Acute pulmonary embolism (PE) poses a significant burden on health and survival. Its severity ranges from asymptomatic, incidentally discovered subsegmental thrombi to massive, pressor-dependent PE complicated by cardiogenic shock and multisystem organ failure. Rapid and accurate risk stratification is therefore of paramount importance to ensure the highest quality of care. This article critically reviews currently available and emerging tools for risk-stratifying acute PE, and particularly for distinguishing between elevated (intermediate) and low risk among normotensive patients. We focus on the potential value of risk assessment strategies for optimizing severity-adjusted management. Apart from reviewing the current evidence on advanced early therapy of acute PE (thrombolysis, surgery, catheter interventions, vena cava filters), we discuss recent advances in oral anticoagulation with vitamin K antagonists, and with new direct inhibitors of factor Xa and thrombin, which may contribute to profound changes in the treatment and secondary prophylaxis of venous thrombo-embolism in the near future.