A 78 year-old woman without previous cardiac disease was trans-ferred to our center for suspected acute myocardial infarction. Shehad a historyof hypertension, dyslipidemia, bronchial hyperreactivityand depression and was receiving ACE inhibitors, beta-blockers,statins, bronchodilators and antidepressant drugs. She complainedof abdominal pain, constipation, and nausea that had started fourdays earlier and were associated to general discomfort and asthenia,without chest pain or dyspnea. A fecaloma was extracted at homeby her primary care nurse without relief. She was referred to theemergency room of her community hospital. Blood pressure was110/75 mm Hg, pulse was regular at 91/min, breathing rate 22/min,oxygen saturation 93% (on 26% oxygen), no abnormal cardiac orbreath sounds were heard, mild, diffuse abdominal tenderness wasnoted and the rectal ampule was empty. The ECG showed sinusrhythm, narrow QRS and ST elevation up to 2 mm in leads V1–V4without reciprocal changes and a chest radiograph was normal.Blood tests were remarkable for mild leukocytosis (10,500/μL), creat-inine 1.3 mg/dL and troponin T 0.39 ng/mL. Although she did notrefer ischemic symptoms, she was transferred to our hospital for ur-gent coronary angiography. This exam was normal and she was ad-mitted to the coronary unit. An echocardiogram immediately afteradmission showed a non-dilated left ventricle with apical dyskinesia,35% ejectionfraction and a mural thrombus (30×15 mm) attached toits septoapical wall (Fig. 1).Anticoagulationwithsubcutaneousenoxaparin(1 mg/kgbid),inad-dition to oral aspirin, enalapril and carvedilol was initiated. Forty-eighthours after admission, she acutely became stuporous and developedleft hemiparesis and dysarthria. A cranial CT-scan and supra-aorticdupplex ultrasound were normal and an embolic stroke was diag-nosed. A new echocardiogram showed improvement of apical con-tractile dysfunction, ejection fraction 43% and persisting ventricularthrombus, now protruding, lobulated and markedly mobile. Anti-Xafactor levels were monitored and were always within the therapeuticrange. The neurological status improved, although some residualmotor deficit persisted. The ECG evolved to normalization of theST-segmentanddevelopmentofnegativeT-wavesandanechocardio-gram on the 5th day showed mild apical hypokinesia, 55% ejectionfraction and persisting ventricular thrombus.Onthe 7thdayshecomplainedof abdominalpainaccompaniedbyprogressive abdominal distension and metabolic acidosis. An abdom-inal CT-scan exhibited a large thrombus at the trunk and branchesof the superior mesenteric artery (Fig. 2) with signs of severe and dif-fuse bowel ischemia. After discussing the management options withher family, comfort measures were adopted and the patient devel-oped progressive hypotension and died on the same day. The thoracic