2026 ACC/AHA Acute Pulmonary Embolism Guideline
2026 ACC/AHA Acute Pulmonary Embolism Guideline
Risk Stratification by Clinical Categories (A–E)
Published Feb 19, 2026, JACC & Circulation
ACC / AHA
Acute PE Clinical Categories — Key Clinical Signs at Each Stage (Including Oxygen)
A-Category A — Asymptomatic / Subclinical PE
Clinical Signs:
• Incidentally detected PE (often on CT)
• No dyspnea
• No chest pain
• Normal blood pressure
• Normal heart rate
• No RV dysfunction
• Normal cardiac biomarkers
• Oxygenation: SpO₂ ≥ 95% on room air (no oxygen requirement)
Management Signal:
No hospitalization required
Outpatient management appropriate
B-Category B — Symptomatic / Low Clinical Severity
Clinical Signs:
• Dyspnea or pleuritic chest pain
• Stable hemodynamics
• Normal blood pressure
• No signs of RV dysfunction
• Normal or minimally elevated biomarkers
• Oxygenation: SpO₂ ≥ 94% on room air (typically no oxygen; may need brief low-flow if borderline)
Management Signal:
-Early discharge possible
-Anticoagulation main therapy
C-Category C — Elevated Clinical Severity
Clinical Signs:
• Symptomatic PE
• Evidence of RV dysfunction on echo or CT
• Elevated troponin and/or BNP
• Stable blood pressure
• No overt shock
• Oxygenation: SpO₂ 90–94% on room air (mild–moderate hypoxemia; may require low-flow oxygen)
Management Signal:
Hospital admission required
Close monitoring
Consider escalation if deterioration
D-Category D — Early Cardiopulmonary Failure
Clinical Signs:
• Transient hypotension
• Borderline systolic BP
• Tachycardia
• Worsening hypoxia
• Signs of RV strain
• Rising lactate possible
• Oxygenation: SpO₂ < 90% on room air (usually requires supplemental oxygen; rising requirement is a red flag)
Management Signal:
Hospitalization mandatory
Consider advanced therapies
Multidisciplinary evaluation
E-Category E — Severe Cardiopulmonary Failure
Clinical Signs:
• Persistent hypotension
• Cardiogenic shock
• Cardiac arrest
• Severe hypoxia
• Marked RV failure
• Multiorgan hypoperfusion
• Oxygenation: SpO₂ < 85% or refractory hypoxemia despite oxygen (may require high-flow/NIV/intubation)
Management Signal:
ICU care
Immediate advanced intervention:
• Systemic thrombolysis
• Catheter-directed therapy
• Mechanical thrombectomy
• Surgical embolectomy
Clinical Insight
The A–E framework builds an escalation ladder using:
Objective clinical severity
Hemodynamic status
RV involvement
Biomarker elevation
Oxygenation trend and oxygen requirement (especially for D–E)
D-dimer:
• Diagnostic screening tool (not severity marker)
• High sensitivity
• Used to rule out PE in low-risk patients
• Not useful for risk stratification once PE is confirmed
Key reminder: SpO₂ alone does not define risk—some high-risk patients can initially have near-normal oxygenation if RV strain/hemodynamics are deteriorating.