2026 AHA/ACC Pulmonary Embolism (PE) Classification
sPESI – Pulmonary embolism severity index
Mnemonic: COPS BP 100 /80A
Cancer, Chronic cardiopulmonary disease, oxygen saturation, pulse rate > 100/min, SBP < 100 mm Hg and Age > 80 years
|
Class |
Meaning |
Clinical Features |
Preferred Initial Anticoagulation |
Reperfusion Strategy |
Memory Hack |
|
A |
Asymptomatic PE |
Incidental PE, no symptoms |
DOAC or LMWH (Enoxaparin) |
Not usually required |
A = Accidental finding |
|
B |
Low-risk symptomatic PE |
S-PESI = 0
stable |
DOAC or LMWH (Enoxaparin) |
None |
B = breathing comfortably/ Backpack home |
|
C |
Compensated PE |
Elevated s-PESI but no impending shock |
LMWH (Enoxaparin); UFH if procedure likely |
Usually anticoagulation alone |
C = Careful monitoring |
|
D |
Decompensating PE |
Normotensive with evidence of impending circulatory collapse (e.g., elevated lactate, AKI, oliguria, altered mental status, low cardiac output) |
IV Unfractionated Heparin (UFH) |
PERT evaluation; consider catheter-directed therapy, systemic thrombolysis, or embolectomy |
D = Deteriorating despite normal blood pressure |
|
E |
Extreme PE |
Persistent hypotension, obstructive shock, vasopressors, or cardiac arrest |
IV Unfractionated Heparin (UFH) |
Immediate systemic thrombolysis if eligible, or catheter thrombectomy/surgical embolectomy |
E = Emergency |
Category C Subclassification
|
Subtype |
RV Dysfunction |
Troponin |
Memory Hack |
|
C1 |
Absent |
Absent |
1 = None positive |
|
C2 |
Present or Absent |
Absent or Present |
2 = One positive |
|
C3 |
Present |
Present |
3 = Two positives |
High-Yield Anticoagulation
Stable (Classes A–C): DOAC or LMWH (Enoxaparin); UFH may be preferred in selected Class C patients if an invasive procedure is anticipated.
Unstable (Classes D–E): IV Unfractionated Heparin (UFH) is preferred because it is rapidly reversible and is ideal when thrombolysis, catheter-based intervention, or surgery may be be required.