2026 AHA/ACC PE Guidelines

2026 Acute PE Clinical Categories

Category A- Subclinical PE

• Incidental and asymptomatic PE
• Treatment
  • Discharge home on AC (DOAC preferred)

Category B- Symptomatic/ Low Risk

• Symptomatic PE with PESI < 85
• B1: subsegmental PE
• B2: includes segmental or more proximal PE
• Treatment
  • Admission is not required. If admitting treat with LMWH then DOAC on discharge

Category C- Symptomatic/ Elevated Risk

• Symptomatic PE with PESI > 85
• C1: normal RV function and normal cardiac biomarkers
• C2: abnormal RV function OR an abnormal cardiac biomarker
• C3: abnormal RV function AND an abnormal cardiac biomarker
• Treatment
  • Admit to hospital and start LMWH

Category D - Incipient Cardiopulmonary Failure

• Patients approaching failure or exhibiting “normotensive shock”
• D1: Transient hypotension: Systolic BP <90 or drop >40 lasting <15 min or that responds to volume expansion with no signs of end-organ hypoperfusion. 
• D2: Normotensive shock: Normal BP but markers of hypoperfusion present, lactate >2, AKI, UOP <720mL in 24h, AMS or cardiac index <2.2, MAP<60 
• Treatment
  • Admit to ICU or step-down. Consider thrombectomy/lysis (class IIb recommendation)

Category E- Cardiopulmonary Failure

• Hemodynamics collapse/Cardiogenic shock
• E1: Recurrent or persistent hypotension with cardiogenic shock (SCAI stage C)
• E2: Refractory cardiogenic shock (SCAI D-E) or cardiac arrest 
• Treatment
  • ICU. Immediate PERT activation. Systemic thrombolysis, surgical embolectomy or ECMO are reasonable (Class IIa)

Respiratory Modifier

• The guideline also adds an R modifier for clinically important respiratory compromise.
  • C: O2<90%, RR>=30, or need supplemental O2
  • D: >6L NC or use of NRB
  • E: Hypoxemic respiratory failure

PESI and HESTIA

• PESI remains useful for estimating clinical severity in symptomatic PE. A low clinical severity score (PESI < 85) helps identify Category B patients, while elevated clinical severity (PESI >85) helps identify Category C patients. Hemodynamic compromise takes priority over PESI and moves the patient into Category D or E.
• HESTIA is 11-step questionnaire to determine eligibility for outpatient management of Category A and B patients. If you answer "yes" to any of the 11-questions you should consider inpatient admission.

Treatment

• Category A and B patients may be appropriate for outpatient treatment or early discharge when there are no other reasons for hospitalization.
• Category C patients generally require hospitalization and therapeutic anticoagulation. Routine reperfusion therapy is not recommended in clinically stable patients.
• Category D patients require close monitoring and early multidisciplinary PE evaluation. Advanced PE therapy may be considered depending on the clinical trajectory.
• Category E patients require urgent critical care management and evaluation for reperfusion therapy such as systemic thrombolysis, catheter based therapy, mechanical thrombectomy, or surgical embolectomy.
• For oral anticoagulation, DOACs are preferred over vitamin K antagonists when appropriate. When initial parenteral anticoagulation is needed, LMWH is preferred over unfractionated heparin in most patients.
• The new classification provides a more practical continuum from low severity PE through cardiopulmonary failure and is designed to guide monitoring intensity, disposition, anticoagulation, and escalation to advanced PE therapy.

Mechanical Thrombectomy vs Catheter-Directed Thrombolysis

• PEERLESS trial: Mechanical thrombectomy and catheter-directed thrombolysis had similar short-term mortality.
• Mechanical thrombectomy showed a favorable signal for some clinical outcomes, although it did not demonstrate a clear mortality benefit.

Anticoagulation

• If parenteral anticoagulation is required, LMWH is preferred over UFH because of lower recurrent VTE and bleeding risk.
• DOACs are preferred over warfarin for most patients eligible for oral anticoagulation.
• Special Populations
  • Antiphospholipid syndrome: Warfarin is preferred.
  • CKD stage 2–3: DOAC therapy is generally preferred when otherwise appropriate.
  • Pregnancy: LMWH is preferred. UFH is an alternative when indicated.

Vasopressors and Other Meds

• Norepinephrine is the preferred initial vasopressor.
• At higher norepinephrine requirements, increasing catecholamine doses may increase pulmonary vascular resistance (>15mcg/min)
• Consider adding a second vasopressor such as vasopressin rather than continuing to escalate norepinephrine alone.
• Pulmonary Vasodilators
  • Class IIb: In selected patients with Category C2 through E, pulmonary vasodilator therapy may be considered.

CTEPD, Not Just CTEPH

Chronic thromboembolic pulmonary disease (CTEPD) represents a broader spectrum than CTEPH.

• CTEPD can cause persistent symptoms and functional limitation with or without pulmonary hypertension.
• CTEPH is the subset of CTEPD associated with pulmonary hypertension.
• Class I: Patients with persistent dyspnea, exercise intolerance, or other PE-related symptoms >3 months after acute PE should be evaluated for CTEPD.
• Evaluation may include:
  • TTE
  • V/Q scan
  • CPET
  • Additional pulmonary vascular evaluation when indicated

Duration of Anticoagulation

• No Major Reversible Risk Factor
  • After a first PE without a major reversible provoking factor, extending anticoagulation beyond the initial 3–6 months is recommended when bleeding risk is acceptable.
• Persistent Risk Factor
  • Extended anticoagulation is recommended when a persistent risk factor remains.
• Major Reversible Risk Factor
  • If the PE occurred in the setting of a major reversible provoking factor, anticoagulation can generally be stopped after the initial 3–6 month treatment phase.