Role of risk stratification tools

This inaugural episode of the CardioNerds Pulmonary Embolism (PE) Series explores the evolution of acute PE care. Dr. Ibrahim Zahid, Dr. Dinu Balanescu, and Dr. Billy Joe Mullinax join guest expert Dr. Kenneth Rosenfield to discuss the shifting landscape of PE management.

Pulmonary embolism (PE) remains a leading cause of cardiovascular mortality and a frequent diagnostic challenge, often masquerading as myocardial infarction or a benign illness. Over the past decade, PE care has evolved from anticoagulation-only strategies to nuanced, risk-stratified, multidisciplinary management. Modern approaches integrate hemodynamics, biomarkers, and advanced imaging to guide therapy, including catheter-directed interventions and large-bore thrombectomy. The Pulmonary Embolism Response Team (PERT) model addresses historical gaps by coordinating rapid, multispecialty decision-making and standardizing care pathways. The PERT Consortium further advances PE care through education, research, and the world’s largest PE registry, while fostering leadership and research opportunities for trainees. Despite advances, long-term outcomes and post-PE syndromes remain important areas for future investigation. Audio editing by CardioNerds Academy intern, student doctor, Pace Wetstein.

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

Pearls

1. PE is a “master masquerader”—maintain suspicion for atypical presentations like myocardial infarction, heart failure, flu, or anxiety.
2. Multidisciplinary management mediated through pulmonary embolism response teams improves outcomes and standardizes care.
3. Risk stratification integrates hemodynamics, biomarkers, and imaging.
4. Advanced therapies have expanded beyond anticoagulation.
5. Long‑term follow‑up and post‑PE syndrome need more research.

Notes

Notes: Notes drafted by Dr. Ibrahim Zahid.

1. How has the clinical approach to PE changed over the past decade?

• PE is the third leading cause of cardiovascular death and historically under‑recognized.
• Symptoms mimic MI, HF, asthma, syncope, and more.PE is a silent killer, and it should be recognized more as a cause of spontaneous cardiac arrest.
• Where life threatening disease like stroke which is owned by neurological specialists and MI is primarily managed by cardiac specialists, PE is an entity without a professional home. The PERT Consortium brings the specialties together for PE care.

2. Ten years ago, a 58-year-old patient with a large bilateral PE, RV dilation, and positive biomarkers might have been managed with anticoagulation and close observation alone. Today, with evolving—but still uneven—data on advanced therapies, PE care feels far more nuanced and highly dependent on where you practice. What are the major gaps in traditional PE management that clinicians should recognize, and what care pathways should they be aware of across different hospital systems?

• Care has shifted from anticoagulation‑only to multidisciplinary approaches like catheter directed thrombectomy.
• Risk‑based pathways and the use of CT angiogram has improved early recognition. Risk stratification tools must be used as tools for early recognition of intermediate risk PE.
• Untreated PE leads to chronic complications like chronic thromboembolic disease and chronic thromboembolic pulmonary hypertension, which requires long term clinic follow up.

3. What is the role of risk stratification tools such as PeSI, sPeSI scores, cardiac biomarkers, and imaging findings in PE, and how do they guide treatment decisions in real world practice?

• Integrate vitals (blood pressure and heart rate), biomarkers (troponin, pro-BNP), RV/LV ratio assessment, acid‑base status, and scores.
• Tools include PESI, sPESI, BOVA, HESTIA, FAST, Geneva, NEWS, shock index.
• Vitals, lactate, acid-base status, and tools like NEWS or shock index track clinical evolution.
• PESI/sPESI estimate 30-day mortality and help identify low-risk patients who may be candidates for early discharge or outpatient therapy.
• Clinical judgment matters—scores don’t fully capture clot burden, trajectory, or bleeding risk.

4. How was the pulmonary embolism response team created, and since its creation, what evidence or outcome data became available to support the PERT model?

• Originated after a sentinel case at MGH: A young, pregnant woman in her 30s, who collapsed at home, underwent thrombectomy, and had to be on ECMO for a few days. The case brought cardiology, cardiac surgeons and critical care physicians together for planning and improvement in her health, which was rewarding.
• Thereby, it was decided to bring specialties involved in PE care together to create a response team.
• The name of the team, Pulmonary Embolism Response Team (PERT), was coined by Richard Channick in the first meeting.
• Posters were set up all over the hospital to call a centralized line when an acute PE is recognized
• A meeting was held to present the concept of putting together a consortium, with development of action items and a PERT database.
• Enabled rapid multidisciplinary input using early teleconferencing tools.

5. Given concerns about having too many ‘cooks in the kitchen’ during the initial PE call—especially with rotating teams—how can institutions reconcile workflow complexity with standardized pathways in a way that meaningfully supports and justifies the added burden on frontline clinicians?

• Every hospital’s PERT is different, catering to their needs and workflow
• At least two disciplines are needed to make a PERTData is currently being collected to guide further on how the workflow can be standardized
• Most importantly, the team brings in resources that were not available prior to PERT formation.

6. What are the main goals of the PERT consortium, and how does it support clinicians and institutions involved?

• To improve care and improve outcomes for patients with PE
• Expand education, refine algorithms, standardize care with Centers of Excellence.
• Maintain the largest PE registry for research and outcomes improvement.

7. Beyond global networking, shared learning from successful systems, and the pathway toward Center of Excellence designation, what additional benefits can clinicians and health systems gain by participating in the PERT Consortium?

• The ability to learn from other systems, the ability to share experiences.
• Allow people to develop their professional careers like leadership experience, becoming a member of the trainee council
• Initiate projects and receive funding for your ideas

8. For trainees interested in pulmonary embolism care, how can a trainee be a champion at their institution? Does PERT provide assistance and how can they really contribute meaningfully even before becoming a fellow/attending?

• Medical students and residents interested in PE should reach out to the consortium and the consortium will hook you up with the correct mentors who can nurture you along.
• Listen to the podcasts.
• Participate with your local PERT team
• PERT wants involvement of people who are social media savvy to help spread the word on PE.

Top three take-away points from this episode

1. Acute PE care has advanced and multiple treatment modalities for acute PE including catheter directed therapy, large bore thrombectomy, are becoming standard of care.
2. Multidisciplinary models like PERT improve coordination and outcomes.
3. Trainees play a vital role in advancing PE care through involvement, research, and education

References

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