Mark Creager, MD, is the director emeritus of the Heart and Vascular Center at Dartmouth University.

Mark Creager, MD

New Pulmonary Embolism Guidelines Highlight Progress, Encourage Research, With Mark Creager, MD

On February 19, 2026, the American College of Cardiology (ACC) and American Heart Association (AHA) released a clinical practice guideline for 

 treatment, the first of its kind from these institutions.

Prominent among this guideline is a new clinical classification scheme, dividing patients into 5 main categories A through E, equivalent to low to high risk of adverse outcomes. Category A includes patients exhibiting incidental and asymptomatic embolism, with no subgroups. Category B includes symptomatic patients with a low clinical severity score and is divided into B1, including subsegmental presentation, and B2, which includes non-subsegmental.

Category C includes patients with an elevated clinical severity score and consists of 3 subgroups. C1 includes those with normal RV and normal biomarkers; C2 includes abnormal RV or ≥1 abnormal biomarker; C3 includes patients with both abnormal RV and ≥1 abnormal biomarker. Category D includes patients with incipient cardiopulmonary failure: D1 includes patients with transient hypotension, while D2 includes those with normotensive shock. Finally, Category E is cardiopulmonary failure, with E1 including recurrent or persistent hypotension with cardiogenic shock and E2 including refractory cardiogenic shock or cardiac arrest.

“This is a new clinical categorization of acute pulmonary embolism, and we’re using this to help guide clinicians who are managing patients with acute pulmonary embolism in how they can manage these patients most effectively and most safely,” Mark Creager, MD, director emeritus of the Heart and Vascular Center at Dartmouth University and chair of the guideline writing committee, told 

 in an exclusive interview. “Let me just remind everyone that this is not the first time clinical categorization has been proposed for managing acute pulmonary embolism, but this is a refinement of what we’ve seen previously based on where we are in terms of assessing pulmonary embolism and the options we have for therapeutic strategies.”

The guideline also encourages the use of direct oral anticoagulant medications over vitamin K antagonists in eligible patients, highlighting their superior efficacy in preventing recurrent venous thromboembolism and reducing major bleeding. The committee provided treatment suggestions for scenarios in which direct oral anticoagulants have not been explicitly tested, including excess body weight or hepatic disease, highlighting low-molecular-weight heparin as an efficacious alternative.

Additionally, the committee acknowledges and highlights several areas in which further research is necessary. A section towards the end of the guideline explicitly notes the need to redefine risk stratification tools, including the validation of the AHA/ACC clinical categories and using novel predictors like RV enlargement metrics and thrombus burden. Moreover, the guideline encourages research into the long-term outcomes of PE, particularly in chronic thromboembolic disease and various patient subgroups.

Although the guideline is almost all-encompassing, Creager highlighted a handful of missed opportunities, primarily patient awareness. PE is still a largely underrepresented condition, and a large swath of patients are unaware that their symptoms may fit this disease.

“What’s not covered in the guidelines, but which we need to cover, is increasing awareness of pulmonary embolism, particularly among the public,” Creager said. “People who are not aware that the symptoms they have may be a pulmonary embolism, they’re not going to do anything about it. When people get these symptoms, they have to seek care and seek it urgently, so that the diagnosis can be made promptly and appropriate treatments can be undertaken properly.”

Editor’s Note: Creager reports no relevant disclosures.

American Heart Association. First AHA/ACC acute pulmonary embolism guideline: prompt diagnosis and treatment are key. Eurekalert. February 19, 2026. Accessed February 20, 2026. 

https://www.eurekalert.org/news-releases/1116906

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. 

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Creager discusses the accomplishments of the ACC and AHA’s joint PE clinical practice guideline while continuing to look to the future of the disease.

Mark Creager, MD

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