The management of acute pulmonary embolism (PE) in the elderly often focuses on hemodynamic compromise — shock, hypoxia, and right ventricular dysfunction. One potentially critical, determinant of outcome: frailty is rarely used in practice.

Frailty, commonly assessed by tools such as the Clinical Frailty Scale (CFS) and Hospital Frailty Risk Score (HFRS), is independently associated with increased in-hospital and 30-day mortality, higher rates of major bleeding, longer hospital stays, and increased readmission rates in patients with acute PE [1,2], not suggesting that incorporation of frailty assessment into traditional risk stratification models (e.g., ESC risk class, PESI score) improves prediction of adverse outcomes and may guide more individualized management strategies [1].

Moreover, frail patients with PE are more likely to have multiple comorbidities, more likely to present with a critical condition, which indicate advanced interventions, including thrombolysis, catheter-directed therapies, and critical care resources [2]. However, the risk-benefit profile of aggressive therapies must be carefully weighed, as frailty increases susceptibility to complications such as bleeding and deconditioning. Nonetheless, advanced interventions for acute pulmonary embolism, particularly catheter-based therapies, are increasingly utilized in frail patients and are associated with reduced major bleeding compared to systemic thrombolysis, offering potential safety advantages in this population [[3], [4], [5]]. Catheter-based therapies are linked to lower in-hospital mortality and reduced 90-day all-cause and VTE-related readmission rates in high-risk and intermediate-risk PE patients [4]. However, frail patients remain at a higher risk for adverse outcomes and readmission overall, even when advanced interventions are employed [[6], [7], [8]].