PESI Score Calculator — Pulmonary Embolism Severity Index (Full)
The Pulmonary Embolism Severity Index (PESI) is a validated clinical prediction rule that stratifies patients with acute pulmonary embolism into five risk classes (I-V) based on 30-day mortality, using 11 clinical variables including age, sex, comorbidities, vital signs, and mental status.
About
The Pulmonary Embolism Severity Index (PESI) was developed by Aujesky et al. and validated in a cohort of over 15,000 inpatients with PE, published in the American Journal of Respiratory and Critical Care Medicine in 2005. Unlike the simplified version (sPESI) which uses 6 binary variables, the full PESI uses 11 variables with age as a continuous variable and differential weighting. The score is calculated as: age in years + 10 points for male sex + 30 for cancer + 10 for heart failure + 10 for chronic lung disease + 20 for pulse ≥110 + 30 for systolic BP <100 + 20 for respiratory rate ≥30 + 20 for temperature <36°C + 60 for altered mental status + 20 for O₂ sat <90%. Total scores range from 0 to >400. Patients are classified into 5 mortality risk classes: Class I (≤65 points, 0-1.6% mortality), Class II (66-85, 1.7-3.5%), Class III (86-105, 3.2-7.1%), Class IV (106-125, 4.0-11.4%), Class V (>125, 10.0-24.5%). PESI is recommended by the ESC Guidelines for initial risk stratification. It has higher sensitivity for identifying low-risk patients than sPESI but is more complex to calculate at bedside.
Formula
Age + Male (10) + Cancer (30) + HF (10) + Lung Disease (10) + HR≥110 (20) + SBP<100 (30) + RR≥30 (20) + Temp<36°C (20) + AMS (60) + SpO₂<90% (20)
The full PESI score is calculated by summing the patient's age in years plus all applicable points from 10 additional variables. Male sex adds 10 points. Cancer (active or treated within 1 year) adds 30 points. Chronic heart failure adds 10 points. Chronic lung disease adds 10 points. Heart rate ≥110 bpm adds 20 points. Systolic BP <100 mmHg adds 30 points. Respiratory rate ≥30/min adds 20 points. Temperature <36°C adds 20 points. Altered mental status adds 60 points (delirium, stupor, coma — the highest single point value). O₂ saturation <90% on room air adds 20 points. The total is classified into 5 risk classes with increasing 30-day mortality.
Score Interpretation
The full PESI is the original and most comprehensively validated risk stratification tool for acute PE, recommended by the 2019 ESC Guidelines as the preferred initial assessment method (alongside sPESI). With 11 variables and 5 risk classes, PESI provides more granular risk stratification than sPESI, particularly for intermediate-risk patients. The score has been validated in over 50,000 patients internationally and is used in quality improvement initiatives including the CMS Venous Thromboembolism measures. The major advantage of PESI over sPESI is the ability to risk-stratify along a 5-class continuum rather than just low vs high risk. However, the complexity of the full PESI (requiring age and weighted scoring) limits its bedside utility compared to the simpler sPESI. Many institutions use sPESI for initial screening and PESI for confirmatory risk classification. Class I patients (≤65) have a 30-day mortality of ≤1.6% and are candidates for outpatient management, representing 20-30% of all PE patients.
Class I — Very Low Risk — 0–65
30-day mortality 0-1.6%. Suitable for outpatient management or early discharge.
Management: Consider outpatient management with DOAC. Early follow-up within 2-7 days.
Class II — Low Risk — 66–85
30-day mortality 1.7-3.5%. Low risk, may be candidate for short-stay admission.
Management: Consider short-stay admission. Anticoagulation with DOAC or LMWH.
Class III — Moderate Risk — 86–105
30-day mortality 3.2-7.1%. Moderate risk. Hospital admission indicated.
Management: Hospital admission. Initiate anticoagulation. Consider echocardiography for RV assessment.
Class IV — High Risk — 106–125
30-day mortality 4.0-11.4%. High risk. Inpatient management required.
Management: Hospital admission. Therapeutic anticoagulation. Echocardiography. Close monitoring for hemodynamic decompensation.
Class V — Very High Risk — 126+
30-day mortality 10.0-24.5%. Very high risk. ICU/cardiac care unit admission.
Management: ICU admission. Consider thrombolysis or embolectomy if unstable. Arterial line for hemodynamic monitoring.
Reference Ranges
| Population | Normal Range | Notes |
|---|---|---|
| Acute PE patients (inpatient and outpatient) | Class I-V | I (≤65): 0-1.6%, II (66-85): 1.7-3.5%, III (86-105): 3.2-7.1%, IV (106-125): 4.0-11.4%, V (>125): 10.0-24.5% |
Dr. Khaled Hassan
Dr. Khaled is a cardiology consultant with experience in acute cardiac care.
View medical review board & editorial policy →Example Calculation
A 72-year-old man with active lung cancer presents with acute dyspnea and pleuritic chest pain. Vitals: HR 115 bpm, SBP 95 mmHg, RR 28/min, temperature 37.0°C, SpO₂ 88% on room air. He is alert and oriented. PESI: Age 72 + Male (10) + Cancer (30) + HF (0) + Lung disease (10 for cancer-related lung involvement not scored separately) + HR≥110 (20) + SBP<100 (30) + RR≥30 (0, RR 28) + Temp<36°C (0) + AMS (0) + SpO₂<90% (20) = 72+10+30+10+20+30+20 = 192. Class V: Very high risk. 30-day mortality 10.0-24.5%. Admit to ICU. Consider advanced therapies.
Related Conditions
Related Medications
Common Mistakes
Using sPESI instead of full PESI when full risk stratification is needed
sPESI provides binary (low vs high) risk classification. The full PESI offers 5 risk classes with more nuanced mortality estimates. Use full PESI when detailed risk stratification is needed for clinical decision-making or research purposes.
Forgetting that age is scored in years, not points
Age is added directly as a continuous variable (e.g., a 72-year-old patient gets +72 points for age alone). This can significantly increase the total score in elderly patients, appropriately reflecting the increased mortality risk with age.
Frequently Asked Questions
What is the main advantage of full PESI over sPESI?
When should full PESI be used instead of sPESI?
References
- Aujesky D, Obrosky DS, Stone RA, et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med. 2005;172(8):1041-1046. PubMed
- Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2020;41(4):543-603. PubMed