Introduction: Pulmonary embolism (PE) is common with potential for morbidity and mortality. Several PE risk-stratification tools exist; however, more granular and patient-specific indicators of potential decompensation or short-term mortality that can be easily obtained are needed for the bedside clinician to further sub-stratify risk and inform management decisions. We sought to determine the association of early emergency department (ED) measurement of the shock index (SI) and SI variants (modified SI, SI to peripheral oxygen saturation ratio, age-adjusted SI, respiratory-adjusted SI, and double product) and mortality among patients with acute PE.
\nMethods: This was an observational case-control study of adult patients who presented to the ED at a single health system (January 2021–April 2023) and had PE response team (PERT) activation for newly diagnosed acute PE. We evaluated the association of 30-day in-hospital mortality with the SI (heart rate/systolic blood pressure) and variants of the SI—modified SI = heart rate/mean arterial pressure; SI to peripheral oxygen saturation ratio = SI/peripheral oxygen saturation; age-adjusted SI = age x SI; respiratory-adjusted SI = SI x (respiratory rate/10); double product = systolic blood pressure x heart rate—in addition to the Simplified Pulmonary Embolism Severity Index (sPESI) and European Society of Cardiology (ESC) risk schema. We used the area under the receiver operating characteristic curve (AUC) to assess discriminatory efficiency of the SI and each variant with the primary outcome. Multivariable logistic regression measured the association between SI and variants with 30-day mortality.
\nResults: Of 121 patients included in the study, 12 (9.9%) died. The SI and variants were all significantly different between survivors and non-survivors (P < .05), while the sPESI was not different (P = .30). The age-adjusted SI had the highest discriminatory efficiency for mortality (AUC 0.82; 95% CI, 0.71-0.93), followed by the SI (AUC 0.78; 0.67-0.89), the SI/peripheral oxygen saturation (AUC 0.77; 0.65-0.90), double product (AUC 0.76; 0.61-0.91), modified SI (AUC 0.75; 0.61-0.90), ESC risk schema (AUC 0.71; 0.52-0.90), and the respiratory-adjusted SI (AUC 0.70; 0.54-0.87).
\nConclusion: Among patients presenting to the ED who had a PERT activation for acute PE, the age-adjusted SI had the highest discriminatory efficiency for mortality, followed by the SI and its other variants. Further investigation regarding use of the age-adjusted SI for prognostication of acute PE and implications on PE management is warranted.
","language":null,"license":{"name":"Creative Commons Attribution 4.0","short_name":"CC BY 4.0","text":"Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.\r\n\r\nNo additional restrictions — You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.","url":"https://creativecommons.org/licenses/by/4.0"},"keywords":[{"word":"pulmonary embolism"},{"word":"Shock index"},{"word":"spesi"},{"word":"pulmonary embolism response team"}],"section":"Critical Care","is_remote":true,"remote_url":"https://escholarship.org/uc/item/5cj2c69s","frozenauthors":[{"first_name":"Cameron","middle_name":"P.","last_name":"Upchurch","name_suffix":"","institution":"University of Vermont Larner College of Medicine, Department of Emergency Medicine, Burlington, Vermont; University of Vermont Larner College of Medicine, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Burlington, Vermont","department":""},{"first_name":"Kristen","middle_name":"","last_name":"Sanfilippo","name_suffix":"","institution":"Washington University in St. Louis School of Medicine, Department of Medicine, Division of Hematology, St. Louis, Missouri","department":""},{"first_name":"Daphne","middle_name":"","last_name":"Lew","name_suffix":"","institution":"Washington University in St. Louis School of Medicine, Institute for Informatics, Data Science, and Biostatistics, Center for Biostatistics and Data Science, St. Louis, Missouri","department":""},{"first_name":"Maanasi","middle_name":"","last_name":"Samant","name_suffix":"","institution":"Northwestern University Feinberg School of Medicine, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Chicago, Illinois","department":""},{"first_name":"Rachel","middle_name":"","last_name":"McDonald","name_suffix":"","institution":"Washington University in St. Louis School of Medicine, Department of Medicine, Division of Pulmonary and Critical Care Medicine, St. Louis, Missouri","department":""}],"date_submitted":"2025-06-19T10:07:37.254000Z","date_accepted":"2025-09-28T10:36:45.106000Z","date_published":"2025-12-23T13:04:00Z","render_galley":null,"galleys":[{"label":"PDF","type":"pdf","path":"https://journalpub.escholarship.org/westjem/article/48698/galley/47914/download/"}]}