2026 AHA/ACC Multi-Society Guideline for Acute Pulmonary Embolism

Authors, Journal, Affiliations, Type, DOI

• Authors: Creager MA, Barnes GD, Giri J, Mukherjee D, Jones WS, Burnett AE, Carman T, Casanegra AI, Castellucci LA, Clark SM, Cushman M, de Wit K, Eaves JM, Fang MC, Goldberg JB, Henkin S, Johnston-Cox H, Kadavath S, Kadian-Dodov D, Keeling WB, Klein AJP, Li J, McDaniel MC, Moores LK, Piazza G, Prenger KS, Pugliese SC, Ranade M, Rosovsky RP, Russo F, Secemsky EA, Sista AK, Tefera L, Weinberg I, Westafer LM, Young MN
• Journal: Circulation. 2026;153:e977–e1051
• Affiliations: AHA/ACC Joint Committee; co-developed with ACCP, ACEP, CHEST, SCAI, SHM, SIR, SVM, SVN
• Type: De novo clinical practice guideline; evidence review February 2024–October 2024; select key studies added to April 2025
• DOI: 10.1161/CIR.0000000000001415

Overview

This de novo AHA/ACC multi-society guideline provides comprehensive, evidence-based recommendations for the evaluation, management, and follow-up of adults (≥18 years) with acute pulmonary embolism (PE). Its central innovation is the introduction of the AHA/ACC Acute PE Clinical Categories (A–E) — a five-category classification that replaces prior risk schemes (AHA 2011 massive/submassive/low-risk; ESC 2019 four-tier) by integrating clinical, hemodynamic, biomarker, and imaging parameters to guide severity classification, prognosis, and therapeutic decision-making. The guideline covers the full continuum from diagnosis through post-acute follow-up including CTEPD surveillance.

Keywords

Acute pulmonary embolism · anticoagulant · diagnosis · chronic thromboembolic pulmonary hypertension · CTEPD · DOAC · heparin · risk assessment · risk stratification · thrombectomy · thrombolytic therapy · venous thromboembolism

Key Takeaways

Evaluation and Diagnosis

Clinical Assessment

• Targeted history and physical exam recommended (COR 1/A) to establish pre-test probability using validated tools (Wells score, Revised Geneva Score, PERC)
• Age-adjusted D-dimer (age × 10 μg/L for FEU assays) safely excludes PE in patients with low/intermediate pre-test probability (<50%), with <2% missed VTE at 3 months (COR 2a/B-R)
• YEARS algorithm (D-dimer threshold 500 μg/L if ≥1 criterion; 1000 μg/L if none) useful to avoid imaging (COR 2a/B-R); pregnancy-adapted YEARS criteria reasonable in pregnant patients (COR 2b/B-NR)

Diagnostic Imaging

• CTPA recommended over V/Q scan as standard imaging modality for PE confirmation (COR 1/B-R); preferred for its accessibility, diagnostic performance, and ability to assess RV
• V/Q SPECT preferred over planar V/Q (COR 2a/B-R)
• In CTPA-confirmed PE, reporting the numerical RV/LV ratio (≥1.0 cut-point: sensitivity 85%, specificity 72%) is recommended for risk stratification (COR 1/B-R)
• Echocardiography is NOT recommended to confirm or refute PE diagnosis (COR 3:No Benefit); however, TTE parameters of RV dysfunction should be fully reported when obtained: RV/LV end-diastolic ratio, TAPSE, estimated RVSP, McConnell's sign, paradoxical septal motion, IVC respirophasic collapse (COR 1/B-NR)
• Venous duplex ultrasound not useful after negative CTPA or normal V/Q SPECT (COR 3:No Benefit)
• Routine CTV as adjunct to CTPA: not recommended (COR 3:No Benefit)

PE Outcomes Risk Stratification — AHA/ACC Acute PE Clinical Categories

The New 5-Category System

• Respiratory modifier (R) added when: O₂ requirement >6 L/min nasal cannula or nonrebreather, or RR >25 (Cat B–D); NIV/invasive ventilation required (Cat E-R)

Clinical Risk Scores

• PESI, sPESI, and Hestia all identify low-risk patients (Cat A/B) suitable for outpatient management (COR 1/B-R)
• HOME-PE trial: sPESI vs Hestia equivalence; physician override common; shared decision-making paramount
• PESI Class I–II or Hestia-negative → 30-day mortality 0.30%, recurrent VTE 0.57%, major bleeding 0.45%

Biomarkers

• Troponin and BNP recommended in Cat C for short-term risk stratification (COR 1/B-NR); troponin elevation: OR 4.33 for all-cause mortality
• Lactate (venous or arterial) recommended in Cat C–E (COR 1/B-NR); elevated lactate: OR 5.13 for all-cause mortality in unselected PE; 4.54 in normotensive PE
• Normotensive shock (lactate >2 mmol/L, AKI, urine output <0.5 mL/kg/hr, cardiac index ≤2.2) found in 34% of intermediate-risk patients (FLASH registry)

RV Imaging for Risk Stratification

• RV imaging (echo or CT) recommended in Cat C–D (COR 1/A); echocardiography preferred over CT (COR 2a/B-NR)
• RV dysfunction on echo: OR 4.01 for PE-related mortality; on CT (RV/LV ≥1): independent predictor of in-hospital death and 30-day mortality
• Thrombus burden quantification NOT recommended for risk stratification in Cat A–C (COR 3:No Benefit)

Acute Management

Hospitalization Decisions

• Cat A and B: outpatient management reasonable (COR 2a/B-R) using Hestia/PESI/sPESI; requires immediate access to anticoagulation and reliable follow-up
• Patients on thrombolytics (systemic or CDL): ICU or intermediate care required (COR 1/C-EO)
• Unstable patients (Cat E): must NOT be transferred before stabilisation (COR 3:Harm)

PE Response Team (PERT)

• PERT is recommended for Cat C–E (COR 1/B-NR) to improve timeliness of care, reduce time-to-anticoagulation, decrease IVC filter use, and reduce length of stay
• PERT functions like code stroke/STEMI team; members vary by institution

Anticoagulation

• Anticoagulation recommended for all without absolute contraindication (COR 1/B-R)
• Parenteral: LMWH > UFH for Cat C1–E1 (COR 1/B-R); lower recurrent VTE without increased bleeding; once/twice daily dosing; no routine anti-Xa monitoring needed (COR 3:No Benefit/A)
• Oral: DOACs > VKAs (COR 1/B-R); lower major bleeding including ICH; lower fatal bleeding and all-cause mortality vs warfarin
• VKA preferred in thrombotic antiphospholipid syndrome (COR 1/A) due to arterial thrombosis risk with DOACs
• Pregnancy: LMWH or UFH only (COR 1/C-LD); DOACs and warfarin contraindicated (COR 3:Harm)
• Breastfeeding: LMWH, UFH, or warfarin over DOACs (COR 1/C-LD)
• Obesity (BMI >30): DOACs preferred over VKA (COR 2a/B-NR); dose reduction of LMWH may be reasonable in class III obesity (COR 2b/B-NR)
• CKD stage 2–3: DOAC over VKA (COR 1/A)
• Liver disease: DOAC reasonable in Child-Pugh A (COR 2a/C-LD) and B (COR 2b/C-LD); Child-Pugh C contraindicated (COR 3:Harm)

Hemodynamic Support

• Vasopressors/inotropes: recommended in Cat D2–E2 (COR 1/C-LD); norepinephrine first-line (SVR increase, modest inotropy, no PVR effect ≤15 μg/min); dobutamine adjunct for low CO
• Cautious fluid resuscitation (≤500 mL): reasonable in Cat D1–2 with reduced preload (COR 2b/B-R); avoid excessive volume (RV overload risk)
• Inhaled pulmonary vasodilators may reduce RV afterload in Cat C2–E (COR 2b/B-R); systemic vasodilators not effective
• Deep sedation and mechanical ventilation: should be avoided in Cat C–E unless clinically necessary (COR 3:Harm); associated with catastrophic hemodynamic collapse
• HFNC preferred over standard nasal cannula for moderate-severe hypoxia (COR 2a/C-LD)

Mechanical Circulatory Support

• VA-ECMO: reasonable for Cat E2 refractory cardiogenic shock (COR 2a/B-NR); continue systemic anticoagulation on ECMO unless bleeding (COR 1/B-NR)
• Additional advanced therapies while on VA-ECMO: not well established (COR 2b/C-LD)

IVC Filters

• Retrievable IVC filters over permanent when anticoagulation contraindicated (COR 1/B-R); retrieve as soon as safe (FDA recommends 29–54 days)
• Routine IVC filter in anticoagulated patients: not recommended (COR 3:Harm/A); increases DVT risk without mortality benefit (PREPIC, PREPIC2)
• Structured follow-up program to improve retrieval rates (COR 2a/C-LD)

Advanced Management (by Category)

Summary Table

Systemic Thrombolysis

• Standard dose: rt-PA 100 mg over 2 hours; tenecteplase has been studied but not FDA-approved for PE
• Cat E1–2: reasonable over anticoagulation alone (COR 2a/C-LD)
• Cat C3–D2 (PEITHO trial, n=1006): prevented cardiovascular collapse but increased ICH (2.4% vs 0.2%) and major extracranial bleeding (6.3% vs 1.2%)
• Lower-dose thrombolytics (25–50 mg rt-PA) may reduce bleeding with similar efficacy (COR 2b/C-LD); PEITHO-3 trial ongoing
• NOT recommended in Cat A1–C2 (COR 3:Harm/B-R)

Catheter-Directed Thrombolysis (CDL)

• rt-PA infused via multi-side-hole catheter directly into PA; standard dose 5–10 mg per PA; reduced dose (<5 mg) not recommended over standard (COR 3:NB/B-NR)
• Cat E1: reasonable (COR 2a/C-LD); Cat D1–2: may consider (COR 2b/B-NR)
• PEERLESS trial (n=550 Cat C2–D2): CDL vs MT — no difference in 30-day mortality or major bleeding; MT had fewer protocol-defined clinical deterioration events requiring bailout
• CDL may be preferred over systemic thrombolysis to reduce major/intracranial bleeding (COR 2b/C-LD)

Mechanical Thrombectomy (MT)

• Large-bore percutaneous suction thrombectomy; no lytic agent; allows non-ICU post-procedure care in most patients
• Cat E1: reasonable (COR 2a/B-NR); FLAME study (n=115 Cat E1): MT primary endpoint 17% vs context arm 63.9%; in-hospital mortality 1.9% vs 29.5%
• Cat D1–2: may consider (COR 2b/B-NR); FLARE and EXTRACT-PE trials: significant RV/LV ratio reduction at 48 hours
• FLASH registry (n=1000): mean PA pressure and cardiac index significantly improved post-procedure; major adverse events 1.8%
• MT preferred over systemic thrombolysis to reduce major bleeding (COR 2b/B-NR)

Surgical Embolectomy

• Cat E1: reasonable (COR 2a/B-NR); survival >97% in modern series among patients without pre-operative CPR
• Cat E2: NOT recommended over other advanced therapies (COR 3:NB/B-NR); most post-operative deaths in this group
• Cat A–C3: NOT recommended (COR 3:NB/C-EO)
• Compared to systemic thrombolysis: lower ICH risk; better RV recovery; equivalent long-term survival in non-randomised comparisons
• Reduces RV size, PA systolic pressure, and improves perfusion better than thrombolysis

Follow-Up and Long-Term Management

Post-Discharge Follow-Up

• Within 1 week of discharge: patient education, adherence, bleeding assessment (COR 1/C-LD)
• At/before 3 months: discuss anticoagulation duration, further testing, symptom assessment (COR 1/C-EO)
• Every visit for ≥1 year: screen for PE-related symptoms and functional limitations to detect CTEPD (COR 1/C-LD)
• Screen for anxiety and depression at follow-up visits (COR 2a/B-NR)
• Specialist PE clinic referral for complex patients (COR 2a/B-NR)
• Cancer screening (thorough history, exam, age-appropriate screening) for unprovoked PE (COR 1/A); routine CT/PET-CT NOT recommended (COR 3:NB/A)
• Thrombophilia testing: reasonable in patients <55 or with family history if results will change management (COR 2b/C-LD)

Anticoagulation Duration

• First PE without major reversible risk factor: extend beyond 3–6 months (COR 1/A); 30–40% recurrence risk at 10 years without extended treatment
• Major reversible risk factor: stop at 3–6 months (COR 1/B-NR); <1%/year recurrence risk post-surgery
• Persistent risk factor (cancer, autoimmune disease, chronic immobility): continue extended phase (COR 1/C-LD)
• Minor reversible risk factor: shared decision-making on stopping vs continuing (COR 2a/B-NR)
• Extended phase agent: DOAC over VKA (COR 1/A); half-dose apixaban 2.5 mg BID or rivaroxaban 10 mg daily recommended to reduce bleeding while maintaining efficacy (COR 1/A); RENOVE and API-CAT trials confirm half-dose safety even in cancer-associated VTE
• VKA for patients unable to take DOAC or refusing it (COR 1/B-R); aspirin reasonable if anticoagulation refused/contraindicated (COR 2a/B-R)

Recurrent PE

• Confirm with CTPA or V/Q scan (COR 1/C-EO); compare with prior imaging
• Investigate for nonadherence, subtherapeutic dosing, cancer, antiphospholipid antibodies, drug interactions (COR 1/C-LD)
• Switch to alternative drug class if recurrence on therapeutic anticoagulation (COR 2a/C-EO)
• If recurrence on reduced-dose DOAC: escalate to full dose (COR 2a/C-EO)
• Cancer with recurrence on LMWH: dose escalation 20–25% (COR 2a/B-NR)

CTEPD Surveillance

• If persistent dyspnea/functional impairment ≥3 months after PE: evaluate for CTEPD with TTE + lung perfusion scan V/Q or SPECT/CT (COR 1/B-NR); CPET useful to exclude CTEPD (COR 2a/B-NR)
• CTEPD with PH: referral to expert centre (COR 1/C-LD); without PH: consider referral (COR 2a/C-LD)
• Pulmonary rehabilitation for persistent impairment when CTEPD excluded (COR 1/B-R)
• Continue anticoagulation during CTEPD evaluation (COR 1/B-NR)
• Routine imaging for resolved, asymptomatic patients: NOT recommended (COR 3:NB/B-NR)

Limitations of the Document

• Literature search concluded October 2024; key studies to April 2025 added by committee; contemporary ongoing trials (PEITHO-3, PEERLESS-2) not included
• Advanced therapy recommendations (CDL, MT, surgical embolectomy) largely based on single-arm prospective studies and registries rather than randomised controlled trials vs anticoagulation alone
• Long-term functional outcomes and quality of life after advanced therapies are not well characterised beyond 30–90 days
• CTEPD prevalence without PH is unknown; optimal diagnostic workup and natural history not established
• CDL vs systemic thrombolysis has not been directly compared in randomised trials
• Most DOAC trials excluded severe renal impairment and severe hepatic disease; recommendations in these groups based on registry data

Key Concepts Mentioned

• concepts/Acute-PE-Clinical-Categories — central classification system (A–E) driving all management decisions
• YEARS algorithm — D-dimer based diagnostic tool
• PERT — PE response team model
• CTEPD — chronic thromboembolic pulmonary disease (without PH); distinct from CTEPH
• Half-dose DOAC for extended anticoagulation

Key Entities Mentioned

• entities/Pulmonary-Embolism — primary entity
• entities/CTEPH — post-PE sequelae; CTEPD distinct entity formalised
• entities/Pulmonary-Hypertension — CTEPD/CTEPH relationship

Wiki Pages Updated

• Created: wiki/sources/acute-pe-aha-2026.md
• Created: wiki/entities/Pulmonary-Embolism.md
• Created: wiki/concepts/Acute-PE-Clinical-Categories.md
• Updated: wiki/entities/CTEPH.md
• Updated: wiki/sourceindex.md
• Updated: wiki/wikiindex.md