Conclusions
We have shown that despite frequent usage and association with treatment decisions in routine clinical practice, risk stratification, defined as the measurement of a biomarker (natriuretic peptide or troponin) or the performance of an echocardiogram, does not improve outcomes in patients with acute PE. This finding could be a result of several nonmutually exclusive explanations, including fixed comorbidities, an unfavorable risk–benefit ratio of treatments beyond anticoagulation, and/or simple lack of actionable information not already available from bedside assessment. The latter explanation is suggested by the finding that 40% of patients with high-risk (PESI class IV–V) acute PE in our investigation did not undergo risk stratification. Furthermore, the possibility exists that mortality would have been higher without the use of risk stratification. Because of the frequent use and uncertain clinical benefit of risk stratification, studies that incorporate it into prospective treatment algorithms should be performed.