HMN 2026: How Prompt diagnosis and treatment are key

Early detection and prompt treatment of acute pulmonary embolism (PE), a sudden and potentially life?threatening blood clot that blocks arteries in the lungs, is critical. Comprehensive recommendations for the evaluation, management and follow?up care for adults with acute PE are detailed in a new clinical practice guideline, published in the Circulation and in JACC.

A PE is a blood clot that typically originates in a deep vein in the leg or pelvis, travels through the heart and becomes lodged in an artery in the lungs. It is part of a condition known as venous thromboembolism (VTE). Acute PE can lower oxygen levels in the blood, damage lung tissue and put serious strain on the heart, making it a potentially fatal medical emergency.

According to the American Heart Association’s 2026 Heart Disease and Stroke Statistics, approximately 470,000 people are hospitalized with PE in the U.S. annually, and approximately one in five high?risk patients die.

“There have been significant advances in the understanding of pulmonary embolism and treatments to effectively manage this condition,” said Chair of the guideline writing committee Mark A. Creager, M.D, FAHA, FACC, a professor of medicine at the Geisel School of Medicine at Dartmouth College in Hanover, New Hampshire, and director emeritus of the Heart and Vascular Center at Dartmouth Health in Lebanon, New Hampshire.

“This guideline is a road map to help clinicians navigate these advances for the safest and most effective approaches to care for people with this condition,” he said.

The new guideline includes patient treatment recommendations by care setting, including which patients can be discharged from the emergency department and managed as outpatients; which patients require hospitalization; and which patients need critical care. It also acknowledges that implementation of the recommendations depends on the availability of local resources, such as specialists for consultations, imaging tests and advanced interventions.

New clinical classification system

New Acute PE Clinical Categories are introduced to classify patients with acute PE into five categories (A–E), based on their severity of symptoms and risk for adverse outcomes.

Patients in Categories A and B have no or mild symptoms and low risk of experiencing severe complications; they can often be safely discharged from the emergency department. Categories C–E include people with symptoms of acute PE who are at higher risk of adverse outcomes and require hospitalization.

Risk factors associated with acute PE

Prompt diagnosis of acute PE is essential for timely treatment, which can prevent severe complications such as cardiac arrest and death. However, timely diagnosis of acute PE is often challenging because many symptoms, such as shortness of breath, chest pain, rapid heartbeat, fainting and/or dizziness, are similar to symptoms of other conditions.

Factors that damage the veins or reduce blood flow, or conditions that promote the likelihood of clot formation, can increase the risk of VTE. When considering the probability of acute PE, clinicians should assess patients for factors that increase the risk for clotting, including:

• Major surgery or trauma
• Hospitalization
• Prolonged immobility (such as bed rest or long travel)
• Pregnancy and postpartum (within six weeks after delivery)
• Use of oral contraceptives or estrogen treatment
• Obesity (defined by BMI ? 30)
• Smoking
• Atherosclerotic cardiovascular disease (heart disease caused by plaque buildup in the arteries)
• Cancer
• Thrombophilias (blood clotting disorders)
• Age (risk increases after age 40)

Laboratory and diagnostic testing

In patients who have a low or intermediate probability (

Patients with normal levels of D?dimer are unlikely to have a pulmonary embolism. If the D?dimer level is elevated, or if the clinical probability of acute PE is deemed high (>50%), imaging to look for a PE is recommended.

Computed tomography pulmonary angiography (CTPA) is the standard imaging test to diagnose or rule out acute PE. It is highly accurate, stand?alone imaging to find and visualize the location and size of the blood clot, and is widely available in emergency rooms across the country.

People who cannot undergo CTPA (for example, patients with an allergy or reaction to iodine?based contrast dye) should be screened for acute PE with a lung ventilation/perfusion scan (a type of nuclear imaging test).

Treatment strategies

Anticoagulants (medications that prevent blood clots from forming) are the primary treatment recommended for patients with confirmed acute PE. Direct oral anticoagulants (DOACs), such as rivaroxaban, apixaban, edoxaban or dabigatran, are recommended over vitamin K antagonists, such as warfarin, to prevent recurrent blood clots, due to their safety, ease of use and reduced risk of major bleeding.

DOACs are not recommended during pregnancy due to potential risks to the fetus. Low?molecular?weight heparin or unfractionated heparin can be safely used for acute PE during pregnancy.

Patients with acute PE in Categories D–E may need advanced treatments and procedures, including intravenous or catheter?based administration of a clot-dissolving drug, catheter?based mechanical removal of the blood clot(s) or surgical removal of the blood clot(s). The guideline also details appropriate sedation, ventilation and mechanical circulatory support to maintain heart and lung function for critically ill patients with acute PE.

Considerations for follow?up management

Follow?up communication and clinic visits are recommended:

• Early follow?up: All patients should have a follow?up communication or clinic visit within one week of hospital discharge. This visit should review the treatment plan, confirm patients are taking medications as prescribed, and check for bleeding complications.
• Additional follow?up: A clinic visit should also occur by three months after diagnosis to determine how long anticoagulant therapy will continue, assess the need for further testing and evaluate ongoing symptoms.
• Long?term monitoring: At every visit for at least one year, patients should be screened for symptoms or functional limitations suggestive of chronic thromboembolic pulmonary disease (CTEPD), a condition in which persistent blood clots cause long?term blockage of arteries in the lungs. CTEPD can lead to shortness of breath, fatigue, pulmonary hypertension and right?sided heart failure.
• Ongoing anticoagulation review: For patients remaining on anticoagulants beyond three to six months, clinicians should periodically reassess the risks and benefits of continued therapy.

Additional considerations for follow?up care include:

• Psychological health: Depression, anxiety and post?traumatic stress disorder are common in patients who have had acute PE. Screening for these mental health conditions and evaluation of quality of life are suggested for appropriate management and referral.
• Physical activity: Once treatment with an anticoagulant for acute PE has begun, walking early in recovery is encouraged to help keep blood flow moving and prevent the body from deconditioning.
• Precautions for travel: Long?haul (?5 hours) travel, whether by car, train or plane, often involves limited mobility, which can increase the risk of another clot. People who have had or are at risk for acute PE should frequently move around, limit long?distance travel and use compression socks or stockings, to reduce the risk of blood clots.
• Birth control/Pregnancy: Women of childbearing age with acute PE should be counseled about contraception and also about anticoagulation options in the event that they become pregnant. In women with a previous acute PE who become pregnant, their multidisciplinary care team should include obstetricians, and also hematologists, cardiologists or other specialists of PE to help minimize pregnancy?related complications.

“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, for people with acute pulmonary embolism,” Creager said.

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