What are the 2026 European Society of Cardiology (ESC) guidelines for diagnosing, risk‑stratifying, treating, and following up patients with acute pulmonary embolism and chronic thrombo‑embolic pulmonary hypertension?

ESC 2026 Pulmonary Embolism Guidelines

Note: There are no published ESC 2026 guidelines for pulmonary embolism. The most recent ESC guidelines are from 2019, published in 2020. 1 I will provide the current ESC recommendations based on the 2019 guidelines, which remain the standard of care.

Diagnosis

Clinical Probability Assessment

• Base your diagnostic strategy on clinical probability using either clinical judgment or a validated prediction rule (Wells score, Geneva score) before ordering any tests. 1
• Stratify patients into low, intermediate, or high clinical probability (three-level) or PE-unlikely/PE-likely (two-level) categories. 2
• Immediately assess for hemodynamic instability (shock or systolic BP <90 mmHg) to identify high-risk PE requiring urgent reperfusion therapy. 1

D-dimer Testing

• Measure D-dimer only in outpatients or emergency department patients with low or intermediate clinical probability, or who are PE-unlikely; use highly sensitive assays. 1
• Do not measure D-dimer in patients with high clinical probability—a normal result does not safely exclude PE. 1
• Reject PE diagnosis without further testing if D-dimer is normal in low or intermediate probability patients. 1

Imaging Strategy

• Perform bedside echocardiography or emergency CTPA (depending on availability) for suspected high-risk PE. 1
• CTPA is the first-choice imaging test for hemodynamically stable patients. 2
• Accept PE diagnosis if CTPA shows segmental or more proximal filling defect in patients with intermediate or high clinical probability. 1
• Reject PE diagnosis if CTPA is normal in patients with low or intermediate clinical probability. 1
• Ventilation-perfusion (V/Q) scintigraphy is a valid alternative when CTPA is contraindicated; reject PE if perfusion scan is normal. 1
• Do not perform CT venography as an adjunct to CTPA. 1
• Do not perform MRA to rule out PE. 1
• Accept VTE diagnosis if compression ultrasound shows proximal DVT in a patient with suspected PE. 1

Risk Stratification

High-Risk PE (Hemodynamically Unstable)

• Defined by shock, persistent hypotension (systolic BP <90 mmHg for ≥15 minutes), or cardiac arrest. 1
• These patients have the highest early mortality risk and require immediate reperfusion therapy. 1

Intermediate-Risk PE

• Hemodynamically stable patients with evidence of right ventricular dysfunction (on echocardiography or CTPA) and/or elevated cardiac biomarkers (troponin, BNP/NT-proBNP). 1
• Further subdivide into intermediate-high risk (both RV dysfunction and biomarker elevation) and intermediate-low risk (one of the two). 1

Low-Risk PE

• Hemodynamically stable without RV dysfunction or biomarker elevation. 1
• These patients are candidates for early discharge and outpatient treatment. 1, 2

Acute Phase Treatment

High-Risk PE Management

• Initiate intravenous unfractionated heparin (UFH) without delay, including a weight-adjusted bolus injection, even before imaging confirmation. 1
• Administer systemic thrombolytic therapy immediately to all high-risk PE patients without high bleeding risk. 1, 2
• Alteplase (rtPA) dosing: 100 mg over 2 hours or 0.6 mg/kg over 15 minutes (maximum 50 mg). 2
• Perform surgical pulmonary embolectomy for high-risk PE when thrombolysis is contraindicated or has failed. 1
• Administer rescue thrombolytic therapy if hemodynamic deterioration occurs despite anticoagulation. 1

Intermediate- and Low-Risk PE Management

• Initiate anticoagulation immediately in patients with high or intermediate clinical probability while diagnostic workup is in progress. 1
• If anticoagulation is initiated parenterally, prefer LMWH or fondaparinux over UFH in hemodynamically stable patients. 1, 2
• Do not routinely administer systemic thrombolysis as primary treatment in intermediate- or low-risk PE. 1, 2

Oral Anticoagulation Selection

• When oral anticoagulation is initiated, prefer a NOAC (apixaban, dabigatran, edoxaban, or rivaroxaban) over a VKA. 1, 2
• As an alternative, administer a VKA overlapping with parenteral anticoagulation until INR reaches 2.5 (range 2.0-3.0). 1
• Do not use NOACs in patients with severe renal impairment (creatinine clearance <25-30 mL/min) or antiphospholipid antibody syndrome. 1, 2

Inferior Vena Cava Filters

• Do not routinely use IVC filters. 1, 2
• Reserve IVC filters only for patients with absolute contraindications to anticoagulation. 2

Duration of Anticoagulation

Minimum Duration

• Administer therapeutic anticoagulation for at least 3 months to all patients with PE. 1, 2

Provoked PE

• Discontinue therapeutic oral anticoagulation after 3 months in patients with first PE secondary to a major transient/reversible risk factor (surgery, trauma, immobilization). 1, 2

Unprovoked PE

• Continue oral anticoagulation indefinitely in patients with unprovoked PE when bleeding risk is low or moderate; annual recurrence risk exceeds 5%. 2
• Reassess at 3-6 months and then yearly for drug tolerance, adherence, hepatic and renal function, and bleeding risk. 1, 2

Recurrent VTE

• Continue oral anticoagulant treatment indefinitely in patients with recurrent VTE (≥1 previous episode of PE or DVT) not related to a major transient or reversible risk factor. 1, 2

Special Populations

• Continue oral anticoagulation with a VKA indefinitely in patients with antiphospholipid antibody syndrome. 1, 2
• Use therapeutic fixed-dose LMWH based on early-pregnancy weight during pregnancy; NOACs are contraindicated during pregnancy and lactation. 1, 2

Follow-Up and CTEPH Screening

Mandatory Reassessment

• Re-examine all patients at 3-6 months after acute PE to assess for persistent dyspnea, functional limitation, signs of VTE recurrence, cancer, or bleeding complications. 1, 2
• Recommend regular follow-up examinations at yearly intervals for patients on extended anticoagulation. 1

CTEPH Evaluation

• If persistent or new-onset dyspnea or functional limitation is present, implement staged diagnostic workup to exclude CTEPH or chronic thromboembolic disease. 1, 2
• Perform V/Q scintigraphy to detect mismatched perfusion defects. 2
• Refer symptomatic patients with persistent perfusion defects to a specialized CTEPH center. 2
• Follow-up imaging is not routinely recommended in asymptomatic patients, but may be considered in patients with risk factors for CTEPH development (unprovoked PE, large perfusion defects, RV dysfunction, hypothyroidism, diabetes). 1, 3

Critical Pitfalls to Avoid

• Never delay anticoagulation in high- or intermediate-probability PE while awaiting diagnostic confirmation. 1, 2
• Never measure D-dimer in high clinical probability patients; proceed directly to imaging. 1, 2
• Never use NOACs in severe renal impairment (<25-30 mL/min) or antiphospholipid syndrome; VKA is mandatory. 1, 2
• Never lose patients to follow-up after acute PE; routine reassessment at 3-6 months is essential for detecting CTEPH and guiding anticoagulation duration. 1, 2
• Never discontinue anticoagulation at 3 months in unprovoked PE without weighing bleeding risk; annual recurrence exceeds 5%. 2
• Never ignore persistent dyspnea, as it may indicate CTEPH requiring specialized evaluation. 2