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Acute pulmonary embolism (PE) is a common and potentially fatal disease (Goldhaber et al., 1999). The most frequent cause of death within 30 days is right ventricular (RV) failure (Goldhaber & Elliott, 2003). Rapid risk stratification is paramount for identifying high-risk patients and for helping to select the appropriate treatment strategy. According to European guidelines (Torbicki et al., 2008), high-risk PE (formerly ‘massive’ PE) implies the presence of shock or hemodynamic instability (mortality >15%) (Goldhaber et al., 1999). Non highrisk PE can be further stratified by the presence of markers of RV dysfunction and/or myocardial injury as intermediateand low-risk PE. Intermediate-risk PE (formerly ‘submassive’ PE) is diagnosed by the presence of at least one marker of RV dysfunction or myocardial injury. Low-risk PE (formerly ‘non-massive’ PE) is diagnosed when RV dysfunction markers are negative (mortality <1%). Reperfusion therapy, including thrombolysis or surgical embolectomy, is indicated for patients with high-risk PE. However, the risks and benefits of reperfusion therapy for patients with intermediate risk PE are less clear. Based on pathophysiological knowledge of the impact of RV dysfunction on acute PE, risk stratification is based on imaging modalities for the visualization of RV dysfunction. Therefore, echocardiographic assessment of RV dysfunction in acute PE may predict early mortality, and may guide decisions regarding reperfusion therapy (Grifoni et al., 2000; Kucher et al., 2005). Echocardiography, however, is time-consuming, operator-dependent, and not always available in an emergency situation, and echocardiographic criteria for assessing RV have not yet been determined. The development of narrow collimation, multi–detector row computed tomography (CT) imaging, and modern workstations for image postprocessing and analysis have made CT pulmonary angiography the modality of choice for the assessment of patients with pulmonary emboli (Ghaye et al., 2006; Schoepf & Costello, 2004). At times, CT is more rapidly accessible in emergency settings, and is more widely available than echocardiography. CT enables the direct visualization of emboli and provides information about cardiac morphology. CT findings, including RV enlargement, the ratio of RV diameter to the diameter of the left ventricle (LV) (RV/LV ratio), interventricular septal bowing, and pulmonary vascular obstruction score, have been associated with early mortality and clinical outcomes (Araoz et al., 2003; Collomb et al., 2003; Coutance et al., 2011; Ghuysen et al., 2005;

Risk Stratification of Submassive Pulmonary Embolism: The Role of Chest Computed Tomography as an Alternative to Echocardiography