Summary

De novo 2026 multisociety guideline for evaluation and management of acute PE in adults, introducing the AHA/ACC Acute PE Clinical Categories (A–E with subcategories and respiratory modifier R) to refine severity, prognosis, and treatment decisions. Emphasizes clinical decision tools with D-dimer for diagnosis, CTPA as standard imaging, PE Response Teams (PERTs), LMWH over UFH for parenteral anticoagulation, DOACs over VKAs for oral therapy, selective use of advanced therapies (systemic lysis, CDL, mechanical thrombectomy, surgical embolectomy) reserved for Categories D–E, and structured post-PE follow-up to detect CTEPD.

Key Recommendations

Use a validated clinical pretest probability tool (Wells, revised Geneva, or gestalt) combined with D-dimer testing before imaging to exclude PE in low/intermediate probability patients.
CTPA is the preferred diagnostic imaging modality; use V/Q (preferably SPECT) when CTPA is contraindicated.
Classify all diagnosed PE using AHA/ACC Categories A–E (with R modifier for respiratory failure) to guide disposition and therapy.
Discharge asymptomatic (Category A) and low-severity symptomatic (Category B, PESI I–II / sPESI 0 / Hestia 0) patients from the ED for outpatient anticoagulation.
Hospitalize Category C–E patients; place D–E patients in ICU/step-down and activate a PERT to guide advanced therapy.
Use LMWH over UFH for initial parenteral anticoagulation in acute PE.
Use DOACs over VKAs for oral anticoagulation unless contraindicated (e.g., triple-positive antiphospholipid syndrome, pregnancy/breastfeeding, severe hepatic impairment Child-Pugh C, mechanical valves).
Reserve advanced reperfusion (systemic thrombolysis, CDL, mechanical thrombectomy, surgical embolectomy) for Category E1 (Class 2a); consider for Category D1–2 (Class 2b); avoid in Categories A–C1.
Norepinephrine is the preferred vasopressor for PE-associated shock; limit IV fluid boluses to ≤500 mL and add dobutamine for low cardiac output.
Avoid IVC filters in anticoagulated patients; reserve retrievable filters for absolute contraindication to anticoagulation and remove promptly once safe.
Continue extended-phase anticoagulation beyond 3–6 months in unprovoked PE and PE with persistent risk factors; stop after initial phase for major reversible provoking factors.
Screen all PE survivors for persistent dyspnea and functional limitation at follow-up visits for at least 1 year to detect CTEPD; refer symptomatic patients with abnormal V/Q perfusion imaging to a CTEPH specialty center.

Thresholds & Doses

Age-adjusted D-dimer threshold: age × 10 μg/L (FEU) for patients >50 years with low/intermediate probability.
YEARS algorithm D-dimer thresholds: 500 μg/L if any YEARS criterion present, 1000 μg/L if none.
PE Rule-Out Criteria (PERC) applies when gestalt probability <15% (e.g., Wells <2).
CTPA RV/LV ratio ≥1.0 defines RV dysfunction (sensitivity 85%, specificity 72%); ≥0.9 more sensitive.
Echocardiographic RV dysfunction: RV EDD >30 mm, RV basal EDD >42 mm, RV/LV >0.9, TAPSE <1.6 cm, tricuspid systolic velocity >2.6 m/s.
PESI classes: I ≤65, II 66–85, III 86–105, IV 106–125, V ≥126; sPESI ≥1 = high risk.
Category D2 criteria: lactate >2 mmol/L, urine output <0.5 mL/kg/hr, cardiac index <2.2 L/min/m², MAP <60 mm Hg.
MAP >80 mm Hg associated with low risk of 48-h clinical deterioration in intermediate-high risk PE.
Norepinephrine ≤15 μg/min preserves PVR; add second vasopressor above this dose. Dobutamine up to 10 μg/kg/min.
Fluid resuscitation: cautious boluses ≤500–1000 mL normal saline.
Initial DOAC dosing: apixaban 10 mg BID × 7 days then 5 mg BID; rivaroxaban 15 mg BID × 21 days then 20 mg daily; dabigatran/edoxaban after ≥5 days parenteral.
Extended-phase reduced doses: apixaban 2.5 mg BID or rivaroxaban 10 mg daily after 6 months.
Standard rt-PA systemic thrombolysis dose: 100 mg IV over 2 hours; reduced dose 25–50 mg being studied.
CDL rt-PA range: 4–24 mg total over 2–24 hours; reduced dose <5 mg/PA, standard 5–10 mg/PA.
IVC filter retrieval window: FDA recommends 29–54 days after placement; retrieval difficulty rises after 50–90 days.
Extended thromboprophylaxis for long travel: consider single prophylactic-dose LMWH or DOAC for flights ≥4 hours in prior travel-related PE.
Avoid DOACs for 4 weeks after bariatric surgery; avoid DOACs in Child-Pugh C hepatic impairment.
Initial treatment phase = 3–6 months; extended phase = beyond 6 months without planned stop date.
Category E2 = refractory cardiogenic shock (SCAI D–E) or cardiac arrest without ROSC after 30 minutes of resuscitation.

Citations

Top Take-Home Messages — 10 headline recommendations including PE Categories A–E, PERT, LMWH>UFH, DOAC>VKA, extended anticoagulation, CTEPD screening.
Section 3.1.1 and Table 3 — clinical decision rules (Wells, revised Geneva, PERC) and D-dimer strategies including age-adjusted and YEARS.
Section 3.2 and Figure 2/Table 5 — AHA/ACC Acute PE Clinical Categories A–E with severity criteria and respiratory modifier.
Section 4.2.1 — anticoagulation therapy: LMWH over UFH; DOAC over VKA; special populations (obesity, CKD, APS, pregnancy, liver disease).
Section 4.4 and Table 7 — summary of advanced therapy recommendations by PE Category (systemic lysis, CDL, MT, surgery).
Section 4.3 — IVC filter indications, PREPIC/PREPIC2 evidence, FDA retrieval window guidance.
Section 5.2 and Table 9 — anticoagulation duration by recurrence risk (major reversible, minor reversible, persistent, unprovoked).
Section 6.1 and Figures 7–8 — evaluation of persistent post-PE symptoms and CTEPD/CTEPH screening pathway.