2026 AHA/ACC PE Guidelines

PE Risk & Treatment Tool

1 · Presentation

Incidental and asymptomatic PE?

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

2026 AHA/ACC Acute PE Clinical Categories

A
Subclinical
Incidental and asymptomatic PE
B
Symptomatic
Low clinical severity score
C
Symptomatic
Elevated clinical severity score
D
Incipient Cardiopulmonary Failure
E
Cardiopulmonary Failure
Lowest risk Highest risk
B1
Subsegmental PE
Single or multiple
B2
Non-subsegmental PE
C1
Normal RV function and normal cardiac biomarkers
C2
Abnormal RV function or at least one abnormal cardiac biomarker
C3
Abnormal RV function and at least one abnormal cardiac biomarker
D1
Transient hypotension
D2
Normotensive shock
E1
Recurrent or persistent hypotension with cardiogenic shock
E2
Refractory cardiogenic shock or cardiac arrest
+/−
+/−
+/−
R
Respiratory modifier
O₂ saturation below 90%
RR 30 or greater
Supplemental O₂ required
R
Respiratory modifier
More than 6 L/min nasal cannula or nonrebreather mask
R
Respiratory modifier
Hypoxemic respiratory failure or ventilatory 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.
Initial Assessment & Management by Acute PE Clinical Category
Hover over a category to highlight its recommended assessment and management
Showing recommendations for
Initiate DOAC
I
Initiate LMWH
I
Initiate LMWH or UFH
I
Use PESI to assess short-term risk
I
Measure at least 1 cardiac biomarker
I
Measure lactate
I
Evaluate RV size and function with CT and/or echocardiography
I
Use HESTIA score to identify suitability for outpatient treatment
IIa
Use PESI score to identify the higher-risk patient
IIa
Evaluate for normotensive shock
IIa
Multidisciplinary PERT assessment to guide clinical management
I
Vasopressor and/or inotropic therapy
I
Systemic thrombolysis if acceptable bleeding risk, catheter-directed thrombolysis, or mechanical thrombectomy in appropriate cases
IIb
Systemic thrombolysis if acceptable bleeding risk, catheter-directed thrombolysis, mechanical thrombectomy, or surgical embolectomy
IIa
Systemic thrombolysis if acceptable bleeding risk
IIa
Consider VA-ECMO
IIa
Class I Recommended
Class IIa Reasonable
Class IIb May be considered

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.
Advanced Therapy for Acute Pulmonary Embolism by Risk Category
PE Category Systemic Thrombolysis Catheter-Directed Thrombolysis Mechanical Thrombectomy Surgical Embolectomy
A–C1 Class III: Harm Level of Evidence A Class III: No Benefit Level of Evidence C, Expert Opinion Class III: No Benefit Level of Evidence C, Expert Opinion Class III: No Benefit Level of Evidence C, Expert Opinion
C2 Class III: Harm Level of Evidence B, Randomized Class IIb: Benefit Uncertain Level of Evidence C, Limited Data Class IIb: Benefit Uncertain Level of Evidence C, Limited Data Class III: No Benefit Level of Evidence C, Expert Opinion
C3 Class IIb: Benefit Uncertain Level of Evidence C, Limited Data Class IIb: Benefit Uncertain Level of Evidence C, Limited Data Class IIb: Benefit Uncertain Level of Evidence C, Limited Data Class III: No Benefit Level of Evidence C, Expert Opinion
D1–D2 Class IIb: May Be Considered Level of Evidence C, Limited Data Class IIb: May Be Considered Level of Evidence B, Nonrandomized Class IIb: May Be Considered Level of Evidence B, Nonrandomized Class IIb: Benefit Uncertain Level of Evidence C, Limited Data
E1 Class IIa: Reasonable Level of Evidence C, Limited Data Class IIb: May Be Considered Level of Evidence B, Nonrandomized Class IIb: May Be Considered Level of Evidence B, Nonrandomized Class IIb: May Be Considered Level of Evidence C, Limited Data
E2 Class IIa: Reasonable Level of Evidence C, Limited Data Not Applicable Not Applicable Class III: No Benefit Level of Evidence B, Nonrandomized
Clot-in-Transit Class IIa: Advanced Therapies Are Reasonable
Class IIa Reasonable
Class IIb May be considered / benefit uncertain
Class III No benefit or harm

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
Evaluating Ongoing Symptoms Following Acute PE
Persistent symptoms ≥3 months after acute PE
IIa
Perform TTE and lung perfusion imaging
V/Q scan or SPECT/CT
IIa
Perform noninvasive CPET
Pulmonary vascular disease limitation on CPET?
No Yes
IIa
CTEPD excluded
IIa
Proceed with TTE and lung perfusion imaging
V/Q scan or SPECT/CT
Normal lung perfusion
Abnormal lung perfusion + low-probability echo
Abnormal lung perfusion + high-probability echo
CTEPD excluded
CTEPD possible
CTEPD likely
IIa
If CTEPD possible
Perform noninvasive CPET
If CTEPD likely
CTEPD with pulmonary hypertension
  • Expert pulmonary vascular evaluation
  • Pulmonary angiography
  • Right-heart catheterization ± exercise
CTEPD without pulmonary hypertension
  • Expert evaluation
  • Pulmonary angiography
  • Right-heart catheterization ± exercise
Pulmonary vascular disease limitation on CPET?
No Yes
CTEPD excluded
CTEPD with pulmonary hypertension
  • Expert pulmonary vascular evaluation
  • Pulmonary angiography
  • Right-heart catheterization ± exercise
CTEPD without pulmonary hypertension
  • Expert evaluation
  • Pulmonary angiography
  • Right-heart catheterization ± exercise
Class I Recommended
Class IIa Reasonable
CTEPD = chronic thromboembolic pulmonary disease. CPET = cardiopulmonary exercise testing. TTE = transthoracic echocardiography. V/Q = ventilation/perfusion. RHC = right-heart catheterization.

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.
References
1
Creager MA, Barnes GD, Giri J, et al. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN guideline for the evaluation and management of acute pulmonary embolism in adults. Circulation. 2026;153. doi:10.1161/CIR.0000000000001415.
View guideline
Primary Guideline
2
Naidu SS, Baran DA, Jentzer JC, et al. SCAI SHOCK stage classification expert consensus update: a review and incorporation of validation studies. J Am Coll Cardiol. 2022;79(9):933-946. doi:10.1016/j.jacc.2022.01.018.
View SCAI consensus
SCAI Shock Staging
3
Jaber WA, Gonsalves CF, Stortecky S, et al. Large-bore mechanical thrombectomy versus catheter-directed thrombolysis in the management of intermediate-risk pulmonary embolism: primary results of the PEERLESS randomized controlled trial. Circulation. 2025;151(5):260-273. doi:10.1161/CIRCULATIONAHA.124.072364.
View PEERLESS trial
PEERLESS
4
Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370:1402-1411. doi:10.1056/NEJMoa1302097.
View PEITHO trial
Systemic Thrombolysis
5
Rosenfield K, et al. Ultrasound-facilitated, catheter-directed fibrinolysis for acute pulmonary embolism. N Engl J Med. 2026. doi:10.1056/NEJMoa2516567.
View HI-PEITHO trial
Catheter-Directed Therapy
6
Jiménez D, Aujesky D, Moores L, et al. Simplification of the Pulmonary Embolism Severity Index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170(15):1383-1389.
View study
PESI / Risk Assessment