COR LOE Recommendations In patients with stroke or TIA and LV thrombus, anticoagulation with therapeutic warfarin for at least 3 months is recommended to reduce the risk of recurrent stroke.504 508 In patients with stroke or TIA in the setting of acute MI, it is reasonable to perform advanced cardiac imaging (eg, contrasted echocar- diogram or cardiac MRI) to assess for the presence of LV thrombus. In patients with stroke or TIA and new LV thrombus (<3 months), the safety of antico- agulation with a direct oral anticoagulant to reduce risk of recurrent stroke is uncertain.509 In patients with stroke or TIA in the setting of acute anterior MI with reduced ejection fraction (EF; <50%) but no evidence of LV thrombus, empirical anticoagulation for at least 3 months might be considered to reduce the risk of recurrent cardioembolic stroke. Synopsis Decreased contractility in the LV, particularly at the LV apex, creates the possibility of blood pooling and subse- quent coagulation and thrombus formation. Thrombus in the LV is then at risk of systemic embolization. Although LV thrombus can form anytime blood stasis occurs, patients with acute MI, who have had acute vessel clo- sure with associated loss of myocardial contractility, are at risk of forming LV thrombus. Patients with anterior MI and reduced EF are a subgroup shown to be at particular risk CLINICAL STATEMENTS AND GUIDELINES Kleindorfer for LV thrombus formation. The associated risk of stroke or systemic embolism in the presence of LV thrombus is reduced by use of systemic anticoagulation. Over time, thrombus in the LV matures and becomes incorporated into the wall of the akinetic segment, and the risk of embolism is reduced. 