Left ventricular (LV) thrombus at autopsy and systemic emboli during life have been frequent findings in patients with dilated cardiomyopathy. Since anticoagulation has substantial risk, noninvasive identification of those patients likely to have emboli is important. Therefore, wide-angle 2-dimensional (2-D) echocardiograms in 123 patients (average age 56 +/- 6 years) with chronic dilated cardiomyopathy were analyzed for the presence of LV thrombus; these findings were compared with the clinical course in 96 patients. On 2-D echocardiography, thrombus was present in 44 patients (36%). Events compatible with systemic emboli occurred in 11 patients (11%), and were not more frequent in those patients with than in those without LV thrombus. In addition, neither the presence of thrombus nor the frequency of systemic emboli differed between patients with and those without associated coronary artery disease. Thus, although 2-D echocardiography shows a high frequency of LV thrombus in patients with dilated cardiomyopathy irrespective of the presence of coronary artery disease, clinical events compatible with systemic emboli are not more frequent in those with than those without LV thrombus.