Over time, thrombus in the LV matures and becomes incorporated into the wall of the akinetic segment, and the risk of embolism is reduced. The exact time for each thrombus to mature to this point is unknown, but the risk of sys- temic embolism or stroke is reduced after 3 months. In the context of secondary stroke prevention, detection of LV thrombus is an important determinant of stroke type and appropriate therapy. Standard transthoracic echocar- diography is relatively insensitive for the detection of LV thrombus. Both contrast echocardiography with the use of a microbubble contrast agent and cardiac MRI are superior imaging modalities for detecting LV thrombus compared with standard transthoracic echocardiography. Recommendation-Specific Supportive Text 1. Patients with stroke or TIA in the context of LV thrombus should be anticoagulated until the thrombus has matured and the risk of further embolism has waned, 3 months. The bulk of evi- dence has used VKA for oral anticoagulation with a goal INR of 2.0 to 3.0. A large cohort study of 2160 patients from 1979 to 1998 noted that the risk of stroke after MI was dramatically higher in the first month after infarct and remained elevated for years afterward.510 In the percutaneous coro- nary angiography era, a multicenter study of 753 patients with ST-segment elevation MI identified LV thrombus in 3.5% and 7.1% of patients after ante- rior ST-segment elevation MI using cardiac MRI, although mural thrombus has been noted in as many as 26% of those studied in other series.504,505 In a meta-analysis of 8 studies encompassing 856 patients, Vaitkus and Barnathan506 noted an increased risk of stroke or systemic embolism in the presence of LV thrombus demonstrated on echocardiogram with an OR of 5.45. 