Acute pulmonary embolism: clinical and echocardiographic recognition of normotensive shock

The 2026 AHA/ACC guideline on acute pulmonary embolism introduces normotensive shock as a clinically relevant pre-cardiopulmonary failure state with implications for treatment escalation. Evidence from cardiogenic shock indicates that tissue hypoperfusion despite preserved arterial blood pressure is associated with substantial mortality, underscoring the need for early recognition. This requires reliable, rapidly obtainable, and broadly applicable criteria. As several proposed indicators are limited by delayed availability or restricted bedside use, shock assessment should integrate concordant clinical signs of tissue hypoperfusion rather than rely on a single marker. Prolonged capillary refill time and skin mottling may complement lactate as bedside markers of abnormal skin perfusion. Critical care echocardiography further supports this multimodal approach by confirming acute right ventricular pressure overload, excluding alternative causes of circulatory failure, and assessing right ventricular adaptation and right ventricular-pulmonary arterial coupling. Early recognition may identify patients at imminent risk of deterioration who could benefit from timely treatment escalation, including consideration of reperfusion therapy.