Shahad M Alhazmi, Abdulelah M Alhazmi, Omar S Badhawi
Left ventricular thrombus (LVT) is a serious complication of ischemic cardiomyopathy and anterior myocardial infarction, with an important risk of systemic embolism and stroke. Transthoracic echocardiography is commonly used for diagnosis and follow-up, but it may fail to detect residual thrombus in some high-risk patients. We report the case of a 64-year-old Saudi man with diabetes mellitus, hypertension, severe ischemic cardiomyopathy, and a known left ventricular apical thrombus after prior anterior myocardial infarction and multivessel coronary intervention. He was treated with apixaban and guideline-directed medical therapy. Follow-up echocardiography later showed no visible thrombus, and anticoagulation was discontinued. However, the patient subsequently developed an ischemic stroke with prolonged disability. This case highlights the diagnostic uncertainty that may remain after apparent resolution of LVT on echocardiography and emphasizes the need for careful clinical judgment before stopping anticoagulation in patients with severe left ventricular dysfunction and high embolic risk. Advanced imaging, such as cardiac magnetic resonance imaging or contrast-enhanced echocardiography, may be considered when diagnostic certainty is required.