Following an anterior STEMI, an ECG on day 3 shows persistent ST elevation with Q waves in V1–V4. Echocardiography reveals a thin akinetic segment with a layered thrombus in the left ventricular apex. The most appropriate additional therapy is:

• A Addition of clopidogrel alone to aspirin
• B Surgical resection of the aneurysm immediately
• C Initiation of amiodarone prophylactically
• D Anticoagulation with warfarin (target INR 2–3) for at least 3 months ✓

Explanation

Left ventricular thrombus complicating anterior MI requires anticoagulation to prevent systemic embolism; warfarin with a target INR of 2–3 for 3–6 months (or longer if thrombus persists) is recommended. DOACs (rivaroxaban, apixaban) are increasingly used but are not yet universally guideline-endorsed for LV thrombus. Dual antiplatelet therapy without anticoagulation is insufficient. Surgical resection is not indicated for thrombus alone. Amiodarone does not address the thrombus.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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