Prognostic Value of CT-Derived Indicators of Right-Heart Strain and Thrombus Burden for In-Hospital Adverse Events in Acute Pulmonary Embolism

<b>Background</b>: Accurate risk stratification in acute pulmonary embolism (PE) is critical for guiding management. This study assessed the prognostic value of computed tomography (CT) indicators of right-heart strain and thrombus burden for predicting in-hospital adverse events. <b>Methods</b>: In this retrospective cohort of 300 patients with CT-confirmed acute PE, the right-to-left ventricular (RV/LV) diameter ratio, Pulmonary Artery Obstruction Index (PAOI), and inferior vena cava (IVC) contrast reflux were measured. The primary endpoint was in-hospital adverse events, including hemodynamic collapse, vasopressor or ventilatory support, rescue reperfusion therapy, or death. Logistic regression and receiver operating characteristic (ROC) analyses were performed. <b>Results</b>: Adverse events occurred in 106 patients (35.3%). Compared with stable patients, those with events had higher RV/LV ratios (1.45 vs. 1.03), higher PAOI (38.8 vs. 24.3), and more frequent IVC reflux (74% vs. 7%) (all <i>p</i> < 0.001). Independent predictors were RV/LV ratio (aOR 3.22 per 0.1), PAOI (aOR 5.53 per 10 points), and IVC reflux (aOR 428.5; all <i>p</i> < 0.001). The model showed excellent discrimination (AUC = 0.96). <b>Conclusions</b>: CT-derived indices of right-heart strain and thrombus burden are strong, independent predictors of in-hospital adverse events in acute PE and should be integrated into routine CT-based risk assessment.