New PE Guidelines from the AHA (Part 2)

Written by Samuel Rouleau

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This is the follow-up to Part 1 and touches on anticoagulation, reperfusion therapy, and hemodynamic management.

“This post is too long, I’m developing a DVT!” – Anonymous JF Reader
Buckle up for the remaining content from the new AHA PE guidelines. This post is geared towards emergency medicine clinicians. Italicized text represents Sam’s personal commentary.

You diagnosed your patient with an acute PE! Now what? (Management schema provided below).

1. Anticoagulate the patient, almost always with low-molecular weight heparin (LMWH).
   • Contraindications to LMWH: renal dysfunction with CrCl < 30 (some institutions may use higher CrCl cut-offs), severe shock/vasopressors (unknown subcutaneous absorption), active bleeding that you are concerned you will need to readily reverse as UFH is easier to reverse with protamine than LMWH.
   • Even if the patient is a candidate for reperfusion therapy with systemic thrombolysis (ST) or catheter-directed therapy (CDT), please still anticoagulate the patient. Anticoagulation with LMWH or UFH is NOT a contraindication to ST or CDT.
   • If I plan on immediately administering systemic thrombolysis to a patient in obstructive shock from PE, I will hold on giving LMWH or UFH and start anticoagulation based on aPTT monitoring after systemic thrombolysis has been administered.

2. Determine if the patient meets criteria for reperfusion therapy.
   • Activate PERT at your institution (if available) for those with RV strain or sicker. The guidelines give a strong recommendation for this, as a meta-analysis suggests a possible mortality benefit. 
   • If there is shock (category E1), then proceed with ST if bleeding risk is acceptable. If contraindications to ST, consider alternatives, such as catheter-directed thrombectomy, surgical embolectomy, or VA-ECMO.
   • I am glad to see VA-ECMO included in these guidelines for patients in extremis. VA-ECMO will have a growing role in management of obstructive shock from PE in those unable to receive or non-responders to reperfusion therapy.
3. If the patient is not in shock, assess them for normotensive shock or severe RV dysfunction.
   • A subset of patients in category C2-C3 will deteriorate. This is where you should rely on specialty consultation/PERT to decide on either reduced-dose ST or CDT. The guidelines give a weak recommendation for proceeding with CDT or ST in C3 as evidence is lacking around patient centered outcomes.
   • Weirdly, these guidelines say considering CDT in category C2 is acceptable, but ST should only be considered for C3.
4. Manage Hemodynamics and Oxygenation
   • If your patient needs vasoactive infusions, these are all temporizing measures while you figure out how to get them reperfusion therapy or VA-ECMO.
   • Use norepinephrine as your first-line vasopressor. At doses less than 15 ug/min, it is probably neutral on PVR. 
   • Consider an inotrope to support the RV. Dobutamine is reasonable, though be prepared for worsening hypotension by dropping SVR.
     • If I am starting dobutamine or milrinone in RV failure, I always have norepi or vasopressin inline to support systemic blood pressure. Remember both the MAP and the diastolic blood pressure matter here, as in RV failure; the RV only perfuses during diastole (under normal parameters the RV perfuses during systole and diastole).
   • Intubation, induction, and sedation are all dangerous and have harms associated with them. (Again, why haven’t you fixed their PE if they are this sick!? Have VA-ECMO on standby if available).
     • There is a lack of evidence on safe practices to intubate these patients. Instead of typing another several hundred words, you should check out this intubation protocol from this abstract.

If you want to read my overall gestalt of the guidelines, see below the figure.

Conceptualizing the Role of Catheters for PE (If you only came for the guidelines, stop here)

13 of the authors on these guidelines have financial disclosures with companies that make endovascular devices to treat PE. In my opinion, the number of catheter studies for PE and these guidelines are setting up a category of patients (i.e. category C2) where future guidelines may start recommending catheter therapy after a systematic review puts together all of these sub-optimal catheter trials and finds a “benefit.” We need to be aware of this as emergency clinicians, because we should only be recommending therapies with patient-centered benefits.

• No catheter study for acute PE has demonstrated a patient-centered benefit. These studies have been designed with primary composite outcomes that include faster improvement in vital signs or imaging parameters. By virtue of any reperfusion therapy, these outcomes are true, so the catheter studies are literally designed to be a positive study. Never once has there been a benefit in patient mortality.
  • HI-PEITHO—only positive for catheters because improvement in NEWS score.
  • STORM-PE—only positive because of improvement in RV/LV ratio at 48 hours. 2 patients died in the catheter group, none died in the anticoagulation group.
  • Everyone loves talking about FLAME, but this wasn’t even an RCT. The amount of potential bias is literally astounding.
  • I could keep going, but I’ll spare you.
• I have responded to PERT pages/consults over the last 2 years, and I have never recommended catheter-directed lysis. I am unsure if this therapy has a role in the management of acute PE (Dr. Farkas lays out historical context here).
• Catheter-directed mechanical thrombectomy is reasonable and a great option for patients with acute PE and in shock or normotensive shock who are not candidates for ST. 
• We need creative trials looking at dosing for ST. Growing evidence suggests we can get away with using a much lower dose of ST for PE (i.e. 25 mg over 6 hours instead of the typical 100 mg over 2 hours for alteplase). This approach is safer, faster, and more applicable outside of tertiary care centers for the treatment of PE. It is our obligation to explore this avenue (even if the money doesn’t exist because, well, catheter companies obviously won’t fund this trial).
  • I am tired of the PEITHO trial being maligned for high rates of ICH in those who received tenecteplase. Read the supplemental tables, people! Out of the 12 patients who suffered a stroke after TNK, only 1 was under the age of 65. PEITHO confirms that ST for elderly individuals is associated with higher risk of bleeding, but the results are often taken out of context.

Source
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. 2026 Mar 24;153(12):e977-e1051. doi: 10.1161/CIR.0000000000001415. Epub 2026 Feb 19. PMID: 41712677.