Clinical Risk Assessment of Acute Intermediate‐Risk Pulmonary Embolism Using Repeat Transthoracic Echocardiography

BACKGROUND: Current risk stratification algorithms for intermediate-risk pulmonary embolism (PE) inadequately identify patients who may benefit from escalated care interventions (ECIs) beyond anticoagulation and do not incorporate temporal assessments of right ventricular (RV) function. OBJECTIVES: To evaluate whether changes in tricuspid annular plane systolic excursion (TAPSE) on repeat transthoracic echocardiography (TTE) before ECIs are associated with clinical outcomes in acute intermediate-risk PE. METHODS: Acute intermediate-risk PE patients at a single quaternary care center were retrospectively identified. Inclusion required two or more TTE studies with TAPSE measurements before discharge or ECI initiation. Patients were stratified into worsening (ΔTAPSE < 0 mm) and stable/improving cohorts. The primary outcome was 30-day mortality. Secondary outcomes included 90-day mortality, intubation, ICU admission, vasopressor requirement, and ECIs. RESULTS: Eighty-eight patients met inclusion criteria (38 worsening, 50 stable/improving). Worsening TAPSE was associated with a significantly increased risk of 30-day mortality (RR 5.26; p = 0.003), 90-day mortality (RR 3.01; p = 0.004), and intubation (RR 1.86; p = 0.010). In univariate logistic regression, each 1 mm increase in ΔTAPSE was associated with lower odds of 30-day mortality (OR 0.86; p = 0.005). Among 53 patients with initial TAPSE ≥16 mm, those with subsequent decline had significantly higher 30-day mortality (33.3% vs. 8.7%; p = 0.048). CONCLUSION: Worsening RV function on repeat echocardiography was associated with short-term mortality in acute intermediate-risk PE, even with initially preserved cardiac function. Serial assessment of RV function may refine risk stratification, and the impact on patient triage and escalation decisions warrants prospective evaluation.