LRH Pulmonary Embolism · AHA/ACC Clinical Categories

1 Hemodynamics & perfusion

Asked first because it outranks everything else: the category is assigned from the most severe indicator, and hypotension or hypoperfusion puts the patient in D or E no matter how benign the severity score looks.

Worst hemodynamic state so far this encounter

None of the below — normotensive and well perfused Transient hypotension Normotensive shock Recurrent or persistent hypotension with cardiogenic shock — SCAI SHOCK stage C Refractory cardiogenic shock, or cardiac arrest

2 Presentation

Category A is reserved for the PE nobody was looking for — found on a scan done for another reason, in a patient with no symptoms of PE.

Symptoms attributable to the PE?

Symptomatic — dyspnea, pleuritic pain, syncope, tachycardia… Incidental & asymptomatic — found on imaging done for another indication

Most proximal clot on imaging — splits B1 from B2

Subsegmental only (single or multiple) Non-subsegmental (segmental or more proximal)

Is the PE confirmed on imaging?

Confirmed Strongly suspected — imaging delayed or not accessible

3 Clinical severity score

The B / C dividing line. Tick the sPESI components and the answer fills itself in, or set it directly from whichever validated score your team used.

sPESI — 1 point each; any point makes the score elevated

– / 6 sPESI points

Not started

Severity score used for the category — auto-fills from sPESI; you can also tap it

Low Elevated

4 Right ventricle & cardiac biomarkers

The C1 / C2 / C3 split, and the only reason a normotensive patient gets called high-acuity. Echocardiography is preferred over CT for this in Categories C–D COR 2a.

RV size and function — echo or CT

Normal RV Abnormal RV Not yet assessed

Cardiac biomarkers — troponin I/T and/or BNP

All normal ≥ 1 abnormal Not yet measured

5 Respiratory modifier (R)

An R is appended (C3R, D2R) when respiratory compromise is prominent. The bar rises with the category — what earns an R in Category C is expected background in Category E — so the threshold applied below is the one for the category you land in.

Worst respiratory support requirement

None of the below — room air, no tachypnea Hypoxemia, tachypnea, or any supplemental oxygen High-flow oxygen or a nonrebreather Hypoxemic respiratory failure or ventilatory failure — noninvasive or invasive positive-pressure ventilation

6 Category & management

AHA/ACC Acute PE Clinical Category

Complete the sections above

Answer section 1 (hemodynamics) and section 2 (presentation) at minimum.

Systemic lysis	Catheter-directed lysis	Mechanical thrombectomy	Surgical embolectomy
–	–	–	–

Listed alphabetically, not in order of preference. Which one to call is a clinical decision — capability, bed state, weather and the patient’s own cardiology all bear on it.

The whole category scheme on one screen

Category	Subcategory	Definition
A — Subclinical	A	Incidental and asymptomatic PE
B — Symptomatic, low clinical severity score*	B1	Subsegmental (single or multiple)
B — Symptomatic, low clinical severity score*	B2	Non-subsegmental
C — Symptomatic, elevated clinical severity score†	C1	Normal RV and normal biomarkers
	C2	Abnormal RV or ≥ 1 abnormal biomarker
	C3	Abnormal RV and ≥ 1 abnormal biomarker
D — Incipient cardiopulmonary failure	D1	Transient hypotension‡
D — Incipient cardiopulmonary failure	D2	Normotensive shock§
E — Cardiopulmonary failure	E1	Recurrent or persistent hypotension with cardiogenic shock (SCAI SHOCK C)
E — Cardiopulmonary failure	E2	Refractory cardiogenic shock (SCAI D–E), or cardiac arrest without ROSC after 30 min of resuscitation
R — respiratory modifier		—

Category and subcategory are assigned from the most severe clinical, laboratory or imaging indicator, and are re-assigned as the patient is reassessed over time.

How this maps to the schemes it replaces

2011 AHA statement	2019 ESC scheme	2026 AHA/ACC categories
Low risk	Low risk	A, B
Submassive	Intermediate-low risk	C1, C2
Submassive	Intermediate-high risk	C3
— (no equivalent)	— (no equivalent)	D1, D2
Massive	High risk	E1, E2

The mapping is approximate and is here for translating an old note or an outside record. The genuinely new ground is Category D — the pre-failure patient who is still normotensive, or transiently hypotensive, and whom the older schemes filed alongside stable submassive PE.

Risk scores this scheme accepts

Score	Components	Bands
PESI	Age in years, plus: male 10 · cancer 30 · heart failure 10 · chronic lung disease 10 · HR ≥ 110 20 · SBP < 100 30 · RR ≥ 30 20 · temp < 36 °C 20 · altered mental status 60 · SpO₂ < 90% 20	I ≤ 65 · II 66–85 · III 86–105 · IV 106–125 · V ≥ 126
sPESI	1 point each: age > 80 · cancer · chronic cardiopulmonary disease · SBP < 100 · HR ≥ 110 · SaO₂ < 90%	0 = low · ≥ 1 = high 30-day mortality risk
Bova	SBP 90–100 (2) · troponin elevation (2) · RV dysfunction (2) · HR ≥ 110 (1)	I 0–2 · II 3–4 · III > 4
Hestia	11 yes/no items: hemodynamically unstable · lysis or embolectomy needed · active bleeding or high bleeding risk · > 24 h oxygen to hold SpO₂ > 90% · PE while already anticoagulated · severe pain needing IV analgesia > 24 h · medical or social reason to stay > 24 h · CrCl < 30 mL/min · severe liver impairment · pregnant · documented history of HIT	All “no” = negative, consider outpatient · any “yes” = positive, consider hospitalization
CPES	1 point each: elevated troponin · elevated BNP · moderately/severely reduced RV function · saddle PE · concomitant DVT · HR ≥ 100	0–5 lower risk of normotensive shock · 6 higher risk

Risk scores are far better at identifying the low-risk patient than the high-risk one. Hestia, PESI and sPESI are the three the guideline names as decision tools for outpatient treatment.

Before the diagnosis: pretest probability and D-dimer

This page starts once PE is on the board. Getting there:

PERC — apply only when gestalt pretest probability is < 15% (eg, Wells < 2). All 8 met → no further testing. Age < 50 · HR < 100 · SpO₂ ≥ 95% · no hemoptysis · no estrogen · no prior DVT/PE · no unilateral leg swelling · no surgery/trauma needing hospitalization in the prior 4 weeks.
Wells — DVT signs 3 · PE more likely than the alternative 3 · HR > 100 1.5 · immobilization ≥ 3 d or surgery within 4 wk 1.5 · prior DVT/PE 1.5 · hemoptysis 1 · cancer 1. Standard: low < 2, moderate 2–6, high > 6. Modified: PE likely > 4.
Age-adjusted D-dimer — in low or intermediate probability (< 50%), a value below age × 10 µg/L (FEU assays) excludes PE and the need for imaging COR 2a. Confirm your lab reports FEU, not D-dimer units.
YEARS — three items: clinical signs of DVT, hemoptysis, PE the most likely diagnosis. None present → D-dimer threshold 1000 µg/L; any present → 500 µg/L COR 2a. In pregnancy, the pregnancy-adapted YEARS criteria may be reasonable COR 2b.

Cautions that apply to every Category C–E patient

Do not deeply sedate and intubate unless clinically indicated COR 3: Harm — induction and positive pressure remove the compensation the failing RV is running on. Case series report a disproportionate rate of sedation-associated arrest in acute PE.
If sedation for intubation is unavoidable, have vasopressors, inotropes and/or VA-ECMO available first COR 1.
For moderate–severe hypoxia, heated high-flow nasal cannula rather than standard nasal cannula COR 2a.
Volume: in Category D, cautious expansion only where preload genuinely looks reduced COR 2b. The overloaded RV does not want the fluid.
Inhaled pulmonary vasodilators may be considered in C2–E to reduce RV afterload COR 2b.
Anyone receiving thrombolysis, systemic or catheter-directed, belongs in an ICU or intermediate-care bed COR 1.

Pulmonary Embolism · AHA/ACC Acute PE Clinical Categories