The 2026 Acute Pulmonary Embolism Guidelines recommend a new approach to risk stratification of patients with acute PE, including measurement of at least one cardiac biomarker and serum lactate, evaluation of RV size and function with CTA or echo (preferred when feasible), and multidisciplinary PERT assessment for all patients with acute PE and elevated clinical severity scores to assist with further risk stratification.

Additional Information

Initial management strategies are based on these risk classifications. Inclusion of assessment of clot burden into risk stratification and management decisions is not recommended.

From a critical care perspective, we are most interested in patients in Classes C, D, and E. 

• Class C: Normotensive but with elevated risk stratification scores (Bova, PESI, ePESI, and Hestia) with or without abnormal RV size or function on CT or echo (echo preferred when feasible), elevated biomarkers of cardiopulmoary dysfunction (trop, BNP)
• Class D: “Pre-cardiopulmonary failure states,” including transient hypotension (for example, improving after a small IVF bolus) or normotensive shock (indicated by persistent lactate elevation >2, acute AKI,  UOP <720mL/24h, CI <2.2, or other marker of persistent poor perfusion or end-organ dysfunction)..
• Class E: Cardiopulmonary failure (historically “high risk” or “massive” PE) with persistent or recurrent hypotension, refractory cardiogenic shock, or arrest.
• Each of these classes can also be tagged with a respiratory modifier: hypoxia or tachypnea with RR >30 for class C, need for >6L NC for D, or respiratory failure requiring NIV or IMV for E.

Initial Management:

• Addressing the Clot:
  • LMWH for everyone Class C and above (though maybe UFH in arrest). Start AC before consulting PERT.
  • Consider systemic thrombolysis, catheter-directed lytics, or mechanical thrombectomy for patients in Class D or E1, and systemic thrombolysis for E2. (UMMC has been involved in trials for catheter directed lytics and mechanical thrombectomy recently, with more results expected soon)
• Hemodynamic Support: 
  • Vasopressor and/or inotropic therapy for Class D2 and above
  • Consider VA-ECMO for Category E2 (note that systemic thrombolysis is not a contraindication to VA-ECMO - some centers are more liberal with VA-ECMO, including select patients with normotensive shock or shock)
• Transfer
  • Hemodynamically stable patients with high risk PE may be considered for transfer to centers that can provide advanced therapies, including thrombectomy or VA-ECMO
  • Unstable patients should be stabilized prior to transfer

This infographic from the new guidelines summarizes treatment recommendations. Note that institution and system-specific guidelines and PERT approaches may not yet have shifted to use these criteria.

References

Creager MA, Barnes GD, Giri J, Mukherjee D, Jones WS, Burnett AE, Carman T, Casanegra AI, Castellucci LA, Clark SM, Cushman M, de Wit K, Eaves JM, Fang MC, Goldberg JB, Henkin S, Johnston-Cox H, Kadavath S, Kadian-Dodov D, Keeling WB, Klein AJP, Li J, McDaniel MC, Moores LK, Piazza G, Prenger KS, Pugliese SC, Ranade M, Rosovsky RP, Russo F, Secemsky EA, Sista AK, Tefera L, Weinberg I, Westafer LM, Young MN. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2026 Feb 19:S0735-1097(25)10161-7. doi: 10.1016/j.jacc.2025.11.005. Epub ahead of print. PMID: 41712898.