We read with interest the analysis by Oblitas et al. of electrocardiographic findings in the RIETE registry [1]. The study examines a highly accessible source of information for patients with acute pulmonary embolism who are haemodynamically stable. The proposed sPESI-ECG strategy identifies a smaller group at very low short term risk. We wish to add a decision-centred perspective on whether this reclassification should change disposition.

The comparison in Table 2 and Table 4 deserves particular attention. sPESI-ECG increased sensitivity for all-cause mortality at 30 days from 94.4% to 97.6% and increased negative predictive value from 99.2% to 99.4%. However, specificity fell from 31.7% to 17.6%, the C statistic remained 0.73, and the low risk group decreased from 30.4% to 16.7%. Mortality at 30 days in the low risk group was numerically lower with sPESI-ECG, 0.62% versus 0.82%, but this difference was not statistically significant, P=.19. Improved sensitivity and negative predictive value therefore do not by themselves establish better clinical utility. Reporting calibration intercept and slope, together with decision curves at a prespecified early discharge threshold, would show whether the reclassification confers net benefit [2].

Further clarity is needed regarding the outcome that drives this reclassification. The composite end point joins all-cause mortality and haemodynamic deterioration with need for escalated therapy. The latter is clinically important, yet may also reflect centre-specific treatment thresholds. Table 4 shows a lower composite event rate with sPESI-ECG but does not separate the effects of each component within the reclassified groups. A supplementary table showing component-specific events, actual disposition, and reclassification by ECG pattern could establish whether the strategy primarily identifies biological risk or changes management behaviour.

This distinction matters as ambulatory pulmonary embolism care is increasingly embedded in structured pathways. In HOME-PE, negative Hestia or sPESI criteria were paired with clinician judgement and patient agreement rather than used as an automatic discharge instruction [3]. The IPEP trial likewise evaluated prognostic assessment alongside predefined management and discharge criteria [4]. A prospective evaluation of sPESI-ECG could therefore prespecify the action associated with each classification and assess consequences for observation, rescue treatment, readmission, and patient experience.

ECG is rapid, inexpensive, and universally available. By showing benefit at an explicit decision threshold rather than only a shift in risk labels, the authors could make this promising strategy more actionable for safe outpatient pulmonary embolism care.