Multicenter validation of the TELOSplus score for 30-day pulmonary embolism–related death in normotensive patients

Background Early risk stratification of normotensive patients with acute pulmonary embolism (PE) remains challenging. The TELOSplus score was recently developed in a retrospective single-center cohort to identify normotensive patients who are at increased risk of hemodynamic decompensation or PE-related death. Purpose To validate the TELOSplus score in a multicenter cohort of normotensive patients with acute symptomatic pulmonary embolism, defined as those with an initial systolic blood pressure ≥90 mmHg and no clinical signs of overt shock. Methods This analysis derives from an ongoing observational multicenter study enrolling normotensive patients with acute PE across more than 10 centers in Italy and other European countries, with a planned sample size of 1,300 patients. The TELOSplus score includes elevated arterial plasma lactate (>2 mmol/L; 2 points), right ventricular dysfunction (1 point), elevated cardiac troponin (1 point), and severe respiratory failure (2 points). Right ventricular dysfunction was defined as the presence of at least two echocardiographic signs among right ventricular dilatation (RV/LV ratio >1), elevated pulmonary artery pressure (tricuspid regurgitation gradient >30 mmHg), right ventricular free-wall hypokinesis or tricuspid annular plane systolic excursion <17 mm, or paradoxical septal motion. Severe respiratory failure was defined as peripheral oxygen saturation <85% on room air at presentation, PaO₂/FiO₂ <250, or the need for high-flow nasal cannula or non-invasive ventilation. Results Among the first 877 consecutively enrolled patients (mean age 70.6 ± 15 years; 51.5% women), the prevalence of TELOSplus components was: elevated troponin 57.6%, respiratory failure 36.8%, right ventricular dysfunction 25.3%, and plasma lactate >2 mmol/L 20.1%. The overall incidence of 30-day PE-related death was 2.7% and increased progressively with higher TELOSplus scores, from 0.4% in patients with TELOSplus ≤2 to 7.0% in those with TELOSplus >2 (p for trend <0.001)(Figure 1). In time-to-event analysis, TELOSplus >2 was associated with a substantially increased risk of PE-related death in the overall population (hazard ratio [HR] 20.2, 95% confidence interval [CI] 4.7–85.7) and among patients with sPESI >0 (HR 15.5, 95% CI 3.6–65.9)(Figure 2). Conclusions In an ongoing observational multicenter cohort study, increasing TELOSplus score values were associated with a graded rise in 30-day PE-related death, supporting the validity and clinical applicability of the score for early risk stratification of normotensive patients with acute PE.Mortality in TELOS plus categoriesFor image description, please refer to the figure legend and surrounding text.30-day PE-related mortality in TELOS plus >2For image description, please refer to the figure legend and surrounding text.