The American Heart Association and American College of Cardiology issued their first joint clinical practice recommendations for acute pulmonary embolism.
RT’s Three Key Takeaways:
- Clinical Classification System: The guideline introduces a five-level category system to assess the severity of blood clots and determine appropriate care settings for adults.
- Diagnostic Protocols: Clinicians are advised to use D-dimer blood tests for initial screening in low-probability cases and computed tomography pulmonary angiography as the standard imaging for confirmation.
- Extended Follow-Up: Recommendations include a follow-up visit within one week of discharge and ongoing monitoring for at least one year to screen for chronic thromboembolic pulmonary disease.
The American Heart Association (AHA) and the American College of Cardiology (ACC) have released the first joint clinical practice guideline for the management of acute pulmonary embolism (PE). The document, published in Circulation and JACC, provides detailed recommendations for the diagnosis, treatment, and follow-up care of adults with the condition, according to the organizations.
Acute PE is a life-threatening condition where a blood clot, typically originating in the leg or pelvis, lodges in a lung artery. It is a form of venous thromboembolism (VTE) that can damage lung tissue, lower blood oxygen levels, and strain the heart. According to AHA 2026 statistics, approximately 470,000 people are hospitalized with PE in the US annually, and 1 in 5 high-risk patients die.
“There have been significant advances in the understanding of pulmonary embolism and treatments to effectively manage this condition,” said Mark A Creager, MD, chair of the guideline writing committee, in a news release. “This guideline is a road map to help clinicians navigate these advances for the safest and most effective approaches to care for people with this condition.”
New Severity Classification
The guideline introduces the Acute PE Clinical Category system, which classifies patients into five categories (A through E) based on symptom severity and risk of adverse outcomes. Patients in Categories A and B have mild or no symptoms and may be eligible for discharge from the emergency department for outpatient management. Patients in Categories C, D, and E require hospitalization or critical care due to higher risks.
Clinicians are encouraged to assess risk factors for clotting when evaluating patients, including major surgery, trauma, hospitalization, prolonged immobility, pregnancy, obesity, smoking, cancer, and blood clotting disorders.
Diagnostic and Treatment Strategies
For patients with a low or intermediate probability of acute PE, the guideline recommends a D-dimer blood test. If D-dimer levels are elevated or if the clinical probability is high, imaging is required. Computed tomography pulmonary angiography (CTPA) is identified as the standard imaging test due to its accuracy and availability. For patients with iodine-based contrast allergies, a lung ventilation/perfusion scan is recommended.
Anticoagulants serve as the primary treatment for confirmed cases. Direct oral anticoagulants (DOACs), including rivaroxaban, apixaban, edoxaban, and dabigatran, are recommended over vitamin K antagonists like warfarin for most patients. However, DOACs are not recommended during pregnancy; instead, low-molecular-weight heparin or unfractionated heparin should be used.
Critically ill patients in Categories D and E may require advanced interventions, such as catheter-based mechanical clot removal, surgical removal, or the administration of clot-dissolving drugs. The guideline also outlines protocols for sedation, ventilation, and mechanical circulatory support to maintain heart and lung function in these patients.
Long-Term Management and Follow-Up
The guideline emphasizes the importance of structured follow-up care to improve patient outcomes. All patients should receive a follow-up communication or clinic visit within one week of hospital discharge to review treatment plans and check for complications. A subsequent visit should occur at the three-month mark to evaluate ongoing symptoms and determine the duration of anticoagulant therapy.
For at least one year following diagnosis, healthcare providers should screen patients for chronic thromboembolic pulmonary disease (CTEPD). This condition involves persistent clots that cause long-term blockage, potentially leading to shortness of breath, fatigue, and right-sided heart failure.
Additional recommendations for recovery include screening for psychological conditions like depression and anxiety, encouraging early physical activity such as walking, and counseling women of childbearing age on contraception and pregnancy-related anticoagulation options.
“We anticipate that decisions guided by these recommendations will result in more rapid diagnosis and application of effective, evidence-based treatments, leading to better outcomes, such as decreased risk of death and disability, for people with acute pulmonary embolism,” said Creager, a professor of medicine at the Geisel School of Medicine at Dartmouth College, in a news release.
