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Objective: To compare the predictive accuracy of the risk stratification strategies from the 2025 Chinese Respiratory Guideline and the 2019 European Society of Cardiology (ESC) Guideline for the prognosis of patients with acute pulmonary embolism (APE). Methods: A retrospective cohort study was conducted, including 713 patients with first-onset APE presented to West China Hospital of Sichuan University between September 1, 2016, and December 30, 2019. Clinical data were collected. Patients were risk-stratified (low-risk, intermediate-low-risk, intermediate-high-risk, high-risk) according to the Chinese Respiratory Guideline and the ESC Guideline. Mortality rates in each stratum were calculated. Using the low-risk group as reference, odds ratios (OR) and 95% confidence intervals (CI) for the association between other strata and in-hospital mortality were computed. Receiver operating characteristic (ROC) curves were plotted to calculate the area under the curve (AUC), and predictive performance indicators such as sensitivity and specificity were compared. The Kaplan-Meier method was used to draw survival curves during hospitalization and for 12 months after discharge. Results: Both guideline risk stratification strategies showed a significant increase in in-hospital mortality with rising risk strata [Chinese respiratory guideline low-risk vs intermediate-low-risk vs intermediate-high-risk vs high-risk: 1.15%(3/260) vs 11.84%(29/245) vs 12.24%(24/196) vs 33.33%(4/12); ESC guideline: 0.69%(1/144) vs 8.20%(36/439) vs 16.10%(19/118) vs 33.33%(4/12), all P<0.001]. The Cochran-Armitage trend test further confirmed a significant ascending linear trend in mortality across the increasing risk categories (P_trend<0.001 for both guidelines). Compared to the low-risk group, the ESC guideline showed a more pronounced incremental gradient in OR for mortality risk across strata (intermediate-low-risk OR=12.77, 95%CI: 1.74-94.03, intermediate-high-risk OR=27.44, 95%CI: 3.62-208.37, high-risk OR=71.50, 95%CI: 7.14-716.08), and the difference in mortality between the intermediate-low-risk and intermediate-high-risk groups was statistically significant (P=0.011). In contrast, the mortality rates and OR values for the intermediate-low-risk and intermediate-high-risk groups in the Chinese Respiratory Guideline were close, with no statistically significant difference between groups. The AUC for predicting in-hospital death were similar between the two guidelines [Chinese respiratory guideline: 0.689 (95%CI: 0.630-0.747); ESC Guideline: 0.673 (95%CI: 0.607-0.740)], with no statistically significant difference (P>0.05). Long-term follow-up (12 months) showed that the ESC guideline low-risk group had the lowest mortality rate [2.10% (3/143)], and the survival curves of the different risk groups showed good separation (log-rank P=0.001). In contrast, there were no significant differences in long-term mortality among the risk groups of the Chinese respiratory guideline (P=0.682). Conclusions: Both the Chinese respiratory guideline and the ESC guideline demonstrate good overall predictive value for in-hospital mortality risk in APE patients. The ESC Guideline shows superior ability to discriminate risk among intermediate-risk patients and better predictive capability for long-term prognosis.