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PESI (Pulmonary Embolism Severity Index)

30-day mortality risk class (I–V) in confirmed acute pulmonary embolism

Sources last checked: 2026-10-13

PESI (Pulmonary Embolism Severity Index)

30-day mortality risk class (I–V) in confirmed acute pulmonary embolism

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Only for confirmed, haemodynamically stable PE. Class I–II identifies low clinical risk but not RV dysfunction; ESC 2019 combines it with imaging/troponin. Mortality ranges span the derivation, internal and external validation cohorts.

Source: Aujesky D et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 2005;172(8):1041-1046.Open

Interpretation

Class I (≤ 65) — very low risk30-day mortality 0–1.6 %. Low-risk PE: ESC 2019 lists early discharge / outpatient treatment as an option in this class.
Class II (66–85) — low risk30-day mortality 1.7–3.5 %. Low-risk PE: ESC 2019 lists early discharge / outpatient treatment as an option in this class.
Class III (86–105) — intermediate risk30-day mortality 3.2–7.1 %. In ESC 2019, PESI classes III–V fall into the intermediate-risk group, for which the guideline foresees in-hospital treatment and assessment of RV function and troponin.
Class IV (106–125) — high risk30-day mortality 4.0–11.4 %. In ESC 2019, PESI classes III–V fall into the intermediate-risk group, for which the guideline foresees in-hospital treatment and assessment of RV function and troponin.
Class V (> 125) — very high risk30-day mortality 10.0–24.5 %. In ESC 2019, PESI classes III–V fall into the intermediate-risk group, for which the guideline foresees in-hospital treatment and assessment of RV function and troponin.

What is the PESI (Pulmonary Embolism Severity Index)?

The Pulmonary Embolism Severity Index sums age in years with weighted points for ten clinical findings to estimate 30-day mortality after acute PE. Aujesky and colleagues derived it from 15,531 inpatients in Pennsylvania (Am J Respir Crit Care Med 2005) and validated it externally in Swiss and French emergency patients. It sorts patients into five classes, with classes I–II at low risk.

When to use it

  • Confirmed, haemodynamically stable acute PE, to estimate short-term mortality.
  • Selecting candidates for outpatient treatment or early discharge (classes I–II).
  • Defining intermediate risk in the ESC 2019 algorithm (class III–V).

When not to use it

  • Before PE is confirmed.
  • Shock or persistent hypotension (high-risk PE).
  • As the sole basis for discharge — RV function, troponin and feasibility of home treatment are not captured.

How it is calculated

PESI = age (years) + 10 (male) + 30 (cancer) + 10 (chronic heart failure) + 10 (chronic lung disease) + 20 (HR ≥ 110/min) + 30 (SBP < 100 mmHg) + 20 (RR ≥ 30/min) + 20 (T < 36 °C) + 60 (altered mental status) + 20 (SaO₂ < 90 %)

Clinical pearls and limitations

  • Only for confirmed, haemodynamically stable PE. Class I–II identifies low clinical risk but not RV dysfunction; ESC 2019 combines it with imaging/troponin. Mortality ranges span the derivation, internal and external validation cohorts.
  • Age contributes 1 point per year, so an 80-year-old starts in class II before any other finding.
  • Altered mental status (+60) is the heaviest item; cancer and hypotension each add 30.
  • Oxygen saturation < 90 % counts whether or not the patient is on supplemental oxygen.
  • The simplified PESI (sPESI) has the same accuracy and is easier to apply at the bedside.

Frequently asked questions

What are the PESI risk classes?

Class I ≤ 65, II 66–85, III 86–105, IV 106–125, V > 125 points. Classes I–II are low risk; III–V are not.

What is the 30-day mortality by PESI class?

Across derivation and validation cohorts: class I 0–1.6 %, II 1.7–3.5 %, III 3.2–7.1 %, IV 4.0–11.4 %, V 10.0–24.5 %.

Can a patient with PESI class II be treated at home?

PESI I–II indicates low clinical risk. ESC 2019 suggests early discharge can be considered if there is no RV dysfunction, no serious comorbidity and home treatment is feasible.

Evidence and guidelines

  1. Primary source: Aujesky D et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 2005;172(8):1041-1046.
  2. ESC 2019 acute PE guideline, Table 7 (PESI classes and 30-day mortality ranges).
  3. Aujesky D et al. Validation of a model to predict adverse outcomes in patients with pulmonary embolism. Eur Heart J 2006;27(4):476-481.

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