AHA/ACC Guidelines Introduce New Risk Stratification System for Acute Pulmonary Embolism

The American Heart Association (AHA) and American College of Cardiology (ACC) published their inaugural clinical practice guideline for the evaluation and management of acute pulmonary embolism (PE) in adults in Circulation and the Journal of the American College of Cardiology. The guideline introduces the AHA/ACC Acute Pulmonary Embolism Clinical Categories—a 5-category system designed to enhance severity classification, improve prognostic accuracy, and guide therapeutic decision-making.¹

Novel 5-Category Risk Stratification

The new classification system stratifies patients into 5 categories, A through E, to more accurately describe the severity and prognosis of PE. Category A encompasses subclinical PE, whereas category B includes symptomatic patients with low clinical severity. Categories C through E represent progressively higher risk, with Category C including patients with elevated clinical severity scores and right ventricular dysfunction, Category D encompassing incipient cardiopulmonary failure, and Category E representing cardiopulmonary failure with persistent hypotension.¹

According to the guideline, patients in Category A can be safely discharged home from the emergency department without hospitalization. Those in Category B can generally be discharged early. Symptomatic patients in Categories C through E should be hospitalized to optimize treatment strategies, which may include anticoagulation therapy or advanced interventions such as systemic thrombolysis, catheter-based therapies, or surgical embolectomy.¹

Craig Beavers, PharmD, FACC, FAHA, FCCP, BCCP, BCPS-AQ Cardiology, CACP, an adjunct assistant professor at the University of Kentucky College of Pharmacy and chair of the ACC Cardiovascular Team, emphasized the practical impact for pharmacists in an interview with Pharmacy Times.

"This [guidance] will provide a clearer framework for implementation and be able to more clearly identify patients for appropriate interventions," Beavers said. "For example, you could feel more confident in patients [who] could be sent home and not admitted. This would be a great role for pharmacists for identification and transitions of care.”

Anticoagulation Recommendations

The authors note in the guidelines that anticoagulation is the mainstay of therapy for patients with confirmed acute PE. The guideline gives a Class 1 recommendation for direct oral anticoagulants (DOACs) over vitamin K antagonists in patients with acute PE who are eligible for oral anticoagulation, unless contraindicated. This recommendation aims to prevent recurrent venous thromboembolism (VTE) and reduce major bleeding risk. For patients requiring initial parenteral anticoagulation, low-molecular-weight heparin is recommended over unfractionated heparin.¹

Beavers acknowledged persistent barriers to optimal DOAC utilization. "There are still some concerns about cost, which is getting somewhat better," he noted. "There are [also] still concerns about appropriate dosing based on indications and those with comorbidities, like renal dysfunction.

“Pharmacists can be key players in dosing, agent selection, education, transitions, monitoring, and bleeding avoidance," Beavers continued.

Multidisciplinary PE Response Teams

The guideline recommends implementation of pulmonary embolism response teams (PERTs) when resources permit. PERTs are institutionally based multidisciplinary teams designed to rapidly assess and provide treatment for patients with acute PE. These teams can make major impacts on care delivery by helping clinicians with dose and intervention selections and ultimately decreasing hospital length of stay. Overall, PERTs can improve patient outcomes through early management of signs and symptoms of PE.¹

A 2022 study published in the Journal of the American College of Clinical Pharmacy demonstrated that pharmacist involvement in PERTs was associated with shorter time to anticoagulation initiation, increased low-molecular-weight heparin use over unfractionated heparin, and fewer major bleeding events.²

Efforts have already been undertaken to improve diagnosis and treatment of patients with PE through using PERTs. The PERT Consortium, established in 2015, has grown to include over 100 medical centers. Research from the consortium indicates PERTs improve standardization of care, particularly for intermediate- and high-risk patients with PE, although more robust randomized trial data are needed. These multidisciplinary teams provide unique value to pharmacists, as they can allow for more tailored interventions to the patient and health system.^1,3

Follow-Up Care

The guideline recommends clinical follow-up within the first week of discharge to provide patient education, address barriers to anticoagulation therapy, ensure medication adherence, and detect bleeding complications. Data show that follow-up shortly after discharge can reduce rates of adverse events or repeat hospitalization. Additionally, patients with acute PE should have a clinical visit after diagnosis during their initial treatment phase—lasting 3 to 6 months—to discuss the duration of anticoagulation treatment, explain the risk of VTE recurrence, and assess for persistent symptoms.^1,4

Aside from physical health considerations, a patient’s mental health is paramount to assess throughout the follow-up process. According to the guidelines, anxiety, posttraumatic stress disorder, and depression are common in patients who have experienced PE, and these conditions can persist over the course of treatment and recovery. Patients have reported delays in accessing crucial information or a lack of support systems throughout treatment. Pharmacists are pivotal to properly educating patients, providing mental health counseling, and referring to a specialty clinic when clinically necessary.^1,5

"I think the staging and updated recommendations are key for pharmacists,” Beavers asserted. “We are still also working on the best strategies for those at high risk. It is critical for all pharmacists, no matter the setting, to be aware of the guidelines. Furthermore, PE is a team-based sport, and [pharmacists can] find ways they can be engaged in implementation."

REFERENCES

1. Writing Committee Members; 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. Circulation. Published online February 19, 2026. doi:10.1161/CIR.0000000000001415

2. Groth CM, Acquisto NM, Wright C, et al. Pharmacists as members of an interdisciplinary pulmonary embolism response team. J Am Coll Clin Pharm. 2022;5(4):390-397. doi:10.1002/jac5.1569

3. Rosovsky R, Zhao K, Sista A, Rivera-Lebron B, Kabrhel C. Pulmonary embolism response teams: purpose, evidence for efficacy, and future research directions. Res Pract Thromb Haemost. 2019;3(3):315-330. doi:10.1002/rth2.12216

4. Erkens PMG, Gandara E, Wells P, et al. Safety of outpatient treatment in acute pulmonary embolism. J Thromb Haemost. 2010;8(11):2412-2417. doi:10.1111/j.1538-7836.2010.04041.x

5. Tran A, Redley M, de Wit K. The psychological impact of pulmonary embolism: a mixed-methods study. Res Pract Thromb Haemost. 2021;5(2):301-307. doi:10.1002/rth2.12484