Top Things to Know: Management of Patients at Risk of Ischemic Stroke With Left Ventricular Systolic Dysfunction in the Absence of Intracardiac Thrombus

Updated: July 02, 2026

Prepared by Anne Leonard MPH, BSN, RN – National Senior Director Science and Medicine.

  1. Left ventricular (LV) systolic dysfunction (LVSD), defined here as reduced LV ejection fraction ≤40% or left wall motion abnormality, and is commonly found in patients with ischemic stroke.
  2. Patients with LVSD (without a detected thrombus) have a higher risk of first and recurrent embolic stroke, however there is limited evidence supporting the use of anticoagulation in these patients.
  3. Although LVSD is an established mechanism of embolic stroke, there remains a gap in terms of definitive therapy, unlike for other sources of cardioembolism, such as atrial fibrillation (AF).
  4. This statement discusses the cardiac diagnostic modalities to identify systolic dysfunction and evaluation for left ventricular (LV) thrombus. Clinical guidance for imaging includes transthoracic echocardiography (TTE) with UEA is ejection fractions is ≤40% or WMA is present on the current or prior TTE. Cardiac computed tomography (CT) or magnetic resonance imaging if suggested if LV dysfunction is present.
  5. People who are at risk of LV thrombus include: prior LV thrombus, recent myocardial infarction, LV akinesis or dyskinesis or aneurysm or LV EF ≤40%.
  6. The paper suggests a holistic integrated management approach using ”ABC”; avoid stroke, better function status and comorbidities and cardiovascular disease management.
  7. Risk stratification of cardioembolic stroke in LVSD for antithrombotic for management in the decision-making time-period is addressed in this paper.
  8. The available evidence examined in this paper supports an independent relationship between LV dysfunction and ischemic stroke risk.
  9. Patients with stroke and LVSD warrant a comprehensive evaluation for any underlying causes of LVSD and for associated cardiac dysrhythmias (such as paroxysmal AF) that could predispose to stroke. A multidisciplinary team approaching this issue is warranted and includes; vascular neurology, cardiology pharmacy etc.
  10. This scientific statement discusses anticoagulation versus antiplatelet (antithrombotic) therapy for the prevention of ischemic stroke in LVSD as well as the timing of anticoagulation initiation if indicated after stroke. With this, the gaps in knowledge are elucidated in this paper.

View the summary for Management of Patients at Risk of Ischemic Stroke With Left Ventricular Systolic Dysfunction in the Absence of Intracardiac Thrombus

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Citation

Sharma R, Levine GN, Spinler SA, Merkler AE, Lip GYH, Ashcraft S, Waken RJ, Skowronski JN, Siegler JE; on behalf of the American Heart Association Stroke Council; Council on Basic Cardiovascular Sciences; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; Council on Clinical Cardiology; and Council on Lifelong Congenital Heart Disease and Heart Health in the Young. Management of patients at risk of ischemic stroke with left ventricular systolic dysfunction in the absence of intracardiac thrombus: a scientific statement from the American Heart Association. Stroke. Published online July 2, 2026. doi: 10.1161/STR.0000000000000528
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