Refining risk stratification in acute pulmonary embolism: A comparative validation of six prognostic scores in a real-life cohort

• PESI score showed the highest accuracy for in-hospital PE-related adverse events. • NEWS-2 outperformed ESC classification and ranked second-best across all outcomes. • CPES, FAST, and modified Bova scores showed limited prognostic value in real-life PE. • PESI and NEWS-2 provided incremental risk discrimination over ESC risk stratification. • Among intermediate-risk PE patients, PESI retained excellent accuracy for clinical endpoints. PESI score showed the highest accuracy for in-hospital PE-related adverse events. NEWS-2 outperformed ESC classification and ranked second-best across all outcomes. CPES, FAST, and modified Bova scores showed limited prognostic value in real-life PE. PESI and NEWS-2 provided incremental risk discrimination over ESC risk stratification. Among intermediate-risk PE patients, PESI retained excellent accuracy for clinical endpoints. Risk stratification in acute pulmonary embolism (PE) is essential to guide clinical management, particularly regarding the need for escalated therapies. Despite the availability of several prognostic scores, their comparative performance in unselected PE populations remains uncertain. To compare the prognostic performance of six widely used risk assessment tools for acute PE in predicting short-term outcomes. We retrospectively collected data from 397 consecutive patients with acute PE from a single institutional registry. Six risk scores (modified Bova, modified FAST, CPES, NEWS-2, PESI, and sPESI) were calculated at admission. The primary endpoint was the composite of in-hospital PE-related death, need for rescue thrombolysis, or severe hemodynamic instability. Secondary endpoints were the individual components of the primary endpoint and all-cause mortality up to 3 months. The primary endpoint occurred in 48 patients (12.1%), including PE-related death in 25(6.3%), severe hemodynamic instability in 25 (6.3%), and systemic thrombolysis in 6 (1.5%). In-hospital mortality was 52 (13.1%), and 3-month all-cause mortality was 65 (16.4%). The PESI score demonstrated the highest predictive performance for all outcomes (AUC for the primary endpoint: 0.84, 95% confidence interval: 0.78–0.90), followed by NEWS-2 and sPESI. PESI and NEWS-2 consistently showed the greatest improvement over ESC classification in terms of net reclassification and increased discrimination. Bootstrap-based ranking confirmed PESI as the most likely best-performing score, while modified Bova, FAST, and CPES showed inferior performance. Findings were consistent across all ESC risk strata. Among commonly used prognostic scores for acute PE, PESI and NEWS-2 provide superior discrimination for short-term clinical outcomes and incremental value over ESC-based stratification. These scores may aid in refining risk assessment and guiding management in acute PE.