The American Heart Association and American College of Cardiology have released the first comprehensive clinical practice guideline for acute pulmonary embolism, introducing a new classification system to standardize care for this potentially fatal condition. Published in Circulation and JACC, the guideline provides evidence-based recommendations for diagnosis, treatment, and follow-up care across various healthcare settings.
Acute pulmonary embolism, a sudden blood clot blocking arteries in the lungs, represents a critical medical emergency that can damage lung tissue, strain the heart, and reduce blood oxygen levels. As part of venous thromboembolism, PE causes approximately 470,000 hospitalizations annually in the United States, with about 20% of high-risk patients dying from the condition. The new guideline addresses significant advances in understanding and managing PE, offering what committee chair Mark A. Creager, M.D., describes as "a road map to help clinicians navigate these advances for the safest and most effective approaches to care."
A central innovation is the new Acute Pulmonary Embolism Clinical Category system, which classifies patients into five categories (A-E) based on symptom severity and risk for adverse outcomes. This classification directly informs treatment decisions, determining whether patients can be safely discharged from emergency departments or require hospitalization and advanced interventions. The system acknowledges that implementation depends on local resource availability, including specialist consultations and imaging capabilities.
Prompt diagnosis remains challenging because PE symptoms—shortness of breath, chest pain, rapid heartbeat, fainting, and dizziness—often mimic other conditions. The guideline details risk factors clinicians should assess, including recent surgery or hospitalization, trauma, prolonged immobility, pregnancy, obesity, cancer, blood clotting disorders, and age over 40. For patients with low or intermediate probability of PE, the guideline recommends D-dimer blood testing, with normal levels indicating unlikely PE. Elevated D-dimer or high clinical probability warrants imaging, primarily computed tomography pulmonary angiography, which is widely available in emergency rooms and highly accurate for visualizing clot location and size.
Treatment recommendations prioritize direct oral anticoagulants over vitamin K antagonists for most patients due to better safety profiles, ease of use, and reduced bleeding risk. However, these medications are not recommended during pregnancy, where low-molecular-weight or unfractionated heparin are preferred. Patients in higher-risk categories may require advanced interventions like catheter-based clot removal or surgical procedures. The guideline also details supportive care for critically ill patients, including appropriate sedation, ventilation, and mechanical circulatory support.
Follow-up care receives substantial attention, with recommendations for communication within one week of discharge and clinic visits by three months after diagnosis. Long-term monitoring includes screening for chronic thromboembolic pulmonary disease, which can develop from persistent clots and lead to pulmonary hypertension and heart failure. Additional considerations address psychological health, as depression, anxiety, and post-traumatic stress disorder are common after PE, and practical guidance on physical activity, travel precautions, and contraception counseling for women of childbearing age.
The guideline represents a collaborative effort endorsed by eight additional healthcare organizations, including the American College of Emergency Physicians and Society for Cardiovascular Angiography & Interventions. By standardizing approaches across care settings, the recommendations aim to improve outcomes through more rapid diagnosis and evidence-based treatment. As Creager notes, "We anticipate that decisions guided by these recommendations will result in more rapid diagnosis and application of effective, evidence-based treatments, leading to better outcomes, such as decreased risk of death and disability."
Healthcare professionals can access the full guideline through the American Heart Association Guideline Hub for Professionals at https://professional.heart.org and the ACC Guideline Clinical App, with additional resources including the Acute PE Guideline-at-a-Glance available through JACC.org at https://www.jacc.org. These standardized approaches may significantly impact clinical practice, potentially reducing the substantial mortality and disability associated with this common cardiovascular emergency.
