**7. Risk of recurrence**

Recurrent PE can occur despite adequate anticoagulation therapy in patients who had survived an acute PE.

Patients with unprovoked PE (PE occurring in the absence of established risk factors or predisposing illnesses) are at a higher risk for recurrent PE compared to patients with risk factors for PE. In contrast, patients with risk factors of PE have a higher mortality risk (Klok

Risk Stratification of Patients with Acute Pulmonary Embolism 33

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et al., 2010). In addition, patients who presented with a first symptomatic PE are at a 4-fold increased risk of recurrent symptomatic PE compared to patients who presented with deep venous thrombosis without symptoms of PE (Eichinger et al., 2004).

In patients with recurrent PE or progressive deep venous thrombosis (DVT) despite adequate anticoagulation therapy, inferior vena cava (IVC) filters may be indicated. IVC filter placement is generally accepted in patients with massive PE or limited cardiopulmonary reserve and DVT. Current evidence indicates that IVC filters are largely effective, with breakthrough PE occurring in only 0% to 6.2% cases. Recurrent PE, IVC thrombosis, filter migration, filter fracture, or penetration of caval wall can sometimes occur with long-term use (Chung et al., 2008).
