<p>Left ventricular thrombus (LVT) is a recognized complication following ST-elevation myocardial infarction (STEMI), most commonly anterior STEMI. This complication typically occurs within the first three months, with 90% of LVTs forming within four weeks of the index event. The main concern surrounding LVT is the associated risk of systemic emboli, including stroke. Current major society guidelines suggest that LVT prophylaxis can be considered in patients presenting with STEMI and antero-apical akinesia; however, this recommendation is conditional and based on limited evidence (Class IIb, Level C) and may increase the risk of major bleeding. This review outlines the pathophysiology of LVT formation in STEMI patients, its complications, risk factors, and the current evidence base for prevention and management strategies. Although the incidence of LVT has declined in the primary percutaneous coronary intervention (PCI) era, it remains a complication with significant clinical consequences. There is currently no standardized, evidence-based approach for prophylactic anticoagulation, and practice patterns vary widely, relying largely on clinician judgment. The most recent 2025 ACC/AHA/ACEP/NAEMSP/SCAI ACS guideline provides no updated recommendations, and neither the ESC nor CCS guidelines address prophylaxis in this context. This lack of guidance reflects the absence of robust, contemporary data in primary PCI era. Unanswered questions remain regarding whether the benefits of anticoagulation outweigh bleeding risks, the optimal agent, timing, and duration of therapy, and how follow-up imaging should be standardized. Future large-scale studies are needed to inform evidence-based recommendations and harmonize international practice.</p> Graphical abstract <p>Risk factors, epidemiology, imaging modalities, and potential prevention strategies for left ventricular thrombus following ST-elevation myocardial infarction.</p>