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 and detailed recommendations aimed at improving diagnosis, treatment, and long-term management of this potentially fatal condition. The guideline, published in Circulation and JACC, addresses approximately 470,000 annual U.S. hospitalizations for pulmonary embolism, where timely intervention is critical as approximately 1 in 5 high-risk patients die.
The new Acute Pulmonary Embolism Clinical Category system classifies patients into five categories (A-E) based on symptom severity and risk for adverse outcomes. This classification helps determine appropriate care settings, with Categories A and B patients often able to be safely discharged from emergency departments, while Categories C-E require hospitalization. The guideline emphasizes that implementation depends on local resource availability, including specialist consultations, imaging tests, and advanced interventions.
Prompt diagnosis remains challenging as symptoms like shortness of breath, chest pain, rapid heartbeat, fainting, and dizziness 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 diagnostic testing, the guideline recommends D-dimer blood tests for patients with low or intermediate probability of acute PE, with computed tomography pulmonary angiography (CTPA) as the standard imaging test when indicated.
Treatment recommendations prioritize direct oral anticoagulants (DOACs) over vitamin K antagonists like warfarin for most patients, citing better safety, ease of use, and reduced bleeding risk. The guideline notes exceptions for pregnancy, where low-molecular-weight heparin or unfractionated heparin are recommended. For higher-risk patients in Categories D-E, advanced treatments including clot-dissolving drugs, catheter-based mechanical removal, or surgical removal may be necessary.
Follow-up care represents a significant advancement, 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 (CTEPD), which can develop from persistent clots. Additional considerations address psychological health, with screening suggested for depression, anxiety, and post-traumatic stress disorder common after acute PE. Physical activity recommendations encourage early walking once anticoagulant treatment begins, while travel precautions advise frequent movement and compression socks for long-haul travel.
The guideline, developed in collaboration with eight other healthcare organizations including the American College of Emergency Physicians and Society for Cardiovascular Angiography & Interventions, provides what committee chair Mark A. Creager, M.D., calls "a road map to help clinicians navigate these advances for the safest and most effective approaches to care." The complete guideline is available through the American Heart Association Guideline Hub for Professionals and JACC.org Guideline Hub.
