A 51-year-old immobilised man, while recovering at stroke rehabilitation, complained of sudden onset chest pain prior to an unconscious collapse. Observations on arrival were heart rate 120 bpm, blood pressure 80/60 mm Hg and oxygen saturations of 90% on 10 L of oxygen. ECG demonstrated new right bundle branch block (RBBB) with classical S1Q3T3 repolarisation abnormality of acute right heart strain (figure 1A). Urgent CT pulmonary angiogram revealed saddle pulmonary embolism with extensive thrombus burden (figure 1B). Transthoracic echocardiogram (TTE) …