Admission Patterns and Clinical Outcomes in a Regional Cohort of Low- to Intermediate-Risk Pulmonary Embolism Patients

In the absence of hypotension or hypoxia, pulmonary embolism (PE) often follows a benign course. Risk tools such as the simplified pulmonary embolism severity index (sPESI) support outpatient management of stable cases; however, current guidelines recommend hospitalization for any evidence of right ventricular (RV) strain—whether by CT or elevated troponin (hs-cTnT)—regardless of sPESI. We aimed to quantify admission rates and the risk of clinical deterioration or therapy escalation among low-intermediate risk patients per ESC guidelines.

We conducted a retrospective cohort study of patients with newly diagnosed PE across eight rural and urban EDs in 2025, excluding cases with hypotension (SBP

Of 250 stable PE cases, 148 (59%) were low-intermediate risk. Among these, 107 (72%) were hospitalized and 41 (28%) discharged. The primary outcome occurred in 22 (15%) cases—all initially admitted. Most admitted cases were sPESI+ (74%) and accounted for 91% of adverse events. Among 38 sPESI- patients, two adverse events occurred, both in those with elevated troponins; none occurred in patients with CT evidence of RV strain. ED clinicians discharged 18 (47%) sPESI- cases despite the presence of either RV strain or troponin elevation and 23 (21%) sPESI+ cases. A single discharged case (sPESI-) was admitted within 72 hours for analgesia.

In a regional sample of low-intermediate risk PE, ED clinicians safely discharged nearly one-third of patients despite guideline recommendations for hospitalization. Nearly all adverse outcomes occurred among sPESI+ cases regardless of CT or biomarker evidence of RV strain. These data call into question the value of RV strain as an adjunct to sPESI and clinical judgment.