Hussien Hishmat: Pulmonary Embolism – How Does Risk Dictate Management

Hussien Hishmat, Professor at Cairo University, Consultant interventional cardiologist at Tadawi Healthcare, Fellow at European Society of Cardiology, shared on LinkedIn:

”The landscape of Pulmonary Embolism (PE) management has officially shifted.

With the release of the February 2026 ACC/AHA guidelines, the terminology we grew up with—massive and submassive—has been retired.

In clinical practice, PE is a ‘chameleon’ of risk.

While the average 30-day mortality sits between 7% and 11%, the reality is a spectrum: from less than 1% in incidental cases to over 30% in obstructive shock.

Here is what you need to know about the new A through E staging system and how it dictates your next move.

1. Why the Shift? The ‘Death BY vs. ‘Death WITH’ Distinction

It is vital to distinguish between patients dying by PE (where the embolus drives RV failure) and those dying with PE (where malignancy or comorbidities are the primary drivers).

The Late Surge: Remember, PE isn’t just an acute event. 50% of survivors report functional impairment at six months, and 2–4% will develop Chronic Thromboembolic Pulmonary Hypertension (CTEPH).

2. The New Staging: From Asymptomatic to Extreme

The 2026 guidelines move toward a sophisticated staging system (A–E), mirroring the SCAI staging for cardiogenic shock.

Stage, Definition, Clinical Implication

A: Asymptomatic – Incidentally discovered (e.g., cancer CT).Outpatient management.

B: Benign – Symptomatic but low risk (Normal BP/Biomarkers).

Early discharge or ward.

C: Serious – Markers of risk (RV strain or high Troponin).

Hospitalization, close monitoring.

D: Dangerous – Incipient failure; ‘normotensive shock.’

ICU; consider advanced therapy.

E: Extreme – Manifest cardiopulmonary failure or arrest.

Emergency intervention/Thrombolysis.

The “R” Modifier: Add ‘R’ if there is a primary respiratory driver (e.g., SaO2 < 90% or requiring mechanical ventilation).

3. Identifying ‘Normotensive Shock’

A stable blood pressure can be deceptive. A

MAP $> 80$ mmHg is a good prognostic sign, but we must look for tissue hypoperfusion even in normotensive patients:

• Rising Serum Lactate: Evidence of anaerobic metabolism.
• Declining Urine Output: Indicating renal hypoperfusion.
• Decreased Cardiac Index: Signs of a failing pump.

4. Tools of the Trade: Clinical Calculators

We no longer expect you to memorize every variable.

Use your EMR or smartphone to calculate these essential scores:

Disposition (Home vs. Hospital): Use sPESI or the Hestia Criteria.

A sPESI of 0 often justifies outpatient treatment.

Predicting Deterioration (Ward vs. ICU): Use the Bova Score or NEWS2 for longitudinal tracking. A NEWS2 score $> 9$ is a major red flag.

5. A Note on Thrombus Burden

A common pitfall is over-relying on the ‘size; of the clot on CTPA.

Thrombus burden does not correlate with short-term risk.

We treat the patient’s hemodynamic response, not the image.

A small distal PE causing RV failure is more dangerous than a large proximal clot with stable hemodynamics.

The Bottom Line 

Risk stratification is the ‘compass’ of PE management.

It tells us who can safely sleep in their own bed tonight and who needs a multidisciplinary PE Response Team (PERT) in the ICU.

Coming Up Next: We will dive into the pharmacological toolkit: from the nuances of DOACs to the latest in catheter-directed thrombolysis.

Stay tuned!”

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