Pulmonary Embolism – Clinical Risk Assessment Tools

Adil Abbasi, MD, FACP

Quick Clinical Summary: How to Measure Each Scale/Tool

1. Wells Score (Diagnosis)

How to Measure (Step-by-Step)

Step 1: Assign points

Variable	Points
Clinical signs of DVT	+3
PE most likely diagnosis	+3
HR >100	+1.5
Immobilization/surgery (4 weeks)	+1.5
Prior DVT/PE	+1.5
Hemoptysis	+1
Cancer	+1

Step 2: Add total score

Step 3: Interpret

Score	Probability
≤4	PE unlikely
>4	PE likely

What You Do Next

≤4 → D-dimer
4 → CTPA directly

Reinforcement

Quick bedside mental math
Includes clinical judgment (“PE most likely”)

2. Revised Geneva Score (Diagnosis)

How to Measure

Step 1: Assign points (objective only)

Variable	Points
Age >65	+1
Prior DVT/PE	+3
Surgery/fracture (1 month)	+2
Active cancer	+2
Unilateral leg pain	+3
Hemoptysis	+2
HR 75–94	+3
HR ≥95	+5
Pain on leg palpation	+4

Step 2: Add score

Step 3: Interpret

Score	Probability
0–3	Low
4–10	Intermediate
≥11	High

Reinforcement

No subjective component
Useful when you want objectivity

3. PESI Score (Mortality Risk)

How to Measure

Step 1: Start with age (baseline score = age)

Step 2: Add points

Variable	Points
Male sex	+10
Cancer	+30
Heart failure	+10
Chronic lung disease	+10
HR ≥110	+20
SBP <100	+30
RR ≥30	+20
Temp <36°C	+20
Altered mental status	+60
O2 sat <90%	+20

Step 3: Total score → classify

Class	Score	Mortality
I	≤65	Very low
II	66–85	Low
III	86–105	Moderate
IV	106–125	High
V	>125	Very high

Reinforcement

Start with age = base score
Then add clinical factors
More detailed but highly validated

4. sPESI (Simplified PESI)

How to Measure

Step 1: Give 1 point for each:

Age >80
Cancer
Chronic cardiopulmonary disease
HR ≥110
SBP <100
O2 sat <90%

Step 2: Total

Score	Interpretation
0	Low risk
≥1	Higher risk

Reinforcement

Much faster than PESI
Common in real-world use

5. Hestia Criteria (Disposition)

How to Measure

Step 1: Go through checklist (YES/NO)

Key domains:

Hemodynamic instability?
Need for oxygen?
High bleeding risk?
Severe pain requiring IV meds?
Renal/liver failure?
Social issues (cannot manage at home)?

Step 2: Interpretation

👉 If ANY = YES → NOT outpatient
👉 If ALL = NO → safe for discharge

Reinforcement

Binary tool (not scoring)
Most practical for real-life decisions

Ultra-High Yield Summary Table

Tool	How to Measure	Output	Key Use
Wells	Add weighted points (includes judgment)	Likely vs unlikely	Diagnosis
Geneva	Add objective points	Low/intermediate/high	Diagnosis
PESI	Age + weighted variables	Class I–V	Mortality
sPESI	6 variables (0 or 1)	Low vs high risk	Quick mortality
Hestia	Yes/No checklist	Safe vs unsafe discharge	Disposition

One-Minute Bedside Workflow

Suspect PE → Wells/Geneva

Score it quickly

Confirm PE → PESI/sPESI

Estimate risk

Disposition → Hestia

Decide home vs admit

Final Reinforcement (Memory Anchor)

Wells/Geneva → Add points → Diagnose
PESI → Add points → Mortality
sPESI → Count variables → Quick risk
Hestia → Yes/No → Disposition

If you want, I can next create:
✔️ A single-page printable cheat sheet
✔️ OR case-based scenarios (like real ER cases using these scores together)

A single-page printable cheat sheet

Here is a clean, single-page printable cheat sheet designed for real bedside use (ER / inpatient / exam review). You can copy-paste into Word/PDF and print.

🫁 ACUTE PULMONARY EMBOLISM (PE) – ONE-PAGE CHEAT SHEET

1. CLINICAL FLOW (MEMORY ANCHOR)

Suspect → Diagnose → Risk → Disposition → Treat

Wells/Geneva → Diagnosis
PESI/sPESI → Mortality risk
Hestia → Disposition

2. DIAGNOSIS (PRETEST PROBABILITY)

WELLS SCORE

Variable	Points
Signs of DVT	+3
PE most likely	+3
HR >100	+1.5
Surgery/immobilization	+1.5
Prior DVT/PE	+1.5
Hemoptysis	+1
Cancer	+1

Interpretation:

≤4 → PE unlikely → D-dimer
4 → PE likely → CTPA

GENEVA SCORE (OBJECTIVE)

Variable	Points
Age >65	+1
Prior DVT/PE	+3
Surgery/fracture	+2
Cancer	+2
Leg pain	+3
Hemoptysis	+2
HR 75–94	+3
HR ≥95	+5
Leg tenderness	+4

Interpretation:

0–3 = Low
4–10 = Intermediate
≥11 = High

DIAGNOSTIC ALGORITHM

Wells/Geneva
Low/intermediate → D-dimer
Positive → CTPA
Very low → PERC → no testing

3. MORTALITY RISK (AFTER DIAGNOSIS)

sPESI (FAST TOOL)

1 point each:

Age >80
Cancer
Cardiopulmonary disease
HR ≥110
SBP <100
O2 sat <90%

Score:

0 → Low risk
≥1 → Higher risk

PESI (DETAILED)

Start = Age (base score)

Add:

Variable	Points
Male	+10
Cancer	+30
CHF	+10
Lung disease	+10
HR ≥110	+20
SBP <100	+30
RR ≥30	+20
Temp <36	+20
AMS	+60
O2 sat <90%	+20

Classes:

I–II → Low risk
III → Moderate
IV–V → High

4. DISPOSITION (Hestia Criteria)

YES/NO CHECKLIST

Ask:

Hemodynamic instability?
Need for oxygen?
High bleeding risk?
Severe pain (IV meds)?
Renal/liver failure?
Social issues?

Interpretation:

ANY “YES” → Admit
ALL “NO” → Outpatient safe

5. RISK CLASSIFICATION (A–E)

Category	Meaning	Action
A	Asymptomatic	Outpatient
B	Low risk	Outpatient
C	RV strain/biomarkers	Admit
D	Deteriorating	ICU
E	Shock	Thrombolysis

6. RV STRAIN (KEY PROGNOSTIC FACTOR)

RV/LV ≥1.0
Septal bowing
Contrast reflux

Echo

RV dilation
TAPSE <1.6
McConnell sign

7. BIOMARKERS

Marker	Meaning
D-dimer	Diagnosis only
Troponin ↑	RV injury
BNP ↑	RV strain

8. ANTICOAGULATION

FIRST-LINE

DOAC (Apixaban / Rivaroxaban)

LMWH (Enoxaparin)

Stable inpatient
Cancer

UFH (CRITICAL USE ONLY)

Use if:

Category D–E
Procedures planned
Severe renal failure
ICU patient
High bleeding risk

9. TREATMENT BY SCENARIO

Scenario	Treatment
Stable outpatient	DOAC
Stable inpatient	DOAC/LMWH
Category C	Admit + anticoagulation
Category D	ICU + UFH
Category E	Thrombolysis

10. REPERFUSION DECISION

Shock → Immediate thrombolysis
Deteriorating → Consider escalation
Stable → NO thrombolysis

11. DURATION OF ANTICOAGULATION

Scenario	Duration
All PE	≥3 months
Provoked	3 months
Unprovoked	3–6+ months
Recurrent/persistent	Indefinite

12. DISCHARGE CRITERIA

Hemodynamically stable
Oxygen stable
Oral anticoagulation tolerated
No bleeding risk

13. HIGH-YIELD PEARLS

RV dysfunction = most important predictor
PESI ≠ disposition tool
Hestia overrides PESI for discharge
DOAC = default therapy
UFH = unstable only
Most PE → short hospital stay (1–3 days)

FINAL MEMORY LINE

👉 “Wells finds it → PESI grades it → Hestia places it → RV defines it → DOAC treats it.”