2026 AHA ACC Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults

Persistent Notes

Highlights

  • Category C p.e991
  • PESI >85 p.e991
  • sPESI ≥1 p.e991
  • The respiratory modifier, R, is applied when hypoxemia or tachypnea p.e991
  • need for supplemental oxygen p.e991
  • Category D p.e991
  • normotensive shock or approaching need for ventilatory support p.e991
  • Category D1 identifies patients with transient or recurrent hypotension p.e991
  • short-lived p.e991
  • responds to volume expansion p.e991
  • Category D2 requires a marker of decreased perfusion or end-organ dysfunction p.e991
  • respiratory modifier, R, would be applied if the patient required either >6 L p.e991
  • use of LMWH reduces recurrent VTE risk more effectively than UFH without increasing major bleeding risk in patients with acute PE p.e1003
  • In patients who have undergone bariatric surgery, however, DOACs should be avoided for at least 4 weeks after their procedure p.e1003
  • There is 1 small RCT evaluating a lower versus a standard dose of enoxaparin (0.8 mg/kg versus 1.0 mg/kg actual body weight twice daily) in patients with severe obesity (BMI ≥40 kg/m2) p.e1004
  • Pregnant patients with acute PE p.e1005
  • LMWH is used more commonly than UFH in pregnant patients p.e1005
  • Therefore, the use of DOACs for patients with acute PE and severe p.e1005
  • hepatic impairment may result in harm and should be avoided. p.e1005
  • norepinephrine (NE) is generally considered the vasopressor of choice p.e1007
  • At doses ≤15 μg/min, NE has little to no effect on PVR p.e1007
  • However, at doses exceeding 15 μg/min, NE may increase PVR p.e1007
  • continuous infusion of dobutamine (up to 10 μg/ kg/min) p.e1007
  • Thus, any amount of sedation should be administered with caution when there is evidence or concern for RV dysfunction. p.e1008
  • deeper sedation and intubation should be avoided p.e1008
  • In patients with acute, refractory cardiogenic shock as a result of known or suspected acute PE (AHA/ ACC PE Category E2), it is reasonable to institute VA-ECMO p.e1008
  • IVC filters can be useful to reduce the short-term incidence of recurrent PE. p.e1009
  • The PREPIC trial demonstrated that IVC filters led to significantly higher rates of DVT and IVC thrombosis over time without improving long-term survival p.e1009
  • PREPIC2 trial p.e1009
  • found no added benefit in preventing recurrent PE p.e1009
  • IVC filter retrieval within 29 and 54 days p.e1010
  • who have evidence of freefloating right atrial and/or RV clot-in-transit, the utilization of advanced therapies over anticoagulation alone is reasonable p.e1011
  • Categories E1-2 p.e1012
  • systemic thrombolysis and anticoagulation is reasonable over anticoagulation alone p.e1012
  • AHA/ACC PE Categories D1-2 p.e1012
  • in whom advanced therapy is being considered, systemic thrombolysis and anticoagulation p.e1012
  • acute PE in AHA/ACC PE Categories A1-C2, systemic thrombolysis should not be used over anticoagulation alone p.e1012
  • Category E1, CDL plus anticoagulation p.e1013
  • acute PE in AHA/ACC PE Category E1, it is reasonable to choose MT plus anticoagulation over anticoagulation alone p.e1015
  • In patients with acute PE in AHA/ACC PE Category E1, surgical embolectomy compared with anticoagulation alone is reasonable p.e1016
  • In patients with acute PE without associated identifiable risk factors, a thorough history, physical examination, and age-appropriate cancer screening p.e1017
  • In patients without a major reversible risk factor21 for acute PE who have a family history of thrombosis or are <55 years of age, it might be reasonable to perform testing for genetic and acquired thrombophilia p.e1017
  • At approximately 3 months after acute PE, a dedicated visit with a physician or advanced practice provider should occur to discuss the duration of anticoagulation, evaluate for ongoing symptoms, and assess the need for further testing. p.e1018
  • Between one-third and one-half of the patients who have had a symptomatic PE will report dyspnea or limitations to physical activity on follow-up for months to years after a PE. p.e1019
  • The prevalence of shortness of breath is higher after an acute PE associated with RV dysfunction and can be a presenting symptom of CTEPD p.e1019
  • cancer is diagnosed in 4% to 10% during the first year when no major reversible risk factors for PE are identified p.e1020

Reference

Writing Committee Members, Creager MA, Barnes GD, et al. 2026 AHA ACC Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults. Circulation. 2026;153(12). doi:10.1161/CIR.0000000000001415