The American Heart Association and American College of Cardiology have released the first comprehensive clinical practice guideline for acute pulmonary embolism, establishing a new framework for classifying severity and determining appropriate treatment pathways for this potentially fatal condition. Published in Circulation and JACC, these evidence-based recommendations address the full spectrum of care from emergency diagnosis through long-term management, representing a significant advancement in standardizing approaches to a condition that affects approximately 470,000 people hospitalized annually in the United States.
The guideline introduces a new Acute Pulmonary Embolism Clinical Category system that classifies patients into five categories (A-E) based on symptom severity and risk for adverse outcomes. This classification helps clinicians determine appropriate care settings, with patients in Categories A and B often able to be safely discharged from emergency departments, while those in Categories C-E typically require hospitalization. The system acknowledges that implementation depends on local resource availability, including specialist consultations, imaging tests, and advanced interventions.
Prompt diagnosis remains critical, as acute PE symptoms—including shortness of breath, chest pain, rapid heartbeat, fainting, and dizziness—often mimic other conditions. The guideline emphasizes assessment of risk factors such as recent surgery or hospitalization, trauma, prolonged immobility, pregnancy, obesity, cancer, and blood clotting disorders. For patients with low or intermediate probability of acute PE, D-dimer blood testing is recommended, while those with high probability or elevated D-dimer levels should undergo computed tomography pulmonary angiography (CTPA), the standard imaging test available in most emergency rooms.
Treatment recommendations prioritize direct oral anticoagulants (DOACs) such as rivaroxaban, apixaban, edoxaban, or dabigatran over vitamin K antagonists like warfarin due to their safety profile and reduced bleeding risk. The guideline notes exceptions for pregnant patients, who should receive low-molecular-weight heparin or unfractionated heparin instead. For critically ill patients in Categories D-E, advanced interventions including catheter-based or surgical clot removal may be necessary alongside mechanical circulatory support.
Follow-up care represents a significant component of the new recommendations, with early communication or clinic visits recommended within one week of discharge to review treatment plans and monitor for complications. Additional visits at three months help determine anticoagulation duration and assess ongoing symptoms. Long-term monitoring includes screening for chronic thromboembolic pulmonary disease (CTEPD), a condition where persistent clots cause long-term arterial blockage leading to pulmonary hypertension and right-sided heart failure. The complete guideline is available through the American Heart Association Guideline Hub for Professionals at https://professional.heart.org.
Beyond medical management, the guidelines address psychological health considerations, noting that depression, anxiety, and post-traumatic stress disorder are common among PE patients. Physical activity recommendations encourage early walking during recovery to maintain blood flow, while travel precautions suggest limiting long-haul journeys and using compression garments to reduce clot risk. For women of childbearing age, counseling about contraception and pregnancy anticoagulation options is emphasized to minimize complications.
The collaborative development process involved eight additional healthcare organizations, including the American College of Emergency Physicians and Society for Cardiovascular Angiography & Interventions, ensuring broad clinical applicability. As Chair Mark A. Creager noted, these evidence-based recommendations should lead to more rapid diagnosis and effective treatment, potentially decreasing mortality and disability rates for this serious cardiovascular emergency. Additional resources including clinical apps and guideline summaries are accessible through JACC.org at https://www.jacc.org.
