Not All PEs Are Created Equal: What to Do After Diagnosis

The CT scan comes back positive. The patient has a PE. And then, as Dr. Eric Steinberg puts it, "well, what do we do now?"

That question is the subject of Part 2 of a two-part conversation on MD Aware: Upgrading Clinical Judgment. Host Dr. Joe Habboushe, co-founder and CEO of MDCalc, returns with Dr. Steinberg to cover the side of PE care that gets far less attention than diagnosis: figuring out how sick a patient actually is, and what that means for patient triage.

Meet the Guest

Dr. Eric Steinberg is an emergency physician and residency director. This episode picks up directly from Part 1, where he and Dr. Habboushe walked through the diagnostic tools for PE. Here, the conversation shifts to PE management.

It's About the Heart, Not the Lungs

Before getting into the calculators, Dr. Habboushe makes a point he says most patients, and plenty of clinicians, don't fully grasp: a PE doesn't kill through the lungs, it kills through pressure on the heart. He walks through why a PE shouldn't cause hypoxia on its own, since blocked blood flow alone doesn't lower oxygen levels the way people assume. It's the downstream strain on the right ventricle, visible on EKG, echo, or in troponin and BNP levels, that determines how dangerous a given PE really is.

sPESI and Hestia: A Pairing, Not a Single Answer

Dr. Steinberg walks through why he never uses a mortality score on its own to decide disposition. The simplified PESI (sPESI) gives a 30-day, all-cause mortality estimate, but all-cause is the key phrase. His example: a patient with a low sPESI who gets discharged and is hit by a truck crossing the street still counts as a mortality in that score, which tells you the tool has real blind spots if used alone. That's where the Hestia criteria comes in. Hestia is a one-directional rule built specifically to answer a different question: is this patient safe to go home, factoring in bleeding risk and practical issues like whether they can actually access their medication. Paired together, sPESI and Hestia give a fuller picture than either does alone.

Bova and the Path to Higher-Level Care

For patients who don't clear sPESI and Hestia, Dr. Steinberg turns to the Bova score, which predicts PE-specific complications, including hemodynamic collapse and recurrent PE, over the following 30 days. He walks through the treatment options that follow a high-risk Bova result, from low molecular weight heparin to catheter-directed thrombolysis to mechanical thrombectomy, and describes activating a PERT team, a multidisciplinary pulmonary embolism response team now recommended in the current guidelines, for patients showing signs of heart strain or shock.

The Bottom Line

Between the two episodes, Dr. Habboushe and Dr. Steinberg cover roughly a third of the 36 PE-related tools on MDCalc, focused on the handful that apply to the large majority of patients: PERC, Wells, Geneva, and YEARS for diagnosis, and sPESI, Hestia, and Bova for what comes after. The rest, including tools built for specific populations like cancer or orthopedic patients, are worth exploring once these core seven are second nature.

MDAware: Upgrading Clinical Judgment is MDCalc's podcast dedicated to breaking down the science behind clinical scores and bringing transparency and confidence to your clinical workflow.