Bova Score for Pulmonary Embolism Complications
Use ONLY in hemodynamically stable patients (sBP ≥90) with confirmed acute PE (pulmonary embolism).
Patients with confirmed acute PE, defined as:
- Intraluminal filling defect on PE protocol spiral CT, or
- Positive V/Q scan, or
- Normal or inconclusive CT or V/Q scan and positive lower extremity ultrasound.
Do not use in hemodynamically unstable patients (sBP <90 mmHg).
- The Bova Score risk stratifies normotensive patients with confirmed PE to identify patients at intermediate and high risk for complications and mortality associated with PE.
- Use only in patients who are hemodynamically stable (sBP ≥90 mmHg).
- Accounts for right ventricular dysfunction and cardiac biomarkers, unlike other scoring systems for PE.
- Differs from the PESI (and sPESI), which were specifically designed to identify patients at low risk for mortality.
- Use variables obtained at the time of diagnosis of acute PE.
- Requires troponin and transthoracic echocardiography (TTE) or CT scan to assess for right ventricular dysfunction.
- In normotensive patients, identifying those at high risk for PE-related events can be challenging.
- The European Society of Cardiology recommends stratifying patients with PE in a stepwise approach using right ventricular dysfunction and cardiac biomarkers as part of the risk assessment. The Bova Score looks at both right ventricular dysfunction and cardiac biomarkers.
- Other clinical models (e.g. sPESI, Hestia Criteria) identify low-risk patients who may be candidates for outpatient therapy, but may not identify well-appearing patients who are at high risk and may benefit from escalated care (e.g. thrombolysis, ICU management).
- May identify intermediate low and intermediate high (previously submassive) risk PE patients who benefit from advanced therapy.
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- Risk of PE-related complications (death from PE, hemodynamic collapse, or recurrent nonfatal PE) increases in patients with higher Bova Score.
- Consider assessing high-risk patients for advanced therapy in addition to anticoagulation (catheter-directed therapy, thrombolytic therapy, IVC filter placement) if warranted.
- Consider monitoring patients with intermediate and high risk Bova Scores in a higher level of care (stepdown unit, ICU).
- Consider standard treatment (anticoagulation alone) for patients with a low risk Bova Score.
- Optimal management of intermediate risk patients with acute PE is unclear, but escalation of care (e.g. thrombolysis, referral to ICU) should be considered in patients who are not low risk.
- Consider multidisciplinary discussion regarding treatment options for patients with a high risk (>4) Bova Score.
- High risk patients (stage III) should be monitored closely and a plan for rescue therapy should be made in case of clinical deterioration.
- Stage III patients may warrant multidisciplinary discussion regarding management.
- Additional findings and pathology not included in the Bova Score should also be considered, such as respiratory rate, need for respiratory support, SpO₂, syncope, elevated lactic acid, coexisting DVT, and other underlying chronic comorbidities.
- The Bova Score does not predict risks of therapy such as bleeding with thrombolytic therapy or anticoagulation.
Addition of the selected points:
>100 mm Hg
Elevated cardiac troponin*
Heart rate, beats/min
*Based on standard manufacturer assays and cutoff values.
**On TTE: Right to left ventricular (RV/LV) ratio >0.9, systolic pulmonary artery pressure (sPAP) >30, RV end diastolic diameter >30mm, RV dilation, or free wall hypokinesis. On CT: RV/LV ratio >1 based on short axis diameter measurements.
Facts & Figures
I (Low risk)
II (Intermediate risk)
III (High risk)
*Defined as a composite including death from PE, hemodynamic collapse, or recurrent nonfatal PE. Hemodynamic collapse = systolic BP <90 mm Hg for at least 15 min or need for catecholamines, thrombolysis, endotracheal intubation, or CPR.
The Bova Score was derived from a meta-analysis of six studies (2,874 patients) that comprised normotensive patients (sBP >90 mmHg) with an objectively confirmed diagnosis of acute PE who received standard anticoagulation alone. The study excluded patients who were hemodynamically unstable or received thrombolytic therapy at the time of diagnosis.
Investigators identified predictors of PE-related complications in the patients studied and used them (systolic blood pressure, heart rate, troponin, right ventricular dysfunction) to build a model to estimate risk of PE-related complications. The PE-related complications considered were: death from PE, hemodynamic collapse, and recurrent non-fatal PE through 30 days after the diagnosis of PE.
Right ventricular dysfunction was defined by TTE as any of the following:
- Right to left ventricular (RV/LV) ratio >0.9.
- Systolic pulmonary artery pressure (sPAP) >30.
- RV end diastolic diameter >30mm.
- RV dilation.
- Free wall hypokinesis.
Right ventricular dysfunction was defined by CT as RV/LV ratio >1 based on short axis diameter measurements. Elevated troponin was defined by positive value based on standard manufacturer assays and cutoff values.
The Bova model was internally validated and performed fairly (AUROC 0.73, 95% CI 0.68–0.77) to predict PE-related complications in normotensive patients with confirmed PE.
The investigators performed a subsequent study to externally validate the Bova Score in 1,083 normotensive patients with proven PE. In this study, the Bova Score performed similarly in predicting PE-related complications (AUROC 0.74, 95% CI 0.68-0.80).
Original/Primary ReferenceBova C, Sanchez O, Prandoni P, et al. Identification of intermediate-risk patients with acute symptomatic pulmonary embolism. Eur Respir J. 2014;44(3):694-703.
ValidationFernández C, Bova C, Sanchez O, et al. Validation of a Model for Identification of Patients at Intermediate to High Risk for Complications Associated With Acute Symptomatic Pulmonary Embolism. Chest. 2015;148(1):211-218.Bova C, Vanni S, Prandoni P, et al. A prospective validation of the Bova score in normotensive patients with acute pulmonary embolism. Thromb Res. 2018;165:107-111.
From the Creator
Why did you develop the Bova Score? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?
Risk stratification in patients with acute pulmonary embolism is important to guide patient management. Most patients with normal blood pressure go well if treated with anticoagulants, but some have adverse events related to pulmonary embolism. Great efforts have been made to realize a tool able to identify these so-called “intermediate-risk” patients. The Bova Score has been created for this purpose. It was the result of an international collaboration of seven authors who pooled the results of six European cohort studies.
What pearls, pitfalls and/or tips do you have for users of the Bova Score? Do you know of cases when it has been applied, interpreted, or used inappropriately?
Stage I of the Bova Score should not be used to identify low-risk PE patients eligible for early discharge or outpatient therapy because it does not consider relevant comorbidities such as cancer or cardiopulmonary diseases.
What recommendations do you have for doctors once they have applied the Bova Score? Are there any adjustments or updates you would make to the score based on new data or practice changes?
Patients belonging to stage III should be closely monitored to rapidly identify hemodynamic deterioration. However, this stage should not be considered, as a single criterion, a compelling indication for the thrombolysis.
How do you use the Bova Score in your own clinical practice? Can you give an example of a scenario in which you use it?
In my opinion, the best scenario for using the Bova Score is in the emergency department.
Why was oxygen saturation <90% not included as part of the scoring system? It appears to be a significant finding to predict PE-related complications.
Oxygen saturation <90% was not included in the scoring system because it was associated with 30-day pulmonary embolism-related complications in the univariate, but not in the multivariate, analysis.
Any thoughts on the modified Bova Score (Keller et al, 2015)?
The article by Keller and collaborators is very interesting because it showed that the Bova Score is useful in predicting adverse events even in hemodynamically unstable patients. However, these results should be confirmed.
Any other research in the pipeline that you’re particularly excited about?
Our group has recently completed a multicenter prospective validation of the Bova Score. We hope the results will be publicly available soon.
About the Creator
Carlo Bova, MD, is an internal medicine physician at Annunziata General Hospital in Cosenza, Italy. He is also one of the investigators of the PESIT (Prevalence of Pulmonary Embolism Among Patients Hospitalized for Syncope) study. Dr. Bova's research interest is in venous thromboembolism, and he has published several papers in this field.
To view Dr. Carlo Bova's publications, visit PubMed
- Robyn Scatena, MD