Pulmonary embolism (PE) is a common cardiopulmonary illness with an age and sex adjusted incidence of approximately 117 cases per 100 000 person years.1 Incidence rises sharply after the age of 60 years in both men and women. While mortality rates exceed 15% in the 3 months following diagnosis, they are reduced to 2–10% if PE is diagnosed and treated promptly.2 3 The majority of patients with PE are haemodynamically stable at presentation and receive anticoagulation with heparin. By contrast, thrombolysis (or embolectomy) is the accepted standard of care in those patients who present with haemodynamic compromise.4 Under such circumstances, mortality approaches 50% and although to date no study has been powered to show a mortality benefit, such treatment potentially outweighs the complication rate of 3%.2 5 Importantly, it is now recognised that there is another cohort of patients who, although haemodynamically stable, are nevertheless at an increased risk of death and who currently receive only standard anticoagulation regimens. To date, no consensus exists regarding the identification, appropriate risk stratification or indeed the further management of these patients. Those who favour thrombolysis for the treatment of PE argue that its use should be extended to the subgroup of patients with preserved systemic arterial pressure but evidence of right ventricular (RV) dysfunction.5 6 …