Beyond Baseline: Dynamic Prognostic Assessment in Acute Pulmonary Embolism

Acute pulmonary embolism (PE) remains one of the most challenging cardiovascular emergencies. Diagnostic accuracy has improved substantially, and current therapeutic strategies include systemic thrombolysis, catheter-based interventions, and multidisciplinary response teams. However, the greatest clinical uncertainty persists in patients with intermediate-to-high-risk PE, in whom the natural progression of right ventricular (RV) dysfunction must be balanced against the risk of bleeding associated with reperfusion therapy.

This uncertainty reflects a major limitation of current risk assessment. Contemporary prognostic models rely largely on variables measured at hospital admission. Clinical scores, biomarkers, and imaging studies have substantially improved early prognostic discrimination; however, they derive their prognostic value primarily from the initial assessment (PESI). Acute PE is inherently a dynamic disease. RV adaptation, pulmonary vascular resistance, systemic arterial pressure, and myocardial injury continue to evolve after treatment begins. Consequently, prognostic information should also reflect the patient’s physiological trajectory.

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