2026 AHA PE Guidelines Have Landed

March 2026 | Casey Parker | #FOAMed

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Pulmonary embolism. The diagnosis that haunts ED doctors more than almost any other. Is it a PE? Is it not? Should I anti-coagulate? Admit or discharge? Should I thrombolyse? And why does every specialty seem to have a different opinion?

Well, hold on to your Wells score – the AHA and ACC have just dropped their first-ever joint PE guideline, and it’s a big one. Endorsed by ten societies (yes, ten), published simultaneously in Circulation and JACC in February 2026, this is a de novo document covering the whole shebang – diagnosis, risk stratification, treatment, and follow-up. FREE PDF copy of the PE Guidelines here for your reference.

Here’s what you actually need to know.

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Creatively-named PE hierarchy: The A-E Clinical Categories

The headline change is the introduction of the AHA/ACC Acute PE Clinical Categories – a five-tier framework (A through E) that replaces the old “massive / submassive / low-risk” language. If you work in ED, this is the thing that will most change how you talk about and manage these patients. This will become the lingua respiratoria when calling specialists about PE patients.

Personally, I would have gone with a more ‘Musky’ naming system eg. Ammahydra, B#+ty, Cuerelean… but apparently A, B, C is easier to recall (and confuse with all the other things we classify. “Mrs Jones had a Webber A, casted, now has a PE-B… she has been moved to Ward C.”). However, this new framework will help us moving into the future as new therapies / strategies emerge and we will hopefully be able to match the right patient to the best therapy.

Category A – Subclinical PE (I have previously referred to these as ‘lung lint’)

Incidentally found, asymptomatic. No haemodynamic compromise, no elevated biomarkers, no RV dysfunction. These patients have been landing in our EDs for years thanks to ever-more-sensitive CT scanners, (and rampant over-diagnosis) and we’ve been quietly unsure what to do with them. The guidance here is fairly reassuring – these patients can generally be managed as outpatients. Don’t panic, don’t lyse. Anticoagulate and send them home. Of course, we should be trying to avoid overdiagnosis and trying to rationalise who we work up for PE in the first place… but that is another post and covered previously.

Category B – Symptomatic, Low Clinical Severity

Symptomatic but stable, simplified PESI = 0, normal biomarkers, normal RV. This is your “classic” uncomplicated PE. Good news: early discharge is appropriate for most of these patients. The guideline backs the outpatient management approach that we have been using in Australia for years.

Category C – Elevated Biomarkers and/or RV Dysfunction This is where it gets more interesting. These patients are symptomatic, look “submassive” in the old language, and have elevated troponin/BNP and/or RV dysfunction on echo or CT. They need to be admitted. The guideline is cautious about jumping straight to advanced therapy here – anticoagulation remains the backbone, but closer monitoring is warranted and this is where your PERT team (more on that below) earns its keep.

Category D – Incipient Cardiopulmonary Failure Things are getting wobbly. These patients are heading toward haemodynamic collapse – transient BP dips with SBP < 90 or other signs of malperfusion eg. AKI, oliguria, lactate rise, altered mental status, decreased cardiac output, worsening RV strain, escalating oxygen requirements. Admit to a monitored setting. Advanced therapy is on the table and needs to be considered urgently. Though he actual evidence for which advanced therapy is a little unclear – this is where we need more research and individualised therapy discussions… PERT team to the rescue!

Category E – Cardiopulmonary Failure with Persistent Hypotension This is your massive PE. Haemodynamically unstable, in shock. Time-critical decision-making required. This is the group where systemic thrombolysis gets its Class I recommendation. If systemic lysis is contraindicated or has failed, catheter-directed therapy or surgical embolectomy enter the picture.

Each Level has a sublevel to help with describing the more subtle physiology. There is also an “R” modifier which is added if there is significant respiratory embarrassment or need for lots of supplemental oxygen.

Ultimately I do not really think that htis is how many ED docs think about PE. We tend to make the diagnosis simultaneously with risk stratification. We are sending bloods, looking at the CT and the patient to decide who is fine, who is sick and who needs something done quick.

Troponin is a reasonable biomarker, however BNP seems like a poor cousin. So we will probably send both on confirmed PE cases but I am not sure a BNP adds much over an echo and just looking at the patient.

The various scoring systems they employ (PESI, sPESI, Bova…) are all validated but probably do not do better than commonsense and careful clinical / echo assessment. So use these if you like but remember that the patient in front of you is unique and has their own risk tolerance too.

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Diagnosis: Nothing Dramatically New, But Good to See It Formalised

The diagnostic algorithm is sensible and evidence-based:

• If clinical probability is low or intermediate (<50%) → get a D-dimer. Normal D-dimer rules it out.
• If probability is high (>50%), or D-dimer is elevated → CTPA. It remains the gold standard and is the go-to imaging test.
• Can’t do CTPA (contrast allergy, renal impairment)? → V/Q scan.
• Pregnancy – “low dose CTPA” is the preferred investigation.

No major curveballs here, but good to have it codified.

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Anticoagulation: DOACs Win, As Expected

The recommendations align with where the evidence has been pointing for a while:

• DOACs over warfarin for eligible patients – better efficacy, less bleeding, no INR monitoring. Apixaban and rivaroxaban are specifically well-supported.
• The vast majority of all Category A and B PEs will be managed with DOACs ( do cat A need anything? .. hard to say)
• If parenteral anticoagulation is needed (e.g. for immediate bridging or when oral isn’t an option) → LMWH over unfractionated heparin.
• UFH still has a role in patients with severe renal impairment, those heading to the cath lab, or when rapid reversibility is needed.

Duration of anticoagulation still follows familiar rules – at least 3 months, longer depending on provoked vs unprovoked status and ongoing risk factors. But that is really a decision for the team in a few months…

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Advanced Therapies: More Nuance, More Options

This is the section that will get the most attention from the interventional crowd. The guideline acknowledges that the landscape has shifted substantially with catheter-based technologies but appropriately notes that the RCT evidence base is “still maturing”. As of my writing this we do not have any randomised data comparing standard IV thrombolysis (in a range of doses) to the newer, more expensive, difficult to access and definitely more invasive options

• Systemic thrombolysis: Class I for Category E (cardiopulmonary failure). High bleeding risk, but in a patient who is dying, you use it.
  • The standard dose is alteplase 100 mg over 2 hours. Which has a “severe bleed” risk of nearly 10% (1.7% ICH)
  • There is a trend towards using “low and slow tPA” eg. 10 mg bolus then 40 mg over 2 hours or other variations on this theme. Similar outcomes, less bleeding is the thinking.
  • Justin and I have reviewed a few of the papers looking at this on the past.
• Catheter-directed thrombolysis (CDT): Reasonable option for Category D/E when systemic lysis has failed or is contraindicated. Lower dose of lytic, delivered right where it needs to go…. makes sense in theory but not much evidence of patient-oriented benefits.
• Mechanical thrombectomy: Emerging data supports use in high-risk patients, particularly when lysis is contraindicated. The guideline endorses it without mandating it – reasonable given the evidence trajectory. Of course, this is only available in a handful of places… so if you work in most places the question becomes – thrombolysis here or transfer there…
  • You can hear us rant about mechanical thrombectomy trials HERE and HERE
• Surgical embolectomy: Still on the table for massive PE when all else fails or is contraindicated. Once again, this is only available in the big Cardiothoracic centres, needs early discussion at the right side of the severity curve.

The key message: for high-risk patients, get your multidisciplinary team together and make a decision. Which brings us to…

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PERT: It’s Official Now

The Pulmonary Embolism Response Team (PERT) model gets a formal nod. The guideline acknowledges this will look different depending on your institution – a major tertiary centre will have cardiologists, interventional radiologists and haematologists; a place like Broome will have… you, the on-call physician, and a phone. The principle is the same: structured multidisciplinary decision-making improves outcomes, even if “multidisciplinary” sometimes means a phone call to your friendly metropolitan colleague.

Our job as ED docs is to resuscitate, make the numbers look good as we can and gather all the data. 99% will have a CTPA once fit enough to pass through the doughnut. This will mean sending lactate, troponin, BNP and doing an echo.

That last bit is controversial, however in 2026 I think most ED docs can look at a heart on echo and measure the basic stuff required by this guideline. Standard cardiac views – we are looking for:

• Dilated RV (absolute basal diameter > 42 mm) but RV/LV ratio >0.9 is easier to call.
• TAPSE decreased < 16 mm (usually easy to get)
• Tricuspid regurg: TRvmax > 2.6 m/sec which is about a pressure of 30 mmHg
• Pulmonary acceleration time < 90 msec (harder to measure in novice hands)

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Follow-Up: Don’t Forget the Long Game

One area the guideline emphasises that is often dropped in the ED rush is post-PE follow-up. Specifically:

• Patients with persistent symptoms or functional limitation at 3 months should be evaluated for chronic thromboembolic pulmonary hypertension (CTEPH) – a nasty and underdiagnosed complication.
• Echocardiography, 6-minute walk testing, and cardiopulmonary exercise testing all have a role in this assessment.
• If CTEPH is suspected, refer to a pulmonary hypertension centre.

When you discharge that Category B patient home on apixaban, make sure there’s a follow-up plan in place. This isn’t just a tick-the-box exercise.

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The Bottom Line

This guideline is a solid, evidence-based resource and the new A-E classification system is a genuine improvement over the old “massive/submassive” binary. For ED practice, the key practical takeaways are:

1. Category A and B = outpatient or early discharge, get them on a DOAC and arrange follow-up.
2. Category C = admit, anticoagulate, monitor closely, consider PERT.
3. Category D/E = this is the danger zone – CODE PERT, consider advanced therapy, don’t delay systemic lysis in frank haemodynamic collapse.
4. DOACs are first-line for eligible patients.

The full guideline is freely available in Circulation – it’s a big document, but the algorithm figures are genuinely useful for the wall above your ED workstation.

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Reference: Creager MA, Barnes GD, Giri J, et al. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults. JACC and Circulation. Published February 19, 2026. doi: 10.1016/j.jacc.2025.11.005

Josh Farkas has some strong ideas to consider over at the Pulmcrit blog... worth a read as a counterpoint to the evidence presented.

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As always – this is a summary and personal interpretation. Read the guideline itself before changing your practice. Learn the lingo so that you sound smart when chatting to the Respiratory team.