Decision support only — not a substitute for the full 2026 AHA/ACC/multisociety guideline, eTG, or your team. Anticoagulate on clinical suspicion (high/intermediate probability) while awaiting imaging unless bleeding risk forbids. AHA/ACC categories are US; Australian pathways may still reference ESC tiers (mapping noted below). Confirm doses and renal cut-offs locally.
1 AHA/ACC Acute PE Clinical Categories — the new spine
ASubclinical≈ incidental
Asymptomatic / incidentally found PE.
Discharge from ED — hospitalisation not required. Anticoagulate (DOAC). No advanced therapy.
BSymptomatic, low severity≈ ESC low-risk
Symptomatic; low clinical severity score (PESI ≤85 / sPESI 0 / Bova ≤4); no RV dysfunction or biomarker rise.
Early discharge generally appropriate. DOAC, outpatient management reasonable if Hestia-negative and supports in place.
CSymptomatic, elevated severity≈ ESC intermediate
Elevated severity score (PESI >85 / sPESI ≥1 / Bova >4) and/or raised biomarkers and/or RV dysfunction. Haemodynamically stable.
Hospitalise. Anticoagulate. CDT benefit unclear here — not routine. No systemic lysis unless deteriorates into D/E.
DIncipient cardiopulmonary failure≈ ESC intermediate-high
Transient hypotension / normotensive shock — hypoperfusion markers (lactate >2, AKI, low UO, altered mentation, CI <2.2, MAP <60) without persistent hypotension.
Hospitalise / monitored bed. Consider systemic thrombolysis if acceptable bleeding risk. Advanced therapy may be considered (D1–2): MT 2b, CDT, surgical embolectomy.
ECardiopulmonary failure≈ ESC high-risk
Persistent hypotension / obstructive (cardiogenic) shock — SBP <90 sustained >15 min or requiring pressors with hypoperfusion. Cardiac arrest.
Systemic thrombolysis. In E1, advanced therapy reasonable: MT 2a, CDT, surgical embolectomy. Pressors/inotropes; VA-ECMO for refractory shock.
Clinical Severity Score: low = PESI ≤85 (class I–II) / sPESI 0 / Bova ≤4; elevated = above those. Add "R" when respiratory criteria met (e.g. C3R, D2R). sPESI (1 pt each): age >80, cancer, chronic cardiopulmonary disease, HR ≥110, SBP <100, SpO₂ <90%. Categories C–E are hospitalised; A discharged from ED; B early discharge.
2 Diagnosis — and what echo is not for
Stable — sequential workup
- PTPYEARS or Wells/Geneva to decide who needs imaging — YEARS validated in pregnancy too.
- D-dimerAge-adjusted (age × 10 µg/L if >50y) for low/intermediate probability. Negative → excludes.
- CTPAImaging test of choice, including in pregnancy. V/Q if contrast/renal contraindication.
Two traps 2026
- EchoDo not use echo to confirm or exclude PE. It is a risk-stratification tool (RV strain), not a diagnostic one.
- UnstableIf too unstable to scan: bedside echo supports the call → treat as Category E now; CTPA once able to transfer.
3 Anticoagulation & the team
DOAC first-line 1
- Apixaban10 mg BD × 7d → 5 mg BD.
- Rivaroxaban15 mg BD × 21d → 20 mg daily.
- Dabigatran150 mg BD after ≥5d LMWH.
- Edoxaban60 mg daily after ≥5d LMWH.
Agent selection
- DOAC>VKAPreferred unless contraindicated — fewer recurrences, less major bleeding. Favoured for most, incl. many with CKD / liver disease (verify severe-impairment limits).
- ParenteralLMWH over UFH when a parenteral agent is needed (Cat C–E). UFH if instability, likely procedure, or severe renal.
- PregnancyLMWH or UFH. No DOAC, no VKA.
- APSTriple-positive → warfarin, not DOAC.
PERT 1
- ActivateMultidisciplinary PE response team for any increased-risk PE (Cat C–E) — improves timeliness of escalation.
- WhyClass 1 recommendation in 2026 — interventional options now multiple; the team decides who actually benefits.
4 Advanced therapy & haemodynamic support
Systemic thrombolysis (alteplase)
- Cat EGive — cardiopulmonary failure.
- Cat DConsider, if acceptable bleeding risk.
- Dose100 mg IV / 2h; 50 mg bolus peri-arrest.
- CIPrior ICH, ischaemic stroke <6mo, CNS tumour, major surgery/trauma <3wk, active bleeding (relative in arrest).
Catheter / surgical
- CDTReasonable in E1; consider in D to prevent deterioration; not in A/B; unclear in C.
- MT+ anticoag: reasonable E1 2a; may consider D 2b.
- SurgerySurgical embolectomy reasonable in E1; consider in D.
Shock & the airway trap
- PressorsVasopressors ± inotropes for shock.
- O₂HFNC over standard nasal cannula for moderate–severe hypoxia.
- IntubationAvoid deep sedation / mechanical ventilation if you can — induction can precipitate collapse in RV failure.
- ECMOVA-ECMO reasonable for refractory cardiogenic shock with known/suspected PE.
5 Duration, recurrence & follow-up
How long
- ReversibleMajor reversible risk factor (surgery) → stop at end of initial phase (3–6 mo).
- OtherwiseFirst PE with no major reversible factor, or a persistent factor → continue into extended phase.
- RecurrenceNew symptoms → image. Recurrent PE while adherent to therapeutic AC → switch drug class.
- IVC filterNot routine — only if anticoagulation truly contraindicated.
After discharge
- ≤1 weekEarly review after discharge is helpful.
- ≤3 monthsClinical visit to decide on anticoagulation duration. Encourage early ambulation.
- CTEPDAsk about dyspnoea / functional limits at every visit for ≥1 year. Persistent symptoms ≥3 mo → evaluate for chronic thromboembolic pulmonary disease.
Primary source.
2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults (Creager et al; Circulation / JACC, Feb 2026; DOI 10.1161/CIR.0000000000001415). Guideline-at-a-Glance (JACC) and AHA Top Things to Know.
Key features: de-novo five-tier Clinical Categories A–E (with "R" respiratory modifier) replacing the ESC binary/tripartite risk taxonomy; Class 1 PERT; DOAC over VKA; LMWH over UFH for parenteral; category-mapped advanced therapy (MT 2a in E1, 2b in D).
Caveats: COR 2 (reasonable / may consider) reflects that intervention-vs-anticoagulation hard-outcome RCT data (PEERLESS II, STORM-PE) are still maturing. Categories are US — Australian local pathways and eTG still lean on ESC 2019 tiers, so map before quoting. Verify edoxaban/DOAC renal and weight cut-offs against local formulary.