05/05/2026
๐๐จ๐๐ ๐๐.
That's what we should be calling it.
Not "massive." Not "submassive."
Those words are gone. The 2026 AHA/ACC guidelines โ 10 societies, one landmark document โ just retired them.
At the Emergency Medicine Symposium 2026 in Da Nang, Dr. SSampavan SivasubramanianFACEM stood on stage and made it plain:
The classification system you trained on is obsolete.
Here's why it matters.
An 18-year-old. OCP for 10 days. Two ED visits in five days.
Sent home as sub-segmental PE on anticoagulation โ twice.
HR 115. SpOโ 94%. BP 110/70.
Stable. Watch and wait.
Under the new AโE framework?
Her lactate at hour 6 was 2.4.
She was Category D. Normotensive shock.
Normal BP was lying to us the entire time.
๐๐ก๐ข๐ฌ ๐ข๐ฌ ๐ญ๐ก๐ ๐ฉ๐๐ซ๐๐๐ข๐ ๐ฆ ๐ฌ๐ก๐ข๐๐ญ.
The old question: Is the BP holding?
The new question: Is the perfusion holding?
Not the same question.
Lactate > 2 = normotensive shock. Full stop. These patients need ICU, PERT activated, and a clinician who isn't being reassured by a number that means nothing.
And PERT is no longer optional.
Class 1 recommendation. C2 through E.
Think Code Stroke โ but for PE. Single call. ED, Cardiology, IR, CT Surgery, ICU at the table before the patient decompensates.
Maqsood 2025 meta-analysis. 15,809 patients. PERT reduced mortality (OR 0.72), reduced major bleeding (OR 0.60), cut length of stay by 1.5 days.
For your low-risk discharges โ the COBRRA trial just settled the DOAC debate.
NEJM. March 2026. 2,760 patients.
Apixaban vs rivaroxaban. Apixaban cut clinically relevant bleeding by 54%.
RR 0.46. The debate is over. Pick apixaban.
This is what we called game changing care in our everyday patient care and advocacy.
This is why the Emergency Medicine Symposium exists.
Not to wait for the evidence to find us.
To go looking for it together โ and bring it back to the bedside.
Many clinicians left that room calling it differently. - Thank you all.
EM Symposium 2026 ยท Da Nang, Vietnam
EM Symposium 2027 โ coming. Watch this space.
Fun in the Sun โ | Amazing Education | Great Location | Grand Social Programme |