UMEM Educational Pearls

Title: The 2026 Acute PE Guidelines

Keywords: Pulmonary embolism, massive PE, submassive PE, RV failure, cardiogenic shock, guidelines (PubMed Search)

Posted: 5/19/2026 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

Not all patients with an acute PE will be crashing and critically ill, but it seemed worthwhile to remind everyone that there are new guidelines and recommendations from AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN/XYZLMNOP about the management of patients with acute pulmonary embolism in the 2026 AHA/ACC Joint Committee statement. A few key takeaways, with highlights for the sicker PE patients:

New Classifications A through E for acute PE (see images below)
- Get familiar with the clinical scores! Hestia, PE Severity Index (PESI), simplified PESI (sPESI)
- ED discharge recommended for Category A and supported for Category B
LMWH recommended over unfractionated heparin when parenteral AC is needed, unless contraindicated
DOACs recommended over warfarin unless contraindicated

Highlights for the sicker PE patients, i.e. Categories C+:

Get a look at the RV! (POCUS, CT, formal echo)
- Further stratify Category C patients/identify Category D earlier
- Find out how close to decompensation the patient might be
- Inform your management if the patient decompensates
  - For PE patients with e/o RV strain (C2+ per this document; for me, particularly those C3+ with respiratory complaints as a marker of poor pulmonary perfusion, or Category D+), consider use of inhaled vasodilators
Be careful with any sedation even if normotensive – decreasing preload / blunting the body's compensatory adrenergic response can be disastrous, have hemodynamic support available
If you have to intubate, choose induction meds wisely and have hemodynamic support ready
For patients with Category D-E acute PE:
1. Norepinephrine = initial vasopressor of choice for hypotension due to modest inotropic effects; max at 15mcg/min due to effects on pulmonary vascular resistance at higher doses, if second vasopressor needed, reach for vasopressin
2. Dobutamine as additional inotropic support OR for normotensive shock
3. Avoid fluid boluses unless patient is also hypovolemic, and then give small boluses (250mL) only
Consider advanced therapies for Category D and particularly E
PE Response Team (PERT) Consultation recommended – and depending on where you practice, can help get the patient transferred if advanced therapies are an option

For a great breakdown and further discussion of the new guidelines, I recommend checking out the Life in the Fast Lane blogpost here.

References

Creager MA 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: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2026 Mar 24;153(12):e977-e1051.