What do the new categories help us decide?
The 2026 American Heart Association/American College of Cardiology multisociety guideline introduces five acute pulmonary embolism (PE) clinical categories, A–E. The framework brings together symptoms, clinical severity, right ventricular (RV) findings, cardiac biomarkers, haemodynamics and respiratory compromise. Its purpose is to make the connection between a patient's clinical state and the next level of care clearer.
The useful bedside questions are straightforward: could this patient be treated safely outside hospital, who needs admission and closer risk assessment, and who is already deteriorating? A preserved blood pressure does not answer all three questions. Equally, an abnormal RV study does not by itself prescribe a reperfusion treatment.
This is a focused practical summary for adults with acute PE. It explains the classification and its implications for care setting and escalation; it is not a complete diagnostic, anticoagulation or resuscitation protocol. Source: original multisociety guideline, Figure 2 and management recommendations .
How do A–E map to the care setting?
| Category | Clinical picture | Practical care decision |
|---|---|---|
| A | Incidental, asymptomatic PE | Assess outpatient suitability; the diagnosis does not automatically require admission. |
| B | Symptomatic PE with a low clinical severity score | Consider early discharge after confirming treatment and discharge safety. |
| C | Symptomatic PE with an elevated clinical severity score | Admit and refine risk using RV assessment and cardiac biomarkers. |
| D | Incipient cardiopulmonary failure | Arrange urgent escalation assessment, monitoring and specialist input. |
| E | Cardiopulmonary failure | Activate emergency resuscitation and evaluate reperfusion options. |
The first two categories are not an instruction to discharge every patient. The remaining categories are not interchangeable levels of “inpatient PE”: evolving hypoperfusion in D requires a different response from an otherwise stable patient in C. Reassess the category when the clinical state changes. Source: guideline clinical categories and AHA care-setting summary .
When is outpatient care appropriate?
Category A describes incidental, asymptomatic PE. Category B describes symptomatic PE with a low clinical severity assessment. Validated tools such as the Pulmonary Embolism Severity Index (PESI), simplified PESI and Hestia criteria help identify patients suitable for an outpatient pathway. PESI class I–II, sPESI 0 or absence of Hestia exclusion criteria should prompt a discharge assessment, rather than end it. Use a tool correctly and consider any overriding clinical concern.
Before discharge, establish that there is no separate medical reason for admission, assess bleeding risk and suitability for the intended anticoagulant, confirm access to treatment and understanding of the regimen, and arrange reliable support and follow-up. Explain which symptoms require urgent reassessment and how the patient can obtain it. These practical arrangements are part of making outpatient treatment safe.
The B subcategories distinguish B1, subsegmental PE, from B2, non-subsegmental PE. This anatomical distinction does not replace clinical severity or a treatment decision. In particular, B1 should not be read as an automatic instruction either to withhold anticoagulation or to discharge the patient. Source: guideline Figure 2, risk assessment and outpatient management sections .
What needs refining in Category C?
Category C starts with symptomatic PE and an elevated clinical severity score. RV assessment and cardiac biomarkers then distinguish three patterns. The conjunctions matter: one abnormal domain is different from both domains being abnormal.
| Subcategory | RV and biomarker pattern |
|---|---|
| C1 | Normal RV assessment and normal cardiac biomarkers. |
| C2 | Abnormal RV with normal biomarkers, or normal RV with at least one abnormal cardiac biomarker. |
| C3 | Abnormal RV and at least one abnormal cardiac biomarker. |
Assess RV size and function with appropriate imaging. Echocardiography and chest CT provide clinically useful RV information; the guideline prefers echocardiography over CT for short-term risk stratification in the relevant patients without persistent hypotension or shock. Troponin and natriuretic peptides contribute myocardial injury or strain information. Interpret the findings alongside the clinical examination and trajectory.
C3 does not automatically mandate thrombolysis. It identifies a risk pattern that requires appropriate inpatient care and reassessment. The presence of an elevated biomarker is not, on its own, a reperfusion indication. Source: guideline Sections 3.2.3–3.2.4 and systemic thrombolysis recommendations .
How can deterioration occur without persistent hypotension?
Category D is the important transition to incipient cardiopulmonary failure. D1 describes transient hypotension; D2 describes normotensive shock. The latter makes explicit that hypoperfusion may be present before blood pressure becomes persistently low.
Look for elevated lactate, reduced urine output, worsening renal function, altered mental status and other evidence that tissue perfusion is deteriorating. Do not interpret these findings in isolation or assume that every abnormality is caused by PE: assess competing causes and the whole clinical picture. The practical implication is to recognise a concerning trajectory early and escalate the level of assessment and monitoring, rather than wait for a sustained hypotensive reading. Source: guideline Section 3.2.2, haemodynamic assessment .
Category E describes established cardiopulmonary failure. E1 comprises recurrent or persistent hypotension with cardiogenic shock. E2 comprises refractory cardiogenic shock or cardiac arrest. These are emergency pathways: mobilise resuscitation, critical care and PE expertise, while evaluating reperfusion in the context of bleeding risk, contraindications and available resources.
Where does the respiratory modifier fit?
The R modifier supplements the category when the relevant respiratory criteria are present; the guideline gives examples such as C3R and D2R. It prevents a purely blood-pressure-based description from obscuring important respiratory compromise.
For Category C, the figure includes oxygen saturation below 90%, respiratory rate at least 30/min or a supplemental oxygen requirement. For D, the modifier captures a higher oxygen-support requirement, including non-rebreather-mask support. For E, it identifies hypoxaemic respiratory failure or ventilatory failure. Consult the original classification figure for the complete operational criteria; use the oxygen device, oxygen requirement and clinical assessment together.
The bedside lesson is to document breathing and circulation together. A patient whose oxygen requirement and work of breathing are worsening needs reassessment even when the most recent blood pressure seems reassuring. Source: guideline Figure 2 and the official category infographic .
Does escalation mean systemic thrombolysis?
No. The category informs the decision, but the treatment still requires a benefit–harm assessment. For the comparison of systemic thrombolysis plus anticoagulation versus anticoagulation alone, the guideline distinguishes the following positions:
| Category | Recommendation and necessary context |
|---|---|
| C3 | Benefit for preventing further deterioration remains uncertain, even with acceptable bleeding risk when advanced therapy is being considered (Class 2b). |
| D1–D2 | Systemic thrombolysis may be considered in selected patients with acceptable bleeding risk when advanced therapy is being considered (Class 2b). |
| E1–E2 | Systemic thrombolysis is reasonable in appropriate patients with acceptable bleeding risk when advanced therapy is being considered (Class 2a). |
Catheter-directed thrombolysis, mechanical thrombectomy and surgical embolectomy have their own category-specific recommendations. They are not interchangeable alternatives with identical evidence. The guideline recommends multidisciplinary pulmonary embolism response team (PERT) assessment for Categories C–E to improve care delivery. Local capability, transfer arrangements and expertise therefore belong in the escalation discussion. Source: guideline advanced-therapy recommendations, summarised in the official JACC guideline-at-a-glance .
What should clinicians take into practice?
Use A–E as a common language for the patient's current condition. Pair it with a care-setting decision, the relevant respiratory information and a plan for reassessment. Anticoagulation remains foundational when not absolutely contraindicated; the classification does not replace selecting and monitoring an appropriate regimen.
For clinical handover, a useful editorial approach is to state the category, the findings that support it, the current oxygen and perfusion status, and the change that would trigger escalation. That is a way to apply the framework, not a separately validated prediction rule.
Classify. Choose care. Reassess. Outpatient suitability needs a safe treatment plan; inpatient care needs recognition of evolving RV and perfusion problems; cardiopulmonary failure needs emergency action. The same classification must never become a reason to ignore a changing patient.
Original guideline and supporting resources
Creager MA, Barnes GD, Giri J, 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. Published online 19 February 2026. Circulation. 2026;153:e977–e1051. doi:10.1161/CIR.0000000000001415 . Also published in JACC: doi:10.1016/j.jacc.2025.11.005 .
Official AHA summary · Official guideline-at-a-glance .
Independent educational summary for healthcare professionals. Read the full guideline and relevant local protocols for individual patient care.