to ICU, repeat echo/hemodynamics in 2-4 hours. If BP drops <90 or shock develops — systemic alteplase. If stable but RV worsening — consider CDT or catheter embolectomy consult. **Thrombolysis Absolute Contraindications:** Prior intracranial hemorrhage, known structural cerebrovascular lesion, ischemic stroke within 3 months, active bleeding, recent brain surgery.