The American Heart Association (AHA) and American College of Cardiology (ACC), with 8 partner societies, released their first joint guideline on acute pulmonary embolism (PE) on February 19, 2026, in Circulation, spanning diagnosis through follow-up care.¹ The document replaces the low-, intermediate-, and high-risk framework with the AHA/ACC Acute PE Clinical Categories, ranging from category A (subclinical) to category E (cardiopulmonary failure).¹ Patients may shift between categories as they are reassessed, and the guideline gives a multidisciplinary pulmonary embolism response team (PERT) assessment a class 1 recommendation for categories C through E.¹

The guideline also provides direction on applying 7 validated PE-specific risk scores and names validation of the new clinical categories as a research priority.¹,² For clinicians accustomed to the European Society of Cardiology (ESC) framework, practical questions center on where the 2 systems diverge at the bedside, when to activate a PERT, and how to recognize normotensive shock before decompensation. Hospitals without an established PERT must also determine how to meet the new class 1 standard with the pulmonary, cardiology, radiology, and pharmacy specialists already on staff.

Parth Rali, MD, associate professor of thoracic medicine and surgery at the Lewis Katz School of Medicine at Temple University, directs the Temple University Health System PERT Program. Rali discussed the guideline’s changes, takeaways, and growing trial landscape as a panelist at the CHEST 2026 Annual Meeting in Phoenix, Arizona. In the following Q&A, Rali explains how the categories compare with ESC risk tiers, how to recognize normotensive shock, and how hospitals can build a PERT.

Q&A: Inside the New AHA/ACC Acute PE Categories

HCPLive: The guideline replaces low, intermediate, and high risk with categories A through E. What problem does this solve, and what is the biggest practice change?

Parth Rali, MD: The goal of the new guideline was to mimic the SCAI Shock Stage Classification that goes from A to E. By doing that, we are able to study several subphenotypes of intermediate-risk PE, which were classified as intermediate-high risk and then low risk [in the original classification].

With the new classification schema, we were able to subclassify that into several categories into C&D. We were also able to add the respiratory modifier, which is the biggest change, in my opinion, to the new guidelines given that it addresses respiratory decompensation into PE classification.

HCPLive: How does this classification compare with the ESC framework, and where might clinicians see real differences at the bedside?

Parth Rali, MD: I would like to clarify that the ESC framework used by many clinicians is still very much validated. This new AHA classification adds an extra layer of filter in further subclassifying intermediate- and high-risk PE.

If physicians are more comfortable with the ESC classification, I think it is completely reasonable. As the PE response team gets involved, and once the PE response team is activated for the patient, it may be beneficial for expert PE members at local institutions to use the AHA classification to further stratify the patient. I do agree that the ESC classification is much easier to follow, particularly when it comes to PERT activation.

HCPLive: Category C seems to hold much of the uncertainty, including normotensive shock. How should clinicians recognize these patients before decompensation, and what should prompt escalation?

Parth Rali, MD: I’d like to clarify that category C and category D truly represent the intermediate-risk PE from the previous classification. In the new AHA classification, subclinical shock, or normotensive shock, is labeled under category D, not category C.

The new classification gives several options to classify patients with normotensive shock. Some of them include shock index, rising lactic acid level, altered mental status, AKI, and the CPES score. This further classification will continue to evolve as we have more data coming in over the next few years.

For now, clinicians can use any of these parameters, which are easily available at the bedside, to identify the patient who may be at risk of normotensive shock. Identifying the patient in an emergency may help the team provide timely, effective, and expedited care for patients with pulmonary embolism.

HCPLive: The guideline gives PERT assessment a class 1 recommendation in categories C through E. How can hospitals without a formal PERT meet that standard?

Parth Rali, MD: I completely agree that the guidelines give a class 1 recommendation for PERT for category C and above. The concept of the PERT is universally accepted. Who should form the PERT depends on local expertise and availability.

Each hospital has the capacity to form a PERT, and as I said, you need dedicated members who are involved in pulmonary embolism care. [That] can span from pulmonary critical care physicians to interventional cardiology, interventional radiology, hematology, vascular surgery, pharmacy, and other allied services.

Most of these subspecialties exist in some form at every single hospital. All we need is to bring this team together and form a multidisciplinary team. I think forming the multidisciplinary PE response team is the responsibility of not only physicians but also hospital administration, given that this is a class 1 recommendation.

References

1. 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. 2026;153(12):e977-e1051. doi:10.1161/CIR.0000000000001415

2. New pulmonary embolism guidelines highlight progress, encourage research, with Mark Creager, MD. HCPLive. Published February 25, 2026. Accessed October 27, 2026. https://www.hcplive.com/view/new-pulmonary-embolism-guidelines-highlight-progress-encourage-research-with-mark-creager-md