Prediction and Risk Stratification for 30-Day Mortality in Stable Acute Pulmonary Embolism: Recalibration of the Multimarker Calculator and Evaluation of the AHA/ACC Classification

BACKGROUND: Risk stratification in haemodynamically stable acute pulmonary embolism (PE) remains challenging. The multimarker calculator (MMC) provides individualized 30-day mortality estimates, whereas the 2026 AHA/ACC Acute PE Clinical Categories (AHA/ACC classification) provide a phenotype-based framework incorporating clinical severity, right ventricular dysfunction, cardiac biomarker elevation, and respiratory compromise. We evaluated these approaches and recalibrated the original MMC in a Chinese multicentre cohort. METHODS: We included adults with haemodynamically stable acute PE from the prospective, multicentre China pUlmonary thromboembolism REgistry Study (2012-2021). The primary outcome was 30-day all-cause mortality. The MMC, 2019 European Society of Cardiology (ESC) model, and AHA/ACC classification were assessed using discrimination, decision-curve analysis, risk classification, and subgroup analyses. Logistic recalibration updated the original MMC linear predictor. The AHA/ACC classification was evaluated using 7-, 4-, and simplified phenotype-based 3-category schemes. RESULTS: Among 11,568 patients, 331 died within 30 days (2.9%). The MMC and 7-category AHA/ACC classification showed better discrimination than the ESC model (AUC, 0.704 and 0.680 vs. 0.606). The original MMC overestimated intermediate-high-risk mortality (mean predicted risk, 16.2%; observed risk, 9.4%). Recalibration improved calibration and identified a smaller intermediate-high-risk subgroup comprising 2.2% of patients, with 13.2% observed mortality. In the 3-category AHA/ACC classification, mortality increased stepwise across category B, partial phenotype involvement, and dual cardiopulmonary phenotype involvement (0.7%, 2.7%, and 6.7%). CONCLUSIONS: The recalibrated MMC may be useful for individualized 30-day mortality risk estimation, whereas the AHA/ACC classification may offer a simple framework for phenotype-based risk grouping.

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Journal
European Heart Journal Acute Cardiovascular Care
Published
2026-10-27
DOI
https://doi.org/10.1093/ehjacc/zuag135
Primary Topic
Venous Thromboembolism Diagnosis and Management
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article
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article

Prediction and Risk Stratification for 30-Day Mortality in Stable Acute Pulmonary Embolism: Recalibration of the Multimarker Calculator and Evaluation of the AHA/ACC Classification

Yiwei Shi, Yingqun Ji, Juhong Shi, Zhaofei Chen et al.
European Heart Journal Acute Cardiovascular Care
Venous Thromboembolism Diagnosis and Management
article

Prediction and Risk Stratification for 30-Day Mortality in Stable Acute Pulmonary Embolism: Recalibration of the Multimarker Calculator and Evaluation of the AHA/ACC Classification

Yiwei Shi, Yingqun Ji, Juhong Shi, Zhaofei Chen, Chunling Dong, Zhenguo Zhai, Yongjun Tang, Behnood Bikdeli, Zhushan Fu, Manuel Monréal, Hong Chen, Qin Luo, Ran Miao, Yuzhi Tao, Chaosheng Deng, Changming Xiong, Shuai Zhang, Rui Liang, Linfeng Xi, Xiaomao Xu, Zhang Jie, Pinyao Lu, Shengfeng Wang, Yanxia Li, Xianglong Meng, Yuhao Li, Maoyun Wang, Xincheng Li, Ling Zhu, Chen Wang, Hong Chen, Zhe Cheng, Jixiang Liu, Yu Zhang
article en

Abstract

BACKGROUND: Risk stratification in haemodynamically stable acute pulmonary embolism (PE) remains challenging. The multimarker calculator (MMC) provides individualized 30-day mortality estimates, whereas the 2026 AHA/ACC Acute PE Clinical Categories (AHA/ACC classification) provide a phenotype-based framework incorporating clinical severity, right ventricular dysfunction, cardiac biomarker elevation, and respiratory compromise. We evaluated these approaches and recalibrated the original MMC in a Chinese multicentre cohort. METHODS: We included adults with haemodynamically stable acute PE from the prospective, multicentre China pUlmonary thromboembolism REgistry Study (2012-2021). The primary outcome was 30-day all-cause mortality. The MMC, 2019 European Society of Cardiology (ESC) model, and AHA/ACC classification were assessed using discrimination, decision-curve analysis, risk classification, and subgroup analyses. Logistic recalibration updated the original MMC linear predictor. The AHA/ACC classification was evaluated using 7-, 4-, and simplified phenotype-based 3-category schemes. RESULTS: Among 11,568 patients, 331 died within 30 days (2.9%). The MMC and 7-category AHA/ACC classification showed better discrimination than the ESC model (AUC, 0.704 and 0.680 vs. 0.606). The original MMC overestimated intermediate-high-risk mortality (mean predicted risk, 16.2%; observed risk, 9.4%). Recalibration improved calibration and identified a smaller intermediate-high-risk subgroup comprising 2.2% of patients, with 13.2% observed mortality. In the 3-category AHA/ACC classification, mortality increased stepwise across category B, partial phenotype involvement, and dual cardiopulmonary phenotype involvement (0.7%, 2.7%, and 6.7%). CONCLUSIONS: The recalibrated MMC may be useful for individualized 30-day mortality risk estimation, whereas the AHA/ACC classification may offer a simple framework for phenotype-based risk grouping.

European Heart Journal Acute Cardiovascular Care
Brigham and Women's Hospital (US), Fujian Medical University (CN), Yale New Haven Hospital (US), Harvard University (US), Xinjiang Medical University (CN), Harbin Medical University (CN), Shanxi Medical University (CN), Beijing University of Chinese Medicine (CN), Shenzhen University (CN), Chengde Medical University (CN), Jilin University (CN), Chinese Academy of Medical Sciences & Peking Union Medical College (CN), Peking University (CN), Sichuan University (CN), China-Japan Friendship Hospital (CN), Peking Union Medical College Hospital (CN), West China Hospital of Sichuan University (CN), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (ES), Affiliated Hospital of Chengde Medical College (CN), Shandong Provincial Hospital (CN), Beijing Hospital (CN), First Affiliated Hospital of Fujian Medical University (CN), First Hospital of Shanxi Medical University (CN), Shanghai East Hospital (CN), The Affiliated Yongchuan Hospital of Chongqing Medical University (CN), Second Affiliated Hospital of Harbin Medical University (CN), First Affiliated Hospital of Dalian Medical University (CN), Second Affiliated Hospital of Jilin University (CN), First Affiliated Hospital of Zhengzhou University (CN), Xiangya Hospital Central South University (CN), Fu Wai Hospital (CN), Shandong First Medical University (CN), Second Affiliated Hospital of Xinjiang Medical University (CN), State Key Laboratory of Cardiovascular Disease (CN), Mass General Brigham (US), Universidad Católica de Murcia (ES)
Openalex Percentile: Top 9%
Venous Thromboembolism Diagnosis and Management
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