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Background Acute pulmonary thromboembolism (APE) causes right ventricular dysfunction (RVD) and cardiac troponin I (cTnI) elevation. Patients with RVD and cTnl elevation have a worse prognosis. Thus, early detection of RVD and cTnl elevation is beneficial for risk stratification. In this study, we assessed 14-day adverse clinical events and combined RVD on transthoracic echocardiography (TTE) with cTnl in risk stratification among a broad spectrum of APE patients.Methods The prospective multi-centre trial included 90 patients with confirmed APE from 12 collaborating hospitals.Acute RVD on TTE was diagnosed in the presence of at least 2 of the following: right ventricular dilatation (without hypertrophy), loss of inspiratory collapse of inferior vena cava (IVC), right ventricular (RV) hypokinesis, tricuspid regurgitant jet velocity ＞2.8 m/s. The study patients were divided into two groups according to clinical and echocardiographic findings at presentation: Group Ⅰ: 50 patients with RVD; Group Ⅱ: 40 patients without RVD.Results More than half of the patients (50/90, 55.6%) had RVD. Nearly one third (26/90, 28.9%) of patients had elevated cTnl at presentation and only 4.2% on the fourth day after initial therapy. A multiple Logistic regression model implied RVD, right and left ventricular end-diastolic diameter ratio (RVED/LVED), and cTnl independently predict an adverse 14-day clinical outcome (P＜0.01). Receiver operating characteristics (ROC) curves revealed that the cut-off values of RVED/LVED and cTnl yielding the highest discriminating power were 0.65 and 0.11 ng/ml, respectively.Furthermore, the incidence of an adverse 14-day clinical event in patients with RVD and elevated cTnl was greater (40.7%) than in patients with elevated cTnl or positive RVD alone (0% and 8.3%, respectively) (P＜0.001).Conclusions RVD, RVED/LVED, and cTnl are independent predictors of 14-day clinical outcomes. The patients with RVED/LVED greater than 0.65 and cTnl higher than 0.11 ng/ml at presentation possibly have adverse 14-day events.RVD combined with cTnl can identify a subgroup of APE patients with a much more guarded prognosis.