What's Hot in Clots: March 2026
Mar 2, 2026
Behnood Bikdeli, MD, MS
Vascular Medicine Advisor, VLN Medical Advisory Board
What's Hot in Clots: March 2026
These are challenging times. I’ve lost count of how many times I’ve begun this blog by wishing for peace; this is another month of that same hope. I pray for a world where people are heard, respected, and can love and live together in safety and dignity. With that said, here is my summary for the month:
The new AHA/ACC guideline for PE: A new era of risk stratification
It’s not every day that a major new thrombosis guideline comes out. To honor that, instead of my usual brief snippets, I have dedicated this entire monthly update to this new guideline.
The first-ever AHA/ACC guideline for pulmonary embolism, in collaboration with several other societies, was released recently. The most notable piece to me is the newly introduced AHA/ACC Clinical Categories. I think of it as a more comprehensive and expanded version of the prior classification criteria (from asymptomatic individuals in Category A to those with sustained hypotension [shock] in Category E). I have heard different opinions about this change. The additional information will likely make the categories more homogenous and accurate. Others share concern over its complexity. Personally, I like the new change and look forward to seeing validation studies. There are many other recommendations including:
Diagnosis: Consider age- or pregnancy-adjusted D‑dimer cutoffs. CTPA is preferable over V/Q imaging but if CT is not possible, consider V/Q (especially V/Q SPECT).
Risk stratification: It includes multiple factors such as symptoms, clinical criteria such as sPESI or Hestia, clot location, troponin results, right ventricular imaging findings, subclinical hemodynamic changes (such as lactate or cardiac index) without change in blood pressure, and overt hypotension.
Respiratory modifier: For the first time, a clear respiratory modifier is added to AHA/ACC Clinical Categories, compared with prior classifications.
Management: It's really risk-based. Those at low risk can go home—soon. Those who are inpatient should preferentially start on low-molecular-weight heparins. Recanalization with thrombectomy or (catheter-directed) fibrinolysis should be considered in sicker patients. In less sick, non-low-risk individuals, their clear role remains uncertain. For those with refractory shock, catheter-based therapies, systemic fibrinolysis, and/or ECMO should be considered.
Long-term care: Although the guideline is named for “acute” PE, it includes several interesting recommendations for post-discharge management, including, but not limited to, considerations for anticoagulation.
While I won’t be able to make it to ACC in person for family reasons, I look forward to covering several important studies for you next month, including HI-PEITHO (design here), SirPAD (design here), and others next month! And in two months, we’ll have more to share about PE. Stay tuned!
Behnood Bikdeli, MD, MS