DALLAS and WASHINGTON – In a landmark move for cardiovascular care, the American Heart Association (AHA) and the American College of Cardiology (ACC) jointly released the first-ever clinical practice guideline for the evaluation and management of acute pulmonary embolism (PE) on Thursday, February 19, 2026. The guideline, published simultaneously in Circulation and JACC, aims to standardize and improve the often-complex process of diagnosing and treating this potentially fatal condition.
Pulmonary embolism occurs when a blood clot, typically originating in a deep vein in the leg or pelvis, travels to the lungs and blocks an artery. This blockage can lead to reduced oxygen levels, lung damage, and strain on the heart. According to the AHA, approximately 470,000 people are hospitalized with PE annually in the United States, with a mortality rate of around 20% for high-risk patients.
“There have been significant advances in the understanding of pulmonary embolism and treatments to effectively manage this condition,” said Dr. Mark A. Creager, chair of the guideline writing committee, professor of medicine at the Geisel School of Medicine at Dartmouth College, and director emeritus of the Heart and Vascular Center at Dartmouth Health. “This guideline is a road map to aid clinicians navigate these advances for the safest and most effective approaches to care for people with this condition.”
A central component of the new guideline is the introduction of five “Acute PE Clinical Categories” (A-E), designed to classify patients based on the severity of their symptoms and their risk of adverse outcomes. Patients in Categories A and B, exhibiting no or mild symptoms and a low risk of complications, may be safely discharged from the emergency department. Those in Categories C-E, with more pronounced symptoms and higher risk, require hospitalization.
The guideline acknowledges the multidisciplinary nature of PE management, noting that effective care requires collaboration across emergency departments, inpatient settings, and outpatient clinics. It likewise emphasizes that the implementation of these recommendations will depend on the availability of local resources, including specialist consultations, imaging capabilities, and advanced intervention options.
Prompt diagnosis remains a critical challenge, as symptoms such as shortness of breath, chest pain, rapid heartbeat, fainting, and dizziness can mimic other conditions. Clinicians are advised to assess patients for risk factors including recent surgery or trauma, prolonged immobility, pregnancy, obesity, cancer, blood clotting disorders, smoking, and atherosclerotic cardiovascular disease.
For diagnostic imaging, computed tomography pulmonary angiography (CTPA) is recommended as the standard test to identify and visualize blood clots. Alternative imaging, such as a lung ventilation/perfusion scan, is advised for patients unable to undergo CTPA due to allergies or other contraindications.
Anticoagulants are the primary recommended treatment for confirmed PE. The guideline favors direct oral anticoagulants (DOACs) – rivaroxaban, apixaban, edoxaban, or dabigatran – over vitamin K antagonists like warfarin, citing their safety, ease of leverage, and reduced bleeding risk. But, DOACs are not recommended during pregnancy, with low-molecular-weight heparin or unfractionated heparin considered safe alternatives.
Patients in more severe categories (D-E) may require advanced treatments, including intravenous or catheter-based clot-dissolving drugs, mechanical clot removal, or surgical embolectomy. The guideline also addresses the need for appropriate sedation, ventilation, and circulatory support for critically ill patients.
The guideline provides detailed recommendations for follow-up care, including early follow-up within one week of discharge to review the treatment plan and monitor for complications. A clinic visit should also occur by three months after diagnosis to determine the duration of anticoagulant therapy and assess ongoing symptoms. Long-term monitoring for chronic thromboembolic pulmonary disease (CTEPD), a condition involving persistent lung blockage, is also recommended.
Beyond medical management, the guideline highlights the importance of addressing psychological health, encouraging early physical activity, and providing precautions for travel, particularly long-distance journeys. It also emphasizes the need for counseling regarding contraception and anticoagulation options for women of childbearing age.
The guideline was developed in collaboration with and endorsed by eight other health care organizations: the American College of Clinical Pharmacy; the American College of Emergency Physicians; the American College of Chest Physicians; the Society for Cardiovascular Angiography & Interventions; the Society of Hospital Medicine; the Society of Interventional Radiology; the Society for Vascular Medicine; and the Society of Vascular Nursing.
