Guideline-based prognostic factors associated with mortality in pulmonary embolism: a systematic review and meta-analysis

Introduction Optimal management for patients with acute pulmonary embolism (PE) at elevated risk of decompensation remains unclear given the lack of predictors and the limitations of existing risk stratification tools. Thus, we aimed to evaluate the prognostic association between clinical variables and short-term mortality in patients with acute PE. Methods Medline and EMBASE were searched from inception through 19 May 2025. We included English-language studies that described adult inpatients with a confirmed acute PE and evaluated prognostic factors associated with short-term mortality. Two authors performed citation screening and data extraction. Only adjusted OR were included in the data synthesis. We performed pooling using a random-effects model and inverse variance weighting. Risk of bias was evaluated using the Quality in Prognosis Studies tool. We assessed certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations approach. Results We included 70 studies involving 1 446 190 participants in our review. Variables with a moderate or high certainty association with short-term mortality in acute PE include increasing age, an elevated Pulmonary Embolism Severity Index (PESI) Score, an abnormal simplified PESI Score, an elevated heart rate, a reduced systolic blood pressure, a lower oxygen saturation, a higher respiratory rate, active malignancy, heart failure, chronic lung disease, an elevated troponin, a larger right ventricle (RV) to left ventricle ratio and evidence of RV dysfunction. Discussion We identified multiple variables associated with early mortality in acute PE. Notably, we demonstrate that RV function, a marker omitted from commonly used risk stratification tools, represents an important prognostic variable that is supported by multiple society guidelines. Registration We registered the protocol with the Open Science Framework ( https://osf.io/9w2jg ).