Chest · 2026
Comparative Short-Term Prognostic Discrimination of the 2026 AHA/ACC and 2019 ESC Risk Classifications in Hospitalized Acute Pulmonary Embolism: A Retrospective Two-Campus Cohort Study.
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Fan Jiawei, He Jian, Wang Miyuan, Xue Wei, Liao Fenglin, Jiang Peng, Guan Wenfei, Li Yu, Tan Chengpeng, Zhang Wuming, Tan Cheng, Mei Fei
Аннотация
BACKGROUND: The 2026 American Heart Association/American College of Cardiology (AHA/ACC) and 2019 European Society of Cardiology (ESC) pulmonary embolism (PE) classifications represent severity differently: AHA/ACC spans subclinical PE through cardiopulmonary failure, whereas ESC defines high risk by hemodynamic instability. Their prognostic separation is uncertain.
RESEARCH QUESTION: How do these classifications compare in mortality discrimination and identification of patients at high observed risk in hospitalized acute PE?
STUDY DESIGN AND METHODS: We retrospectively studied 2,251 patients at a two-campus Chinese tertiary hospital (2013-2025). Index time was admission for community-acquired PE and symptom onset or first objective imaging for hospital-acquired PE. The primary outcome was 30-day all-cause mortality; institutionally determined PE-related mortality was post hoc. Paired DeLong tests compared ordinal areas under the receiver operating characteristic curves (AUCs), and AHA/ACC categories D-E defined the analysis high-risk threshold.
RESULTS: 127 patients (5.6%) died within 30 days and 80 (3.6%) had PE-related death. Thirty-day AUCs were 0.885 (95% confidence interval [CI], 0.858-0.912) for AHA/ACC and 0.763 (95% CI, 0.721-0.806) for ESC (difference, 0.122; 95% CI, 0.084-0.160; P < .001). PE-related mortality AUCs were 0.942 and 0.826, respectively (difference, 0.116; 95% CI, 0.068-0.164; P < .001). At the analysis-defined high-risk thresholds, sensitivities for PE-related death were 83.8% for AHA/ACC categories D-E and 58.8% for the ESC high-risk stratum, with specificities of 95.1% and 95.8%, respectively. Among 37 patients in AHA/ACC categories D-E but the ESC intermediate-risk stratum, 75.7% died by 30 days and 54.1% had PE-related death. Excluding AHA/ACC A and E attenuated the 30-day AUC difference to 0.112 (95% CI, 0.038-0.186).
INTERPRETATION: Under inpatient care, the AHA/ACC categories showed greater full-spectrum ordinal separation and identified a phenotype with substantial observed mortality risk that was not classified as ESC high risk. Attenuation within the central severity range indicated that the difference was spectrum dependent.
TAKE HOME POINTS: Study Question:How do the 2026 AHA/ACC Acute PE Clinical Categories and the 2019 ESC scheme compare for short-term mortality prognosis in hospitalized acute PE?
RESULTS: AHA/ACC showed greater full-spectrum ordinal separation for 30-day all-cause and institutionally determined PE-related mortality and identified an ESC intermediate-risk subgroup with high early mortality, although the difference attenuated when the AHA/ACC severity extremes were removed.
INTERPRETATION: The findings suggest that broader severity phenotyping may identify clinically important discordance while remaining limited to prognostic performance under observed care.
RESEARCH QUESTION: How do these classifications compare in mortality discrimination and identification of patients at high observed risk in hospitalized acute PE?
STUDY DESIGN AND METHODS: We retrospectively studied 2,251 patients at a two-campus Chinese tertiary hospital (2013-2025). Index time was admission for community-acquired PE and symptom onset or first objective imaging for hospital-acquired PE. The primary outcome was 30-day all-cause mortality; institutionally determined PE-related mortality was post hoc. Paired DeLong tests compared ordinal areas under the receiver operating characteristic curves (AUCs), and AHA/ACC categories D-E defined the analysis high-risk threshold.
RESULTS: 127 patients (5.6%) died within 30 days and 80 (3.6%) had PE-related death. Thirty-day AUCs were 0.885 (95% confidence interval [CI], 0.858-0.912) for AHA/ACC and 0.763 (95% CI, 0.721-0.806) for ESC (difference, 0.122; 95% CI, 0.084-0.160; P < .001). PE-related mortality AUCs were 0.942 and 0.826, respectively (difference, 0.116; 95% CI, 0.068-0.164; P < .001). At the analysis-defined high-risk thresholds, sensitivities for PE-related death were 83.8% for AHA/ACC categories D-E and 58.8% for the ESC high-risk stratum, with specificities of 95.1% and 95.8%, respectively. Among 37 patients in AHA/ACC categories D-E but the ESC intermediate-risk stratum, 75.7% died by 30 days and 54.1% had PE-related death. Excluding AHA/ACC A and E attenuated the 30-day AUC difference to 0.112 (95% CI, 0.038-0.186).
INTERPRETATION: Under inpatient care, the AHA/ACC categories showed greater full-spectrum ordinal separation and identified a phenotype with substantial observed mortality risk that was not classified as ESC high risk. Attenuation within the central severity range indicated that the difference was spectrum dependent.
TAKE HOME POINTS: Study Question:How do the 2026 AHA/ACC Acute PE Clinical Categories and the 2019 ESC scheme compare for short-term mortality prognosis in hospitalized acute PE?
RESULTS: AHA/ACC showed greater full-spectrum ordinal separation for 30-day all-cause and institutionally determined PE-related mortality and identified an ESC intermediate-risk subgroup with high early mortality, although the difference attenuated when the AHA/ACC severity extremes were removed.
INTERPRETATION: The findings suggest that broader severity phenotyping may identify clinically important discordance while remaining limited to prognostic performance under observed care.