Bova Score for Pulmonary Embolism Complications

Why use it

The Bova Score fills a critical gap: sPESI and PESI identify low-risk patients, but do not distinguish high from intermediate-risk normotensive patients who may benefit from early thrombolysis, catheter-directed therapy, or ICU admission. The 2019 ESC PE Guidelines incorporate the Bova Score (Stage III = ≥5 points) as a tool for identifying the highest-risk normotensive PE patients who may warrant consideration of reperfusion therapy.

About

The Bova Score is a validated clinical prediction rule designed to stratify hemodynamically stable (normotensive) patients with acute pulmonary embolism (PE) into three risk groups for PE-related complications within 30 days. It identifies patients among those who are initially stable (normotensive) who are at high risk of deterioration — a critical subgroup where outcomes improve with aggressive management or ICU-level care. The score uses four variables: systolic blood pressure (90–99 mmHg = shock index proxy), heart rate, right ventricular (RV) dysfunction on echocardiogram or CT-PA, and elevated cardiac troponin.

When to use

• Normotensive patients (SBP ≥ 90 mmHg) with confirmed acute PE
• Stratification after sPESI to identify intermediate-high risk PE
• Decision support for ICU vs. ward admission in intermediate-risk PE
• Guiding escalation therapy discussions (thrombolysis, catheter-directed therapy)
• Patients with echocardiogram or CT-PA results showing RV dysfunction

Formula

Pearls & pitfalls

• Bova Score applies ONLY to normotensive patients (SBP ≥ 90 mmHg) — massive PE with SBP < 90 mmHg requires immediate reperfusion regardless.
• RV dysfunction can be assessed by echocardiography (RV/LV ratio > 1, RV hypokinesis) or CT-PA (RV/LV ratio > 1 on 4-chamber view).
• Troponin elevation (any elevated troponin I or T, or hsTnT > 14 ng/L) scores +2 points — the most heavily weighted individual item along with RV dysfunction.
• Heart rate ≥ 110 bpm scores +1 point and can be a sensitive early marker of hemodynamic stress.
• SBP 90–99 mmHg (subclinical hemodynamic compromise) adds +2 points and signals impending decompensation.
• The PEITHO trial showed that normotensive PE patients with RV dysfunction + elevated troponin (i.e., Bova Stage III) had 5-6% risk of hemodynamic collapse within 7 days.
• Combined Bova Stage III + sPESI ≥ 1 identifies the highest-risk normotensive PE group in ESC 2019 guidelines.

Next steps

Stage I (0–2 points, ~4.2% 30-day complications): Ward admission. Standard anticoagulation. No escalation therapy needed. Stage II (3–4 points, ~18% 30-day complications): Consider step-down unit or ICU. Intensified monitoring. If deteriorating, reperfusion therapy indicated. Stage III (≥5 points, ~42% 30-day complications): ICU admission. High risk of hemodynamic deterioration. Strong consideration for early escalation (systemic thrombolysis or catheter-directed therapy) in rapidly deteriorating patients.

Evidence

Bova C et al. (Chest 2014) derived the score in 1,001 normotensive PE patients; 30-day PE-related complication rates: Stage I 4.2%, Stage II 18%, Stage III 42%. Externally validated in the RIETE registry (>8,000 patients). AUC 0.74 for 30-day PE complications. Endorsed by ESC 2019 PE Guidelines for risk stratification of normotensive PE.

References

1. Bova C et al. Prognostic value of right ventricular dysfunction and elevated cardiac troponin in hemodynamically stable patients with pulmonary embolism. Chest. 2014;145(2):319-324. — link
2. Konstantinides SV et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2020;41(4):543-603. — link