Bova Score for Pulmonary Embolism Complications
Why Use
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.
When to Use
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).
Formula
Pearls / Pitfalls
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.
Management
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.
Critical Actions
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.
Advice
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.
More Information
Interpretation: Bova Score Stage PE-related complications* PE-related mortality 0–2 I (Low risk) 4.4% 3.1% 3–4 II (Intermediate risk) 18% 6.8% >4 III (High risk) 42% 10% *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.