EMA Topics · Pulmonary · Cardiovascular

Pulmonary embolism

Updated Oct 15, 2026Adults · ED management17 sources · 9 checked in PubMed1 figureAHA/ACC 2026 guideline

Bottom line

Start with gestalt. If pretest probability is low (under 15%) and all eight PERC criteria are negative, stop: no D-dimer, no imaging.^3,4,13
Use a smarter D-dimer cutoff. YEARS (1000 ng/mL with no YEARS items) and the age-adjusted cutoff (age × 10 over 50) safely avoid many scans.^5,6,14
Classify confirmed PE as A–E with the 2026 AHA/ACC categories. Many category B patients (sPESI 0) can be treated at home on an oral anticoagulant.^1,2
Anticoagulate. In hospitalized patients prefer LMWH over unfractionated heparin (Class 1). For outpatients prefer a DOAC.^1,2
Advanced therapy is for category E, and maybe D. Systemic lysis, catheter-directed therapy and thrombectomy are Class 2a in category E and 2b in D and C3.^1,2

Ruling out

Estimate pretest probability by gestalt or a validated score.¹³
Low gestalt (< 15%): apply PERC. If all eight criteria are negative, PE is ruled out.^3,4,13
Otherwise: D-dimer with an adjusted cutoff. Use YEARS or an age-adjusted threshold, then image only if the D-dimer is above it.^5,6,7
Image with CT pulmonary angiography when the D-dimer is above the cutoff or probability is high.⁵

PERC: all must be absent
Age ≥ 50	Hemoptysis
Heart rate ≥ 100	Surgery or trauma needing general anesthesia within 4 weeks
Room-air SpO2 < 95%	Prior PE or DVT
Unilateral leg swelling	Hormone use (oral contraceptive, hormone replacement, estrogen)

Apply PERC only when gestalt probability is low (under 15%).¹³

What the rule-out studies show

PERC, 8,138 patients: low gestalt plus negative PERC applied to 20% of patients, with a 1.0% miss rate.³
PROPER trial, 1,916 patients: a PERC strategy had 0.1% thromboembolic events at 3 months, cut CT use from 23% to 13%, and shortened ED stays by 36 minutes.⁴
YEARS, 3,465 patients: three items (clinical signs of DVT, hemoptysis, PE the most likely diagnosis). The D-dimer cutoff is 1000 ng/mL with none of them and 500 ng/mL with any.¹⁴ Missed VTE at 3 months was 0.61%, and 14% fewer patients needed CT.⁵
Age-adjusted D-dimer (ADJUST-PE, 3,346 patients): a cutoff of age × 10 µg/L over age 50.¹⁵ Patients between 500 and their age-adjusted cutoff had a 0.3% 3-month failure rate. In patients 75 and older, D-dimer excluded PE in 29.7% instead of 6.4%.⁶
PEGeD, 2,017 patients: low clinical probability plus D-dimer under 1000 ng/mL had no VTE at follow-up, and chest imaging fell from 51.9% to 34.3%.⁷
Pregnancy (pregnancy-adapted YEARS, 498 patients): no PE during follow-up, and CT avoided in 39% overall (65% in the first trimester, 32% in the third).⁸

Severity: AHA/ACC categories

Category	Definition	Usual path
A	Asymptomatic, found incidentally (e.g. on cancer-staging CT)	Benefit of treatment still under study
B	Symptomatic, low severity score: PESI ≤ 85, sPESI 0, or Bova ≤ 4	Many can go home on an oral anticoagulant
C	Symptomatic, higher score: PESI > 85, sPESI ≥ 1, or Bova > 4. C3 adds more RV imaging and biomarker abnormalities	Usually admitted; rarely benefit beyond anticoagulation
D	Incipient cardiopulmonary failure. D1 transient hypotension (e.g. syncope); D2 normotensive shock (e.g. raised lactate, AKI)	Consider advanced therapy (2b)
E	Persistent hypotension or cardiopulmonary failure. E1 cardiogenic shock; E2 refractory shock or arrest	Advanced therapy (2a)

A respiratory modifier can be added to categories C–E. When respiratory and hemodynamic categories conflict, assign the higher one.²

sPESI (one point each)

Item	Point if
Age	> 80 years
Cancer	history of
Chronic cardiopulmonary disease	history of
Heart rate	≥ 110
Systolic BP	< 100 mm Hg
SpO2	< 90%

Thresholds as listed by MDCalc.¹⁶ In the derivation study, sPESI 0 meant a 30-day mortality of 1.0% vs 10.9% for ≥ 1, and 1.1% vs 8.9% in a 7,106-patient validation cohort.⁹

Axial CT pulmonary angiogram with red arrows on clot in both main pulmonary arteries at the bifurcation — FIG 1Saddle embolism. Filling defects (arrows) straddle the pulmonary artery bifurcation on CT pulmonary angiography.James Heilman, MD · Wikimedia Commons · CC BY-SA 3.0

Anticoagulation

Hospitalized (categories C–E1): prefer LMWH over unfractionated heparin (Class 1), including for patients heading to catheter therapy or lysis.^1,2
Outpatients (A and B): prefer a DOAC over warfarin, including in obesity. Warfarin remains the choice in antiphospholipid syndrome and advanced liver disease.^1,2

Drug	PE treatment dose (FDA label)
Enoxaparin	1 mg/kg SC every 12 h, or 1.5 mg/kg SC once daily (inpatient)
Apixaban	10 mg PO twice daily × 7 days, then 5 mg twice daily
Rivaroxaban	15 mg PO twice daily with food × 21 days, then 20 mg daily; avoid if CrCl < 15

Unreviewed doses. Verify against the current label and your institution's protocol before giving anything.

Doses from the FDA labels.^11,12 Check renal function, weight and interactions; the apixaban label halves the dose with combined strong CYP3A4 and P-gp inhibitors.¹¹

Advanced therapy

Category	Systemic lysis, catheter-directed therapy, thrombectomy
E	Class 2a. The three are now treated as equivalent options; systemic lysis no longer comes first
D	Class 2b. May be considered; benefit unclear
C3	Class 2b. Benefit unclear

Call the PE response team (PERT) for categories C–E (Class 1).^1,2
Alteplase dose (label): 100 mg IV over 2 hours. Start parenteral anticoagulation near the end of the infusion, once the PTT is no more than twice normal.¹⁷
The bleeding trade-off (PEITHO, 1,005 intermediate-risk patients): tenecteplase cut death or decompensation (2.6% vs 5.6%) but raised major extracranial bleeding (6.3% vs 1.2%) and stroke (2.4% vs 0.2%). Day-30 mortality did not differ.¹⁰

Disposition and follow-up

Category B: many patients can be discharged on an oral anticoagulant.^1,2 sPESI 0 is a low-risk signal, but home care also needs a stable patient, safe anticoagulation and follow-up.¹⁶
About 1 week after discharge: a visit or call to check access, bleeding and understanding (Class 1).^1,2
Within 3 months: follow-up for complications and persistent symptoms. If symptoms persist, test for chronic thromboembolic disease.^1,2
Duration: stop after 3–6 months for a first, strongly provoked PE without ongoing risk factors. Otherwise continued anticoagulation is generally preferred; reduced-dose apixaban or rivaroxaban can lower bleeding.²

Pitfalls

Applying PERC to patients who aren't low risk by gestalt.¹³
Ordering a D-dimer you will interpret with a fixed 500 cutoff in an 80-year-old.⁶
Using a D-dimer to "rule out" PE in a high-probability patient. Go to imaging.^5,7
Reaching for lysis in category C. Most of these patients do not benefit beyond anticoagulation, and PEITHO showed the bleeding cost.^2,10
Discharging category B patients without a plan for anticoagulant access and early follow-up.^1,2

How strong is the evidence?

The rule-out strategies are supported by large prospective studies and one randomized trial.^3,4,5,6,7,8 Advanced therapy recommendations are mostly Class 2a–2b. The 2026 guideline is the first AHA/ACC acute PE guideline; its full text was not openly accessible, so recommendations here come from a published summary and are cited to both.^1,2 For deeper reading, see LITFL and Emergency Medicine Cases.

On-shift teaching

Questions to ask a learner at the bedside. Tap a question to see the answer. Every answer uses facts cited above.

Q1Who can you apply PERC to?

Only patients whose gestalt pretest probability is low (under 15%). If all eight criteria are negative, stop: no D-dimer and no imaging.^13,3

Q2A low-probability 80-year-old has a D-dimer of 700 µg/L. Is PE ruled out?

Yes, by the age-adjusted cutoff. Over age 50 the cutoff is age × 10, so 800 µg/L here.¹⁵ In ADJUST-PE, patients between 500 and their age-adjusted cutoff had a 0.3% 3-month failure rate.⁶

Q3What are the YEARS items, and how do they change the D-dimer cutoff?

Clinical signs of DVT, hemoptysis, and PE as the most likely diagnosis. With none, the cutoff is 1000 ng/mL; with any, 500 ng/mL.¹⁴ YEARS cut CT use by 14% with a 0.61% 3-month miss rate.⁵

Q4What is category B, and what does it mean for disposition?

Symptomatic PE with a low severity score: PESI ≤ 85, sPESI 0 or Bova ≤ 4. Many of these patients can be treated at home on an oral anticoagulant.^1,2

Q5Why not give lytics to every intermediate-risk PE?

In PEITHO, tenecteplase cut death or decompensation (2.6% vs 5.6%) but raised major extracranial bleeding (6.3% vs 1.2%) and stroke (2.4% vs 0.2%), with no difference in day-30 mortality.¹⁰ The 2026 guideline rates advanced therapy only Class 2b for categories C3 and D.²

Q6What is the apixaban dose for acute PE?

10 mg twice daily for 7 days, then 5 mg twice daily. Halve the dose with combined strong CYP3A4 and P-gp inhibitors.¹¹

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. Circulation. 2026;153(12):e977–e1051.GuidelinePMID 41712677 DOIPubMed record; full text not openly accessible
2
The 2026 AHA/ACC guideline for the management of acute pulmonary embolism. Endovascular Today, July 2026 supplement.Summaryevtoday.comPage read
3
Kline JA, Courtney DM, Kabrhel C, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost. 2008;6(5):772–780.Diagnostic studyPMID 18318689PubMed
4
Freund Y, Cachanado M, Aubry A, et al. Effect of the pulmonary embolism rule-out criteria on subsequent thromboembolic events among low-risk emergency department patients: the PROPER randomized clinical trial. JAMA. 2018;319(6):559–566.RCTPMID 29450523 PMCPubMed
5
van der Hulle T, Cheung WY, Kooij S, et al. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study). Lancet. 2017;390(10091):289–297.Diagnostic studyPMID 28549662PubMed
6
Righini M, et al. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA. 2014;311(11):1117–1124.Diagnostic studyPMID 24643601PubMed
7
Kearon C, de Wit K, Parpia S, et al. Diagnosis of pulmonary embolism with D-dimer adjusted to clinical probability (PEGeD). N Engl J Med. 2019;381(22):2125–2134.Diagnostic studyPMID 31774957PubMed
8
van der Pol LM, Tromeur C, Bistervels IM, et al. Pregnancy-adapted YEARS algorithm for diagnosis of suspected pulmonary embolism. N Engl J Med. 2019;380(12):1139–1149.Diagnostic studyPMID 30893534PubMed
9
Jiménez D, Aujesky D, Moores L, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170(15):1383–1389.CohortPMID 20696966PubMed
10
Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism (PEITHO). N Engl J Med. 2014;370(15):1402–1411.RCTPMID 24716681PubMed
11
Eliquis (apixaban) prescribing information. DailyMed, US National Library of Medicine.Drug labelDailyMedLabel text read
12
Xarelto (rivaroxaban) and Lovenox (enoxaparin) prescribing information. DailyMed, US National Library of Medicine.Drug labelDailyMed DailyMedLabel text read
13
MDCalc. PERC Rule for Pulmonary Embolism.Summarymdcalc.comPage read
14
Cloyd T, Swaminathan A. YEARS. Core EM journal review; November 16, 2017.FOAMcoreem.netPage read
15
Wiki Journal Club. ADJUST-PE.Summarywikijournalclub.orgPage read
16
MDCalc. Simplified PESI (Pulmonary Embolism Severity Index).Summarymdcalc.comPage read
17
Activase (alteplase) prescribing information. DailyMed, US National Library of Medicine.Drug labelDailyMedLabel text read

Not for clinical use

AI-generated draft. Not reviewed by a physician. This page is for education only and may contain errors, including in doses. Do not use it to diagnose, treat or make decisions about any patient. Rely on your own clinical judgment, your institution's protocols and current drug labeling. Reading this page does not create a physician-patient relationship. Full terms