[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-detail-42823-en":3,"doc-seo-42823-105":30,"detail-sidebar-cat-0-en-105":91},{"code":4,"msg":5,"data":6},0,"success",{"doc_id":7,"user_id":8,"nickname":9,"user_avatar":10,"doc_module":4,"category_id":11,"category_name":12,"doc_title":13,"doc_description":14,"doc_content":15,"file_id":16,"file_url":17,"file_type":18,"file_size":19,"view_count":20,"is_deleted":4,"is_public":21,"is_downloadable":21,"audit_status":21,"page_count":22,"language":23,"language_code":24,"site_id":25,"html_lang":24,"table_of_contents":26,"faqs":27,"seo_title":13,"seo_description":14,"update_tm":28,"read_time":29},42823,1099513958607,"Jiven","https://ap-avatar.wpscdn.com/avatar/100002390cf8733938c?x-image-process=image/resize,m_fixed,w_180,h_180&k=1778829742770036399",8,"Research & Report","Intermediate-Risk and High-Risk Pulmonary Embolism: Recognition and Management","Intermediate-risk and high-risk pulmonary embolism (PE) remains challenging to diagnose and manage due to its wide clinical spectrum, from asymptomatic presentations to hemodynamic instability and right-sided heart failure. PE is a major contributor to cardiovascular death globally and is driven primarily by thromboembolism arising from venous thromboembolism mechanisms described by Virchow’s triad. The review outlines contemporary approaches to risk stratification and the recognition and treatment strategies tailored to intermediate-risk and high-risk categories.","Author Manuscript Author Manuscript Author Manuscript Author Manuscript  \n\n|  | HHS Public Access\u003Cbr>Author manuscript\u003Cbr>Cardiol Clin. Author manuscript; available in PMC 2025 May 01. |\n| --- | --- |\n\nPublished in final edited form as:  \nCardiol Clin. 2024 May ; 42(2): 215–235. doi:10.1016/j.ccl.2024.02.008 .  \nIntermediate-Risk and High-Risk Pulmonary Embolism:  \nRecognition and Management:  \nCardiology Clinics: Cardiac Emergencies  \nDrew A. Birrenkott, MD, DPhila,b, Christopher Kabrhel, MD, MPHa,b, David M. Dudzinski, MDb,c,d,*  \na Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA  \nbCenter for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA  \nc Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA dCardiac Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA  \nKeywords  \nPulmonary embolism; Risk stratification; Thrombolysis; Catheter-directed therapy; Pulmonary embolism response team (PERT)  \nINTRODUCTION AND NATURE OF THE PROBLEM OF PULMONARY EMBOLISM  \nPulmonary embolism (PE) remains both difficult to diagnose and complex to treat despite over 50 years of recognition as a cause of significant morbidity and mortality.1 Behind ischemic heart disease and stroke, PE is the third leading cause of cardiovascular death worldwide.2,3  \nThe estimated annual population incidence of venous thromboembolism (VTE), including PE, ranges from 0.2 to 1.1 per 1000.4–7 While the incidence of PE is low in younger populations, the incidence increases approximately 8-fold between the fourth decade and the eighth decade of life.8,9 In addition, longitudinal data suggest that the annual incidence of PE is increasing, and the 1% to 3% of hospitalized patients with PEs who are in shock or ventilator-dependent have approximately 10-fold higher case fatality rates.10–14 While not completely explained, this observed increase is likely multifactorial, including more sensitive imaging modalities (computed tomographic pulmonary angiography [CTPA]), and an increase in the number of individuals with severe comorbidities associated with developing Pes.10, 15–19  \n*Corresponding author. Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114. [ddudzinski@partners.org](ddudzinski@partners.org).  \nAuthor Manuscript Author Manuscript Author Manuscript Author Manuscript  \nBirrenkott et al. Page 2  \nThe spectrum in PE ranges from asymptomatic to hemodynamic instability and right-sided heart failure.20 PE represents obstruction of the pulmonary artery, and can be caused by multiple sources including tumors, fat, air, amniotic fluid, and septic emboli, though the vast majority are thromboembolic—the focus of this review.21 VTE, including PE, develop secondary to factors known as Virchow triad: stasis in blood flow, endothelial injury, and hypercoagulability, either inherited or acquired.22 The majority of PEs are caused by embolization of a deep venous thrombosis (DVT) .9 Acute PE results in abnormal gas exchange and circulation whereas mortality in PE is caused by increased right ventricular (RV) afterload causing a cascade leading to obstructive shock and death.10  \nAcute PE has been stratified into 3 categories: high-risk (formerly massive), intermediaterisk (formerly submassive), and low-risk based on both imaging findings and patient characteristics. High-risk PE is defined by sustained hypotension (systolic blood pressure [SBP] \u003C 90 mm Hg) for at least 15 minutes or a vasopressor requirement where thereis no other reasonable explanation for shock.23,24 Intermediate-low risk PE is defined by evidence of imaging RV dysfunction or biomarker evidence (myocardial necrosis or chamber dilatation) in the absence of sustained hypotension.10,24 A subcategory of intermediate-high risk PE features patients with both imaging and biomarker evidence of RV dysfun","cbCaivV1506CTmhX","https://ap.wps.com/l/cbCaivV1506CTmhX","pdf",446262,2,1,34,"English","en",105,"# INTRODUCTION AND NATURE OF THE PROBLEM OF PULMONARY EMBOLISM\n## Risk categories for acute PE\n# RECOGNITION: DIAGNOSIS AND PROGNOSIS\n## History and physical examination\n## Pre-test probability","[{\"question\":\"How is acute PE risk stratified into high-risk, intermediate-risk, and low-risk categories?\",\"answer\":\"Acute PE is categorized using imaging findings and patient characteristics. High-risk PE involves sustained hypotension or vasopressor requirement without another explanation; intermediate-risk includes imaging RV dysfunction and/or biomarker evidence without sustained hypotension; low-risk does not meet high- or intermediate-risk criteria.\"},{\"question\":\"Why is PE often missed despite being a commonly considered emergency diagnosis?\",\"answer\":\"PE is difficult to recognize because clinical presentations are heterogeneous, ranging from asymptomatic illness to obstructive shock, with symptoms that mimic other cardiopulmonary conditions. Diagnostic studies may be overused while PE remains underdiagnosed in systematic reviews.\"},{\"question\":\"What factors contribute to the development of PE from a pathophysiologic perspective?\",\"answer\":\"PE is primarily thromboembolic and results from venous thromboembolism linked to Virchow’s triad: stasis of blood flow, endothelial injury, and hypercoagulability from inherited or acquired causes.\"}]",1783371776,86,{"code":4,"msg":31,"data":32},"ok",{"site_id":25,"language":24,"slug":33,"title":13,"keywords":34,"description":14,"schema_data":35,"social_meta":86,"head_meta":88,"extra_data":90,"updated_unix":28},"intermediate-risk-and-high-risk-pulmonary-embolism-recognition-and-management","",{"@graph":36,"@context":85},[37,53,68],{"@type":38,"itemListElement":39},"BreadcrumbList",[40,44,47,50],{"item":41,"name":42,"@type":43,"position":21},"https://docshare.wps.com","Home","ListItem",{"item":45,"name":46,"@type":43,"position":20},"https://docshare.wps.com/document/","Document",{"item":48,"name":12,"@type":43,"position":49},"https://docshare.wps.com/document/research-report/",3,{"item":51,"name":13,"@type":43,"position":52},"https://docshare.wps.com/document/intermediate-risk-and-high-risk-pulmonary-embolism-recognition-and-management/42823/",4,{"url":51,"name":13,"@type":54,"author":55,"headline":13,"publisher":57,"fileFormat":60,"inLanguage":24,"description":14,"dateModified":61,"datePublished":62,"encodingFormat":60,"isAccessibleForFree":63,"interactionStatistic":64},"DigitalDocument",{"name":9,"@type":56},"Person",{"url":41,"name":58,"@type":59},"DocShare","Organization","application/pdf","2026-07-10","2026-07-06",true,{"@type":65,"interactionType":66,"userInteractionCount":20},"InteractionCounter",{"@type":67},"ViewAction",{"@type":69,"mainEntity":70},"FAQPage",[71,77,81],{"name":72,"@type":73,"acceptedAnswer":74},"How is acute PE risk stratified into high-risk, intermediate-risk, and low-risk categories?","Question",{"text":75,"@type":76},"Acute PE is categorized using imaging findings and patient characteristics. High-risk PE involves sustained hypotension or vasopressor requirement without another explanation; intermediate-risk includes imaging RV dysfunction and/or biomarker evidence without sustained hypotension; low-risk does not meet high- or intermediate-risk criteria.","Answer",{"name":78,"@type":73,"acceptedAnswer":79},"Why is PE often missed despite being a commonly considered emergency diagnosis?",{"text":80,"@type":76},"PE is difficult to recognize because clinical presentations are heterogeneous, ranging from asymptomatic illness to obstructive shock, with symptoms that mimic other cardiopulmonary conditions. Diagnostic studies may be overused while PE remains underdiagnosed in systematic reviews.",{"name":82,"@type":73,"acceptedAnswer":83},"What factors contribute to the development of PE from a pathophysiologic perspective?",{"text":84,"@type":76},"PE is primarily thromboembolic and results from venous thromboembolism linked to Virchow’s triad: stasis of blood flow, endothelial injury, and hypercoagulability from inherited or acquired causes.","https://schema.org",{"og:url":51,"og:type":87,"og:title":13,"og:site_name":58,"og:description":14},"article",{"robots":89,"canonical":51},"index,follow",{"doc_id":7,"site_id":25},{"code":4,"msg":5,"data":92},[93,97,101,105,110,115,120,123,128,131,135],{"id":21,"doc_module":4,"doc_module_name":46,"category_name":94,"show_sort_weight":95,"slug":96},"Story & Novel",90,"story-novel",{"id":20,"doc_module":4,"doc_module_name":46,"category_name":98,"show_sort_weight":99,"slug":100},"Literature",80,"literature",{"id":52,"doc_module":4,"doc_module_name":46,"category_name":102,"show_sort_weight":103,"slug":104},"Exam",70,"exam",{"id":106,"doc_module":4,"doc_module_name":46,"category_name":107,"show_sort_weight":108,"slug":109},5,"Comic",60,"comic",{"id":111,"doc_module":4,"doc_module_name":46,"category_name":112,"show_sort_weight":113,"slug":114},6,"Technology",50,"technology",{"id":116,"doc_module":4,"doc_module_name":46,"category_name":117,"show_sort_weight":118,"slug":119},7,"Healthcare",40,"healthcare",{"id":11,"doc_module":4,"doc_module_name":46,"category_name":12,"show_sort_weight":121,"slug":122},30,"research-report",{"id":124,"doc_module":4,"doc_module_name":46,"category_name":125,"show_sort_weight":126,"slug":127},9,"Religion & Spirituality",20,"religion-spirituality",{"id":126,"doc_module":4,"doc_module_name":46,"category_name":129,"show_sort_weight":126,"slug":130},"World Cup","world-cup",{"id":132,"doc_module":4,"doc_module_name":46,"category_name":133,"show_sort_weight":132,"slug":134},10,"Lifestyle","lifestyle",{"id":136,"doc_module":4,"doc_module_name":46,"category_name":137,"show_sort_weight":106,"slug":138},19,"General","general"]