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pulm.pe.core.v1PRODUCTION
pulm.pe.core.v1

Pulmonary Embolism (acute + extended)

pulmonologyacuteadult
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm acute PE scope (NOT chronic CTEPH — route persistent post-PE PH to pulm.pulmonary_htn_group2_to_5.v1) and adult population (ESC 2019 §1; AHA/ACC 2026)

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Actions
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Advance rule
Set
Advance when

Acute presentation confirmed

Patient inputs (22)

Age-adjusted D-dimer threshold (>50 yr: age × 10 ng/mL FEU) shifts the test LR− favorably (ADJUST-PE Righini JAMA 2014 PMID 24643601)

Pretest probability band (Wells / revised Geneva) — sets the prior for Bayesian update; D-dimer LR is conditional on this band

Sustained SBP <90 → high-risk Category E (AHA/ACC 2026; ESC 2019 Table 4)

Wells HR >100 (Wells 2000); sPESI HR ≥110 (Jiménez Arch Intern Med 2010 PMID 20696966)

sPESI SpO2 <90 (Jiménez 2010 PMID 20696966); ESC 2019 severity stratification

CrCl (Cockcroft-Gault, NOT eGFR) for DOAC selection; eGFR/CrCl divergence matters at extremes of weight/age (CHEST 2021; ASH 2020)

Bleeding risk + transfusion threshold for thrombolysis (AHA/ACC 2026)

Thrombocytopenia precludes thrombolysis (<50k) and full-dose LMWH; screen HIT if heparin-exposed (AHA/ACC 2026; CHEST 2021)

Provoked (transient) vs unprovoked vs cancer → duration logic (CHEST 2021; ESC 2019 §7.5)

Active bleeding, recent surgery, recent ICH — contraindicates anticoag/thrombolysis (AHA/ACC 2026 Table; ESC 2019 Table 10)

Tachypnea + hemodynamic compromise (ESC 2019)

Cancer-associated VTE — DOAC vs LMWH by tumor site; extended therapy (Caravaggio NEJM 2020 PMID 32223112; Hokusai-VTE Cancer PMID 29231094; SELECT-D PMID 29746227)

LMWH (NOT DOAC/VKA); CTPA vs V/Q radiation/breast-dose trade-off (ESC 2019 §10; ASH 2020)

Triple-positive APS → warfarin, NOT DOAC (TRAPS Pengo; rivaroxaban arm stopped for excess arterial events; JTH 2020 PMID 33128325)

Obesity (BMI ≥40 / >120 kg): apixaban & rivaroxaban acceptable per ISTH 2021 SSC; dabigatran/edoxaban less data — informs agent

Breakthrough PE on therapeutic anticoagulation → reassess adherence/APS/cancer + escalate (CHEST 2021; ESC 2019)

Rule-out test in low/intermediate pretest probability; LR− depends on Wells band (conditional dependency — do not multiply independently). YEARS van der Hulle Lancet 2017 PMID 28549662

Definitive PE diagnosis — segmental+ filling defect LR+ ≥ 50; also clot burden + RV:LV ratio (ESC 2019 Class I; AHA/ACC 2026)

V/Q when CTPA contraindicated (renal, contrast allergy, pregnancy) — high-probability scan LR+ high; normal scan LR− very low (ESC 2019 §6)

Risk (not diagnosis): troponin elevation → intermediate-high (Category D). Interpreted conditional on time-since-onset — early draw can be falsely negative (ESC 2019 Table 4; AHA/ACC 2026)

RV strain biomarker — intermediate-high risk (ESC 2019 Table 5)

RV dysfunction + McConnell sign — risk stratification + reperfusion decision, not primary diagnosis (ESC 2019 §7.3; AHA/ACC 2026)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningsustained_hypotension_or_arrest_category_E
    SBP <90 mmHg sustained ≥15 min OR vasopressor requirement OR cardiac arrest from PE — Category E (AHA/ACC 2026; ESC 2019 Table 4)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmassive_bleeding_on_anticoag_or_tPA
    Active major bleeding on anticoagulation or post-thrombolysis — intracranial, GI, retroperitoneal, or with hemodynamic compromise
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererv_strain_plus_troponin_decompensating_category_D
    RV/LV ≥1.0 + troponin elevated (interpreted conditional on time-since-onset) + clinical decompensation despite anticoagulation — Category D escalating
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecancer_associated_VTE
    Active malignancy with PE — agent selection by tumor site (ASH 2020; AHA/ACC 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_with_PE
    PE during pregnancy or postpartum (ESC 2019 §10; ASH 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereantiphospholipid_triple_positive
    Confirmed triple-positive antiphospholipid syndrome with VTE
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebreakthrough_PE_on_anticoagulation
    New PE while on therapeutic anticoagulation (CHEST 2021; ESC 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepersistent_dyspnea_3_to_6mo_post_PE_CTEPH
    Persistent dyspnea or functional limitation at 3-6 months post-PE (ESC 2019 §9)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildperc_negative_low_pretest_rule_out
    LOW pretest probability (Wells ≤4 / Geneva low) AND all 8 PERC criteria negative — posterior PE probability < T_test ≈ 1.8-2% (Pauker-Kassirer testing threshold)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildd_dimer_negative_conditional_on_wells
    Age-adjusted D-dimer negative in NON-high pretest probability (Wells ≤4 or YEARS 0 items) — posterior < T_test
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

CONTEXTrequiredDrives risk stratification
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Recommended regimen

2026 AHA/ACC PE — anticoagulation + reperfusion ladder by Clinical Category A-E
axis: pe_anticoagulation_by_categorystep A_B_low_risk - Category A-B (low-risk) — sPESI 0 / Hestia 0, normotensive, no RV strain, no troponin elevation
Selected step "Category A-B (low-risk) — sPESI 0 / Hestia 0, normotensive, no RV strain, no troponin elevation" — Hemodynamically stable, sPESI 0 OR Hestia 0, normal RV on echo/CT, normal troponin/BNP — outpatient or early-discharge candidate (HoT-PE Barco EHJ 2020 PMID 31120118)
  • apixaban
    first line
    DOAC_factor_Xa_inhibitor
    10 mg PO BID × 7 d (loading) → 5 mg PO BID (maintenance) • PO • 10 mg BID × 7 d, then 5 mg BID
    triggers: CrCl_>=25, no_severe_hepatic_impairment, no_triple_positive_APS, no_pregnancy
    2026 AHA/ACC Class 1 — DOAC over VKA. Therapeutic anticoagulation onset within hours of first oral dose (no parenteral lead-in). AMPLIFY (Agnelli NEJM 2013 PMID 23808982): recurrent VTE/VTE-death 2.3% vs 2.7%, RR 0.84 (95% CI 0.60–1.18, non-inferior p<0.001); major bleeding 0.6% vs 1.8%, RR 0.31 (95% CI 0.17–0.55, p<0.001 superiority) vs enoxaparin/warfarin. RxCUI 1364430 aligned to DrugEffectProfile registry.
    rxcui 1364430
  • rivaroxaban
    first line
    DOAC_factor_Xa_inhibitor
    15 mg PO BID × 21 d (loading) → 20 mg PO daily with food (maintenance) • PO • BID × 21 d, then daily
    triggers: CrCl_>=30, no_triple_positive_APS
    Single-drug oral, no parenteral lead-in; peak anticoagulant effect 2–4 h. EINSTEIN-PE (NEJM 2012 PMID 22449293): recurrent VTE 2.1% vs 1.8%, HR 1.12 (95% CI 0.75–1.68, non-inferior); major bleeding 1.1% vs 2.2%, HR 0.49 (95% CI 0.31–0.79, p=0.003) vs enoxaparin/VKA. RxCUI 1114195 aligned to DrugEffectProfile registry.
    rxcui 1114195
  • edoxaban
    first line
    DOAC_factor_Xa_inhibitor
    60 mg PO daily (30 mg if CrCl 15-50, weight ≤60 kg, or strong P-gp inhibitor) — after ≥5 d parenteral lead-in • PO • daily
    triggers: parenteral_bridge_5d_first, CrCl_>=15
    Requires ≥5 d LMWH/UFH lead-in (anticoagulation from parenteral agent, edoxaban steady state ~3 d). Hokusai-VTE (Büller NEJM 2013 PMID 23991658): recurrent VTE 3.2% vs 3.5%, HR 0.89 (95% CI 0.70–1.13, non-inferior); clinically-relevant bleeding 8.5% vs 10.3%, HR 0.81 (95% CI 0.71–0.94, p=0.004) vs warfarin. RxCUI 1599538 aligned to DrugEffectProfile registry.
    rxcui 1599538
  • dabigatran
    second line
    DOAC_thrombin_inhibitor
    150 mg PO BID after 5-10 d parenteral lead-in (110 mg if age ≥80 or high bleeding risk) • PO • BID
    triggers: CrCl_>=30, parenteral_bridge_5_10d_first
    Requires 5–10 d parenteral lead-in (median 9 d in trial). RE-COVER (Schulman NEJM 2009 PMID 19966341): recurrent VTE 2.4% vs 2.1%, HR 1.10 (95% CI 0.65–1.84, non-inferior); major bleeding 1.6% vs 1.9%, HR 0.82 (95% CI 0.45–1.48); any bleeding HR 0.71 (95% CI 0.59–0.85) vs warfarin. Idarucizumab specific reversal. RxCUI 1037042 aligned to DrugEffectProfile registry.
    rxcui 1037042
  • warfarin
    contraindication substitute
    VKA
    5 mg PO daily, target INR 2-3, with LMWH/UFH bridge until INR ≥2 × 24 h • PO • daily, INR-driven
    triggers: DOAC_contraindicated, antiphospholipid_triple_positive, CrCl_<15, mechanical_valve_overlap
    Reserve for DOAC contraindications; therapeutic INR takes ~5 d so requires LMWH/UFH bridge. Triple-positive APS: TRAPS 2-yr (Pengo JTH 2020 PMID 33128325) — DOAC-arm thromboembolic events 33.3% (2/6) vs warfarin 5.7% (6/109), HR 6.9 (95% CI 1.4–34.5, p=0.018) → warfarin INR 2-3 only. RxCUI 11289 aligned to DrugEffectProfile registry.
    rxcui 11289

outpatient playbook — drug actions (4)

  1. 1. continue full-dose DOAC
    Apixaban 5 mg BID OR rivaroxaban 20 mg daily • PO • as prescribed
    trigger: Months 0-6 post-PE
    Standard 3-6 month course (CHEST 2021; ESC 2019)
  2. 2. reduced-dose DOAC (extended)
    Apixaban 2.5 mg PO BID OR rivaroxaban 10 mg PO daily • PO • BID or daily
    trigger: Unprovoked / recurrent VTE, low bleeding risk, after ≥6 mo full dose
    AMPLIFY-EXT (Agnelli NEJM 2013 PMID 23216615): apixaban 2.5 mg recurrence 1.7% vs 8.8% placebo, no excess major bleeding; EINSTEIN-CHOICE similar
  3. 3. discontinue anticoagulation
    Stop • n/a • n/a
    trigger: Provoked PE with major transient factor (surgery, immobility), 3-mo course complete, HERDOO2/DASH low
    Provoked VTE — discontinuation safe (CHEST 2021)
  4. 4. extended LMWH or DOAC for cancer
    As during acute • SC/PO • as prescribed
    trigger: Active cancer / on chemotherapy
    Continue indefinitely while cancer active (ASH 2020; Caravaggio PMID 32223112)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Acute dyspnea, pleuritic chest pain, syncope, or hemoptysis (ESC 2019 §5; AHA/ACC 2026); Unexplained tachycardia + hypoxia (ESC 2019 §5); Elevated D-dimer with PE-compatible pretest probability (ESC 2019 §6.3) — interpret conditional on Wells band.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pulmonary Embolism (acute + extended)** (pulm.pe.core.v1).
Phenotype framing: PE vs ACS vs aortic dissection vs pneumothorax vs pneumonia vs decompensated HF vs anxiety; anatomic categories saddle vs lobar vs segmental vs subsegmental (ESC 2019 §5; AHA/ACC 2026)
Scope: Confirm acute PE scope (NOT chronic CTEPH — route persistent post-PE PH to pulm.pulmonary_htn_group2_to_5.v1) and adult population (ESC 2019 §1; AHA/ACC 2026)

No severity triggers fired against current inputs.

Plan

Regimen axis: **2026 AHA/ACC PE — anticoagulation + reperfusion ladder by Clinical Category A-E** — step "Category A-B (low-risk) — sPESI 0 / Hestia 0, normotensive, no RV strain, no troponin elevation".
1. apixaban 10 mg PO BID × 7 d (loading) → 5 mg PO BID (maintenance) PO 10 mg BID × 7 d, then 5 mg BID (DOAC_factor_Xa_inhibitor, first line) — 2026 AHA/ACC Class 1 — DOAC over VKA. Therapeutic anticoagulation onset within hours of first oral dose (no parenteral lead-in). AMPLIFY (Agnelli NEJM 2013 PMID 23808982): recurrent VTE/VTE-death 2.3% vs 2.7%, RR 0.84 (95% CI 0.60–1.18, non-inferior p<0.001); major bleeding 0.6% vs 1.8%, RR 0.31 (95% CI 0.17–0.55, p<0.001 superiority) vs enoxaparin/warfarin. RxCUI 1364430 aligned to DrugEffectProfile registry.
2. rivaroxaban 15 mg PO BID × 21 d (loading) → 20 mg PO daily with food (maintenance) PO BID × 21 d, then daily (DOAC_factor_Xa_inhibitor, first line) — Single-drug oral, no parenteral lead-in; peak anticoagulant effect 2–4 h. EINSTEIN-PE (NEJM 2012 PMID 22449293): recurrent VTE 2.1% vs 1.8%, HR 1.12 (95% CI 0.75–1.68, non-inferior); major bleeding 1.1% vs 2.2%, HR 0.49 (95% CI 0.31–0.79, p=0.003) vs enoxaparin/VKA. RxCUI 1114195 aligned to DrugEffectProfile registry.
3. edoxaban 60 mg PO daily (30 mg if CrCl 15-50, weight ≤60 kg, or strong P-gp inhibitor) — after ≥5 d parenteral lead-in PO daily (DOAC_factor_Xa_inhibitor, first line) — Requires ≥5 d LMWH/UFH lead-in (anticoagulation from parenteral agent, edoxaban steady state ~3 d). Hokusai-VTE (Büller NEJM 2013 PMID 23991658): recurrent VTE 3.2% vs 3.5%, HR 0.89 (95% CI 0.70–1.13, non-inferior); clinically-relevant bleeding 8.5% vs 10.3%, HR 0.81 (95% CI 0.71–0.94, p=0.004) vs warfarin. RxCUI 1599538 aligned to DrugEffectProfile registry.
4. dabigatran 150 mg PO BID after 5-10 d parenteral lead-in (110 mg if age ≥80 or high bleeding risk) PO BID (DOAC_thrombin_inhibitor, second line) — Requires 5–10 d parenteral lead-in (median 9 d in trial). RE-COVER (Schulman NEJM 2009 PMID 19966341): recurrent VTE 2.4% vs 2.1%, HR 1.10 (95% CI 0.65–1.84, non-inferior); major bleeding 1.6% vs 1.9%, HR 0.82 (95% CI 0.45–1.48); any bleeding HR 0.71 (95% CI 0.59–0.85) vs warfarin. Idarucizumab specific reversal. RxCUI 1037042 aligned to DrugEffectProfile registry.
5. warfarin 5 mg PO daily, target INR 2-3, with LMWH/UFH bridge until INR ≥2 × 24 h PO daily, INR-driven (VKA, contraindication substitute) — Reserve for DOAC contraindications; therapeutic INR takes ~5 d so requires LMWH/UFH bridge. Triple-positive APS: TRAPS 2-yr (Pengo JTH 2020 PMID 33128325) — DOAC-arm thromboembolic events 33.3% (2/6) vs warfarin 5.7% (6/109), HR 6.9 (95% CI 1.4–34.5, p=0.018) → warfarin INR 2-3 only. RxCUI 11289 aligned to DrugEffectProfile registry.

Setting playbook (outpatient) — Complete anticoagulation duration, decide extended therapy at 3 months (provoked vs unprovoked vs cancer; HERDOO2/DASH), monitor bleeding, screen CTEPH at 3-6 months if persistent symptoms
6. continue full-dose DOAC Apixaban 5 mg BID OR rivaroxaban 20 mg daily PO as prescribed — Months 0-6 post-PE (Standard 3-6 month course (CHEST 2021; ESC 2019))
7. reduced-dose DOAC (extended) Apixaban 2.5 mg PO BID OR rivaroxaban 10 mg PO daily PO BID or daily — Unprovoked / recurrent VTE, low bleeding risk, after ≥6 mo full dose (AMPLIFY-EXT (Agnelli NEJM 2013 PMID 23216615): apixaban 2.5 mg recurrence 1.7% vs 8.8% placebo, no excess major bleeding; EINSTEIN-CHOICE similar)
8. discontinue anticoagulation Stop n/a n/a — Provoked PE with major transient factor (surgery, immobility), 3-mo course complete, HERDOO2/DASH low (Provoked VTE — discontinuation safe (CHEST 2021))
9. extended LMWH or DOAC for cancer As during acute SC/PO as prescribed — Active cancer / on chemotherapy (Continue indefinitely while cancer active (ASH 2020; Caravaggio PMID 32223112))

Non-pharmacologic actions:
- Anticoagulation safety reinforcement (AHA/ACC 2026)
- Peri-procedural anticoag interruption planning (CHEST 2021)
- CTEPH screen 3-6 mo if persistent dyspnea — V/Q, echo, RHC if abnormal → route pulm.pulmonary_htn_group2_to_5.v1 (ESC 2019 §9)
- Smoking cessation, weight management (AHA/ACC 2026)
- Vaccinations — flu, pneumococcal, COVID (AHA/ACC 2026)

AVOID / contraindication checks:
-  absolute thrombolysis contraindications — active bleed, prior ICH, ischemic stroke <3 mo, structural intracranial neoplasm/AVM, aortic dissection, recent major surgery/trauma (AHA/ACC 2026; ESC 2019 Table 10)
-  relative thrombolysis contraindications — SBP >180/DBP >110, recent non compressible puncture, recent GI bleed, pregnancy, age >75 (ESC 2019 Table 10)
-  thrombocytopenia <50k precludes thrombolysis and full dose LMWH; HIT screen if heparin exposed with falling platelets (CHEST 2021)
-  IVC filter only if absolute anticoagulation contraindication + active VTE (PREPIC2 PMID 25919526)

Monitoring

Regimen monitoring:
- aPTT q6h on UFH until therapeutic then q24h (CHEST 2021)
- anti-Xa (LMWH) in pregnancy / extreme weight / renal impairment (ASH 2020)
- INR q2-3d on warfarin until two consecutive in-range, then monthly (CHEST 2021)
- CrCl (Cockcroft-Gault) q3-6mo on DOAC, sooner if acute illness (ESC 2019 §7.5)
- CBC for bleeding screen at each visit; HIT 4T-score if heparin-exposed thrombocytopenia (AHA/ACC 2026; CHEST 2021)
- reassess at 3 months: provoked vs unprovoked vs cancer → duration decision (CHEST 2021)
- unprovoked stop-decision: HERDOO2 (women — low if ≤1 point) or DASH score to weigh extended therapy (CHEST 2021)
- CTEPH screen 3-6mo if persistent dyspnea — V/Q + echo + RHC (ESC 2019 §9; route → pulm.pulmonary htn group2 to 5.v1)

Setting (outpatient) monitoring:
- CBC + CrCl q3-6 months (ESC 2019 §7.5)
- 3-month and annual VTE clinic visit (CHEST 2021)
- Bleeding diary (AHA/ACC 2026)

Follow-up plan: Reassess provoked vs unprovoked vs cancer; extended anticoagulation Class I for unprovoked (AHA/ACC 2026); reduced-dose DOAC (AMPLIFY-EXT Agnelli NEJM 2013 PMID 23216615; EINSTEIN-CHOICE); HERDOO2 (women) / DASH scores to guide stopping unprovoked; PEmb-QoL; occupational return
- Close-out criterion: Duration decision + return precautions documented

Monitoring phase: Anticoagulant adherence + bleeding surveillance; 3-month re-evaluation for extended therapy (CHEST 2021); CTEPH screen at 3-6 months if persistent dyspnea — V/Q + echo + RHC (ESC 2019 §9; PEITHO long-term Konstantinides JACC 2017 PMID 28335835 — ~33% persistent functional limitation, CTEPH ~2-3%)

Disposition

Current setting: outpatient — Complete anticoagulation duration, decide extended therapy at 3 months (provoked vs unprovoked vs cancer; HERDOO2/DASH), monitor bleeding, screen CTEPH at 3-6 months if persistent symptoms

Disposition criteria:
- Continue / step-down / discontinue per provoked-vs-unprovoked + bleeding risk + HERDOO2/DASH (CHEST 2021; AHA/ACC 2026)

Escalation triggers (move to higher acuity):
- Recurrent VTE on anticoag → reassess agent/dose/cancer/APS (CHEST 2021; ESC 2019)
- Major bleed → reverse if needed; reassess risk-benefit (AHA/ACC 2026)
- Persistent dyspnea / functional limit → CTEPH workup (ESC 2019 §9)

Patient Action Plan

**PE anticoagulation safety + recurrence plan**
Personalised values: anticoagulant_name_and_dose, next_clinic_date, reversal_agent_available, emergency_contact.

**On track — no bleeding, no new symptoms (AHA/ACC 2026)** (green):
Triggers:
- Taking anticoagulant as prescribed (AHA/ACC 2026)
- No nosebleeds, gum bleeding, blood in urine/stool (AHA/ACC 2026)
- No new dyspnea, chest pain, calf swelling (ESC 2019)
Actions:
- Continue anticoagulant as prescribed (AHA/ACC 2026)
- Avoid NSAIDs, aspirin, herbal supplements without clinician approval (CHEST 2021)
- Inform any new clinician (dentist, surgeon) about anticoagulation (AHA/ACC 2026)
- Wear medical alert ID (AHA/ACC 2026)
- Keep next clinic appointment (AHA/ACC 2026)

**Caution — minor bleeding or worsening symptoms (AHA/ACC 2026)** (yellow):
Triggers:
- Persistent nosebleed >10 minutes (AHA/ACC 2026)
- Bleeding gums on brushing more than usual (AHA/ACC 2026)
- Bruising larger than a quarter without cause (AHA/ACC 2026)
- Pink-tinged urine (AHA/ACC 2026)
- Black or tarry stool (AHA/ACC 2026)
- New/worsening dyspnea or leg swelling (ESC 2019)
Actions:
- Apply firm pressure to bleeding site for 10 minutes (AHA/ACC 2026)
- Hold next dose ONLY if instructed — do not stop without speaking to clinician (AHA/ACC 2026)
- Call anticoagulation clinic / physician within 24 h (AHA/ACC 2026)
Contact provider when:
- Any of the above symptoms (AHA/ACC 2026)
- Need to start or stop a medication (CHEST 2021)
- Planned dental or surgical procedure (CHEST 2021)

**Medical alert — major bleeding, recurrence, or instability (AHA/ACC 2026)** (red):
Triggers:
- Vomiting blood or coffee-grounds material (AHA/ACC 2026)
- Bright red blood in stool (AHA/ACC 2026)
- Severe headache, weakness, slurred speech, vision change (AHA/ACC 2026)
- Chest pain, severe shortness of breath, loss of consciousness (ESC 2019)
- Trauma with possible internal bleeding — head, abdomen (AHA/ACC 2026)
- Heavy menstrual bleeding requiring frequent pad changes (AHA/ACC 2026)
Actions:
- Call 911 / emergency services NOW (AHA/ACC 2026)
- Bring anticoagulant name + dose information (AHA/ACC 2026)
- Dabigatran → ED has idarucizumab; apixaban/rivaroxaban/edoxaban → andexanet alfa or 4F-PCC; warfarin → 4F-PCC + IV vitamin K (CHEST 2021; ESC 2019)
- Do not take next dose until evaluated (AHA/ACC 2026)
Contact provider when:
- Any red-zone symptom — go to ED immediately (AHA/ACC 2026)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] SBP <90 mmHg sustained ≥15 min OR vasopressor requirement OR cardiac arrest from PE — Category E (AHA/ACC 2026; ESC 2019 Table 4)
- [LIFE_THREATENING] Active major bleeding on anticoagulation or post-thrombolysis — intracranial, GI, retroperitoneal, or with hemodynamic compromise
- [SEVERE] RV/LV ≥1.0 + troponin elevated (interpreted conditional on time-since-onset) + clinical decompensation despite anticoagulation — Category D escalating

Citations

- 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Acute PE Guideline (Circulation 2026; PMID 41712677; DOI 10.1161/CIR.0000000000001415) + 2019 ESC Acute PE Guideline (PMID 31504429) + CHEST 2021 antithrombotic + ASH 2020 VTE [PMID:41712677](https://pubmed.ncbi.nlm.nih.gov/41712677/)
- Cited evidence (PMID 31504429) [PMID:31504429](https://pubmed.ncbi.nlm.nih.gov/31504429/)
- Cited evidence (PMID 18318689) [PMID:18318689](https://pubmed.ncbi.nlm.nih.gov/18318689/)
- Cited evidence (PMID 24643601) [PMID:24643601](https://pubmed.ncbi.nlm.nih.gov/24643601/)
- Cited evidence (PMID 28549662) [PMID:28549662](https://pubmed.ncbi.nlm.nih.gov/28549662/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Acute PE Guideline (Circulation 2026; PMID 41712677; DOI 10.1161/CIR.0000000000001415) + 2019 ESC Acute PE Guideline (PMID 31504429) + CHEST 2021 antithrombotic + ASH 2020 VTE — PMID:41712677
  • Cited evidence (PMID 31504429) — PMID:31504429
  • Cited evidence (PMID 18318689) — PMID:18318689
  • Cited evidence (PMID 24643601) — PMID:24643601
  • Cited evidence (PMID 28549662) — PMID:28549662