question: A 30-year-old female with a past medical history of heart failure with reduced ejection fraction (HFrEF of 20%), non-ST segment elevation-acute coronary syndrome (NSTE-ACS), and polysubstance abuse (heavy alcohol and methamphetamine use) was admitted for a heart failure exacerbation. Electrocardiogram and troponin levels were negative. Pro brain natriuretic peptide was elevated at 4,152 pg/mL. The patient was restarted on guideline-directed HFrEF therapy and continued to improve. Two days after presentation, the patient was transferred to the intensive care unit for severe alcohol withdrawal, requiring intravenous phenobarbital and dexmedetomidine. After her withdrawal symptoms resolved, she complained of right-sided weakness and stroke-like symptoms. Brain magnetic resonance imaging (MRI) and computed tomography (CT) were both negative. Echocardiography revealed an ejection fraction of 20% and a severely dilated left ventricle with a 2.1 x 1.2 cm apical density, suggestive of a thrombus, and the patient was started on apixaban. Echocardiography two months prior to this admission revealed an ejection fraction of 20%, but there was no evidence of a thrombus. Our patient had three major risk factors for left ventricular thrombus (LVT) formation: severely reduced left ventricular ejection fraction (LVEF), dilated cardiomyopathy (DCM), and a recent NSTE-ACS two months prior. This case highlights the importance of anticoagulation in patients at high risk for LVT formation and emphasizes the DCM may be seen in younger patients with heavy alcohol and amphetamine use.