The initial clinical presentation and echocardiography have key roles in risk stratification of patients with acute pulmonary embolism (PE). To assess the value of shock index and echocardiographic abnormalities as predictors of in-hospital complications and mortality, echocardiographic features of 159 patients diagnosed with acute PE were reviewed. A shock index > or =1, independent of echocardiographic findings, was associated with increased in-hospital mortality. Regardless of shock index, moderate to severe right ventricular (RV) hypokinesis and a ratio of RV to left ventricular (LV) end-diastolic diameter >1 was significantly associated with in-hospital mortality and demonstrated the best predictive values for short-term outcomes. The sensitivity and negative predictive value of diastolic LV impairment (E/A wave <1), RV hypokinesis, RV/LV >1, and end-diastolic RV diameter >3 cm for in-hospital mortality were 100%. Systolic pulmonary artery pressure (PAP) was higher in patients who died before discharge. A cut-off point >50 mm Hg for systolic PAP was significantly associated with increased in-hospital death. In conclusion, among conventional echocardiographic abnormalities attributed to RV dysfunction (E/A wave <1, RV hypokinesis, RV/LV >1, RV end-diastolic diameter >3 cm, and interventricular septal flattening), moderate to severe RV hypokinesis and RV/LV >1 have better predictive values for short-term outcomes of patients with acute PE. In addition, a shock index > or =1 and systolic PAP >50 mm Hg could also be helpful in the triage of these patients.