Too Old for PESI?: Risk Stratification of Octogenarians with Pulmonary Embolism in the Emergency Department

Abstract Pulmonary embolism (PE) in octogenarians (i.e., patients > 80 years) is associated with substantial morbidity and mortality, yet this population remains underrepresented in major studies. We compared the predictive performance of the Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI), European Society of Cardiology (ESC) risk classes, and National Early Warning Score (NEWS) for mortality prediction in octogenarians versus younger emergency department (ED) patients. In this single-center retrospective cohort study, adults with confirmed PE presenting to an ED in Vienna, Austria, between January 2017 and December 2024 were included. Patients were categorized as octogenarians or ≤80 years. Clinical characteristics, treatment, and outcomes were compared. Predictive performance for 30-day mortality was assessed using receiver operating characteristic analyses and diagnostic accuracy measures. Sensitivity analyses and evaluation of 7-day mortality were also performed. Among 773 patients, 114 were octogenarians. Compared with younger patients, octogenarians had more cardiovascular comorbidities, higher cardiac biomarker levels, more right ventricular strain, and significantly higher 30-day mortality. PESI showed the most consistent overall prognostic performance but was less accurate in octogenarians. sPESI demonstrated limited specificity because most octogenarians were classified as high risk. ESC risk classes provided moderate discrimination. NEWS ≥ 7 showed prognostic value for short-term mortality among octogenarians, although the differences from PESI were not statistically significant. Established PE prognostic tools perform less well in octogenarians. PESI showed the most consistent overall performance, while NEWS demonstrated promising short-term prognostic value that warrants further investigation.