Case presentation
A 48-year-old Asian male with history of ischemic cardiomyopathy with low Ejection fraction (EF 15%). Received thrombolysis 2 months ago due to Right middle cerebral artery stroke. Presented with low cardiac output state require vasopressors support. patient was receiving anti-platelet medication (aspirin) but no anticoagulation. On repeating ECHO, there is excess intra-cardiac smoke-like Echoes fig (1-2). In the context of old stroke and excess intra-cardiac Smoke -like Echoes the Soft indication for therapeutic anticoagulation turned to Strong indication.