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A 62-year-old man presented with a 5-day history of progressively worsening dyspnea and orthopnea after returning from a 3-day business trip to the Far East. On physical examination, the heart rate was 102 beats per minute, and the blood pressure 110/60 mm Hg. The arterial oxygen saturation was 86 % while the patient was breathing am-bient air. The neck veins were distended. There was no heart murmur. The lungs were clear, and the extremities appeared normal. The d-dimer level was 5.13 mg per liter (normal level, less than 0.5), and the troponin T level was less than 0.01 μg per liter. A computed tomographic (CT) scan showed multiple thrombi in the pulmonary ar-teries and a dilated right ventricle. How should this case be managed? The Clinic a l Problem Acute pulmonary embolism is a major cause of complications and death associated with surgery, injury, and medical illnesses, and it may occur after long-distance air travel. Venous thromboembolism is responsible for up to 15 % of all in-hospital deaths, and it also accounts for 20 to 30 % of deaths associated with pregnancy and delivery in the United States and Europe. Overall, the annual incidence of pulmonary embo