Pulmonary embolism new guidelines
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pulmonary embolism new guidelines 2025 2026 ESC AHA treatment
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PMID: 41712677
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PMID: 40587333
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2026 AHA/ACC Acute Pulmonary Embolism Guidelines - Key Updates
The most important development in PE management is the first-ever dedicated joint AHA/ACC guideline for acute PE in adults, published simultaneously in Circulation and JACC on February 19, 2026. It is co-authored by 10 professional societies (AHA, ACC, ACCP, ACEP, CHEST, SCAI, SHM, SIR, SVM, SVN) under writing committee chair Mark A. Creager, MD (PMID 41712677, PMID 41712898). Note: an erratum has been published (PMID 42441758).
1. New Clinical Classification: 5-Tier "AHA/ACC PE Categories" (A-E)
This is the single biggest change - the old low/intermediate/high-risk binary/ternary model is replaced by a more granular, physiopathologically-grounded 5-category system:
| Category | Description | Disposition |
|---|---|---|
| A | Asymptomatic (incidental PE) | ED discharge, outpatient management |
| B | Symptomatic, low clinical severity score | Early discharge generally recommended |
| C | Symptomatic with elevated severity score, RV dysfunction, or elevated biomarkers | Hospitalization required |
| D (D1/D2) | Incipient cardiopulmonary failure | Hospitalization, consider advanced therapy |
| E (E1/E2) | Persistent hypotension / overt cardiopulmonary failure (highest risk) | Critical care; advanced therapy indicated |
This replaces the ESC 2019 low/intermediate/high taxonomy with subcategories that better guide therapeutic decisions.
2. Anticoagulation
- DOACs are now the preferred oral anticoagulants over vitamin K antagonists (warfarin) in eligible patients - reduce recurrent VTE and major bleeding.
- LMWH is preferred over unfractionated heparin when parenteral therapy is needed.
- DOACs are NOT recommended in pregnancy - LMWH or UFH are appropriate alternatives.
- Extended anticoagulation beyond 3-6 months is recommended for first acute PE without a major reversible risk factor, or with persistent risk factors.
3. Care Setting Recommendations
- Category A (asymptomatic): Safe to discharge from the ED without hospitalization - a landmark departure from prior practice.
- Category B: Early discharge generally appropriate.
- Categories C-E: Require hospitalization; Category E warrants critical care or ICU-level monitoring.
- The guideline formally addresses intrahospital transfer to more resourced facilities for those needing advanced interventions.
4. Pulmonary Embolism Response Teams (PERTs) - Class 1 Recommendation
PERTs - multidisciplinary teams including cardiologists, pulmonologists, ER physicians, hematologists, interventional radiologists, and cardiac surgeons - are elevated to a Class 1 recommendation. This is a major shift from the 2019 ESC guidelines where PERTs lacked equivalent formal emphasis. PERTs are recommended particularly for intermediate- and high-risk categories (C-E).
5. Advanced Interventional Therapies
Systemic Thrombolysis
- Remains an option for select Category E1 patients (massive PE with hemodynamic collapse).
Catheter-Based Thrombolysis (CDT)
- Reasonable for select Category E1 patients, and may be considered in D1-D2.
Mechanical Thrombectomy (MT) - New Specific Recommendations
- Class 2a: Category E1 (high-risk PE) - considered reasonable
- Class 2b: Category D1-D2 (intermediate-high risk) - may be considered
- Class 3 (NOT recommended): Categories A through C1 (low-risk PE) - explicit guardrails against overuse
- MT may be preferred over systemic thrombolysis in D1-E1 patients when bleeding risk is a concern, though efficacy superiority over systemic thrombolysis has not been established.
Surgical Embolectomy
- Remains an option for Category E1 with high in-hospital survival (>97% in many series) and acceptable for selected D1-D2 patients.
6. Longitudinal / Follow-up Care
The guideline expands on post-PE follow-up, including:
- Surveillance for chronic thromboembolic pulmonary hypertension (CTEPH)
- Assessment for post-PE syndrome
- Shared decision-making about duration of anticoagulation
- Special populations: pregnancy, cancer-associated PE, renal/hepatic impairment
7. Diagnosis
- CTPA (CT pulmonary angiography) remains the primary imaging modality.
- The pregnancy-adapted YEARS algorithm (3 clinical criteria + D-dimer thresholds) may help risk-stratify pregnant patients, though evidence is still evolving (Murray & Nadel's Textbook of Respiratory Medicine).
- AI-based PE detection on CTPA shows high sensitivity in meta-analyses (PMID 40412084) but is not yet a guideline recommendation.
8. Parallel 2025 ESVM Guideline on Interventional Treatment
The European Society of Vascular Medicine (ESVM) also published separate 2025 guidelines on interventional treatment of VTE (PMID 40587333), covering indications for catheter-directed thrombolysis and mechanical thrombectomy, emphasizing that these procedures should be performed at experienced VTE intervention centers with vascular specialist input.
Summary of Key Paradigm Shifts vs. Prior Guidelines
| Old Approach | 2026 AHA/ACC Update |
|---|---|
| Low/Intermediate/High risk (3-tier) | 5-Category A-E system with subcategories |
| Most PE patients admitted | Category A/B can be discharged from ED |
| PERTs as "suggested" | PERTs = Class 1 recommendation |
| Warfarin still prominent | DOACs are preferred over VKAs |
| MT largely uncharacterized | MT has specific class recommendations by category |
| Limited follow-up guidance | Formal CTEPH surveillance + post-PE syndrome protocols |
The official guideline is published in Circulation 2026;153:e977-e1051. The AHA also published a companion scientific statement on disparities in PE management (March 2025).
For an overview from the writing committee chairs, here is the official AHA video:
Explain the PE Category A-E classification in detail with clinical examples
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2026 AHA ACC PE clinical categories A B C D E subcategories detailed criteria definition
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2026 AHA ACC pulmonary embolism category D1 D2 E1 E2 classification criteria hemodynamics biomarkers
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https://litfl.com/goodbye-massive-and-submassive
I now have comprehensive detail on all categories including subcategories, criteria, the respiratory modifier, and management implications. Here is the full breakdown:
AHA/ACC 2026 PE Clinical Categories A-E: Detailed Breakdown
The new system integrates clinical symptoms, validated severity scores (PESI/sPESI/Hestia), cardiac biomarkers (troponin, BNP/NT-proBNP), imaging (RV size/function on echo or CT), hemodynamics, end-organ perfusion markers (lactate, creatinine), and respiratory status into a single unified framework.
Key principle: A patient is assigned the most severe category that any single indicator supports. Categories are not fixed - patients can transition between categories over time.
There is also a Respiratory Modifier (R) that can be appended to any subcategory (e.g., C2-R, D1-R) when hypoxia, tachypnea, or escalating oxygen requirements are present.
Category A - Asymptomatic / Incidental PE
Definition: Confirmed PE in a patient who has no symptoms - typically discovered on CT performed for another indication (cancer staging, trauma workup, post-procedure imaging) without any clinical suspicion of PE.
Key features:
- No dyspnea, pleuritis, hemoptysis, tachycardia
- Normal hemodynamics
- Often subsegmental or incidental bilateral clots
Management: Safe to discharge from the ED - no hospitalization required. This is a landmark change. Anticoagulation decision is individualized (e.g., cancer patients may have higher clot burden and need treatment, whereas isolated subsegmental PE in low-risk patients may warrant surveillance discussion). Advanced therapies are Class 3 (not recommended).
Clinical Example:
A 58-year-old woman with breast cancer undergoes routine staging CT. No respiratory symptoms, no tachycardia (HR 76), BP 126/78. The radiologist notes bilateral subsegmental PE. She feels well. She is Category A - she can be started on anticoagulation counseling and discharged home with close outpatient follow-up rather than admitted.
Category B - Symptomatic, Low Clinical Severity
Definition: Symptomatic PE (dyspnea, pleuritic chest pain, etc.) but low risk on validated severity indices: PESI Class I-II (score ≤85), sPESI = 0, or Hestia = 0. No RV dysfunction, no elevated biomarkers.
Key features:
- Symptoms present
- Low clinical severity score
- Normal troponin and BNP
- No RV dilatation or dysfunction on imaging
- Hemodynamically stable
Management: Early discharge generally recommended - outpatient treatment with DOAC is appropriate (supported by the HOME-PE trial comparing Hestia vs sPESI). A guaranteed follow-up pathway is mandatory before discharge. DOACs preferred (rivaroxaban or apixaban as monotherapy, or LMWH bridge to warfarin if needed). Advanced therapies not recommended.
Clinical Example:
A 32-year-old woman on the oral contraceptive pill presents with 2 days of right-sided pleuritic chest pain. CTPA confirms a right lower lobe segmental PE. HR 88, BP 122/74, SpO₂ 97% on room air. Troponin normal, BNP normal. sPESI = 0 (age <80, no cancer, no chronic cardiopulmonary disease, HR <110, SpO₂ ≥90%). She is Category B - discharged on rivaroxaban with 48-hour follow-up arranged.
Category C - Symptomatic, Elevated Severity (with Subcategories C1, C2, C3)
Definition: Symptomatic PE with an elevated clinical severity score - PESI Class III-V, sPESI ≥1, or Hestia ≥1 - with or without RV dysfunction and biomarker elevation.
Subcategories:
| Subcategory | RV Dysfunction | Biomarkers (Troponin/BNP) |
|---|---|---|
| C1 | Absent | Absent/Normal |
| C2 | Present OR elevated | One or both abnormal |
| C3 | Present AND elevated | Both abnormal |
RV dysfunction on imaging = RV:LV ratio >0.9 on CT or echo, RVEDD >30 mm, TAPSE <1.6 cm, pulmonary acceleration time <90 ms, tricuspid systolic velocity >2.6 m/s.
Management: Hospitalization required. Measure at minimum one cardiac biomarker (troponin or BNP) - lactate is now a Class 1 recommendation for Categories C-E. Echo is preferred over CT for RV assessment. Activate PERT for Categories C-E (Class 1 recommendation). Advanced interventional therapies in Category C have uncertain benefit - escalation requires clinical progression plus multidisciplinary PERT deliberation. RV dysfunction alone, without hemodynamic compromise, should NOT trigger reflexive catheter-based or surgical therapy.
Clinical Example (C1):
A 74-year-old man with COPD presents with worsening dyspnea. CTPA shows bilateral PE. BP 118/72, HR 104, SpO₂ 91% on 2L. PESI Class III. Troponin normal, BNP normal. Echo shows no RV dilatation. He is Category C1 - admitted, anticoagulated, monitored, PERT notified.
Clinical Example (C3):
A 68-year-old woman presents with dyspnea and lightheadedness. BP 108/68 (stable), HR 118. CTPA shows large bilateral saddle-type PE with RV:LV ratio 1.2 on CT. Troponin elevated (0.9 ng/mL), NT-proBNP 3,200 pg/mL. She is Category C3 - admitted to intermediate care (step-down unit), PERT activated, close hemodynamic monitoring. No advanced therapy yet, but the team is on standby.
Category D - Incipient Cardiopulmonary Failure (Subcategories D1, D2)
Definition: The patient is on the hemodynamic knife-edge - not yet in frank shock, but showing signs of imminent circulatory deterioration: progressive tachycardia, borderline/transient hypotension, worsening oxygenation. This is a brand new construct with no direct equivalent in prior guidelines - it captures what was previously an ill-defined gray zone within "submassive" PE.
Subcategory D1 - Transient Hypotension, No End-Organ Dysfunction
Criteria: Transient or recurrent hypotension (including relative hypotension compared to the patient's own baseline) that:
- Is short-lived, OR
- Responds to a fluid trial (500-1000 mL normal saline IV)
- No signs of reduced perfusion or end-organ dysfunction
Clinical Example (D1):
A 55-year-old man with PE arrives with BP 88/52 mmHg. HR 124. He is given 1L normal saline and BP rises to 102/68 within 20 minutes. Lactate 1.4 mmol/L (normal). Creatinine stable. He is Category D1 - incipient failure that responded to volume. ICU monitoring, PERT activated, advanced therapy being considered.
Subcategory D2 - Transient Hypotension WITH End-Organ Dysfunction
Criteria: Transient hypotension PLUS at least one marker of reduced perfusion or end-organ dysfunction:
- Lactate >2 mmol/L
- Acute kidney injury (creatinine rise or urine output <0.5 mL/kg/hr)
- Mental status change
- Cardiac index <2.2 L/min/m²
- Mean arterial pressure <60 mmHg
- Elevated shock score (SKY shock stage B or C)
Management for D1-D2: ICU or high-dependency unit admission. Vasopressors/inotropes recommended (Class 1, Level C-LD) for cardiogenic shock. Advanced therapies (systemic thrombolysis, CDT, MT, surgical embolectomy) are Class 2b - may be considered. MT may be preferred over systemic thrombolysis when bleeding risk is a concern.
Clinical Example (D2):
A 61-year-old man with massive bilateral PE. BP 84/50, transiently. Lactate 3.1 mmol/L. Creatinine rising (from baseline 1.0 to 1.8 mg/dL). Urine output 0.2 mL/kg/hr. Echo: severely dilated RV. He is Category D2 - full resuscitation, PERT emergency activation, strong consideration for catheter-based therapy or surgical embolectomy.
Category E - Overt Cardiopulmonary Failure (Subcategories E1, E2)
Definition: Established cardiopulmonary failure with persistent hypotension - equivalent to the old "massive" or "high-risk" PE. This is the most time-critical category.
Subcategory E1 - Persistent Hypotension / Cardiogenic Shock (No Cardiac Arrest)
Criteria:
- Persistent SBP <90 mmHg despite fluid resuscitation
- Signs of cardiogenic shock (end-organ hypoperfusion, high vasopressor requirement)
- Without cardiac arrest
Management: Advanced therapies are reasonable (Class 2a): systemic thrombolysis, CDT, MT, surgical embolectomy. MT receives a Class 2a recommendation here. Vasopressors + inotropes indicated. PERT activation is mandatory. Surgical embolectomy has reported in-hospital survival >97% in series of E1 patients.
Clinical Example (E1):
A 48-year-old man collapses in the waiting room. BP 72/40 despite 2L IV fluids, norepinephrine running. CTPA shows massive saddle PE. Troponin markedly elevated, lactate 5.6 mmol/L. Echo: severely dilated RV with septal bowing, near-absent RV function. He is Category E1 - emergent PERT activation. Decision made for catheter-directed mechanical thrombectomy (Penumbra Indigo system) given high bleeding risk (recent GI bleed).
Subcategory E2 - Refractory Cardiogenic Shock or Cardiac Arrest
Criteria:
- Refractory cardiogenic shock (persisting despite maximal vasopressor/inotrope support), OR
- Active cardiac arrest (in context of PE)
Management: Most aggressive tier - systemic thrombolysis during CPR (supported by meta-analysis data, PMID 38037310), emergency surgical embolectomy, or ECMO bridge to definitive therapy. Survival depends on rapid recognition and mobilization.
Clinical Example (E2):
A 52-year-old woman goes into pulseless electrical activity (PEA) arrest in the ED. Last known BP 30 minutes ago was 68 systolic. POCUS shows severely dilated RV. PE is the presumed cause. She is Category E2 - CPR ongoing, systemic thrombolysis administered (alteplase 50 mg IV bolus), resuscitation continued for 60-90 minutes post-thrombolytic. Surgical team on standby for embolectomy.
The Respiratory Modifier (R)
Any category from A through E2 can have "-R" appended when the patient has:
- Hypoxia (SpO₂ <90% or significant drop from baseline)
- Tachypnea
- Escalating oxygen requirements
This signals additional respiratory risk independent of hemodynamic status and may influence the care setting decision (e.g., a Category B-R patient may need observation rather than immediate discharge).
Example: Category C2-R = symptomatic PE, elevated severity score, RV dysfunction with elevated biomarkers, AND significant hypoxia requiring supplemental O₂.
Summary Table: Categories at a Glance
| Category | Old Equivalent | Symptoms | PESI/sPESI | RV/Biomarkers | Hemodynamics | Setting | Advanced Therapy |
|---|---|---|---|---|---|---|---|
| A | Low-risk (incidental) | None | N/A | Normal | Stable | ED discharge | Class 3 (avoid) |
| B | Low-risk | Yes | PESI I-II / sPESI 0 | Normal | Stable | Early discharge | Not indicated |
| C1 | Intermediate-low | Yes | PESI III-V / sPESI ≥1 | Normal | Stable | Admit | Uncertain benefit |
| C2/C3 | Intermediate-high | Yes | Elevated | RV dysfx ± elevated biomarkers | Stable | Admit / Step-down | Uncertain; PERT-guided |
| D1 | -- (new) | Yes | Elevated | Abnormal | Transient hypotension, responds to fluids, no organ failure | ICU/HDU | Class 2b |
| D2 | -- (new) | Yes | Elevated | Abnormal | Transient hypotension + organ dysfunction | ICU | Class 2b |
| E1 | Massive/High-risk | Yes | N/A | Severely abnormal | Persistent SBP <90, shock | ICU/Critical care | Class 2a (recommended) |
| E2 | Massive + arrest | Yes | N/A | Severely abnormal | Refractory shock / arrest | Resuscitation bay | Emergent thrombolysis/surgery |
Why This Matters Clinically
The old "submassive" label lumped together patients as different as C1 (mildly elevated PESI, normal echo, going home in 48 hours) and D2 (normotensive but lactate 3.5, oliguric, about to crash) under one umbrella. The new system gives each of those patients their own name, their own monitoring level, and their own treatment pathway - which is exactly what the evidence now supports.
For a visual overview from the AHA writing committee:
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