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Background Left ventricular thrombus (LVT) is a serious complication associated with various cardiac conditions. Early and accurate detection is crucial to prevent systemic embolization and adverse outcomes. This study aims to compare the diagnostic accuracy of transthoracic echocardiography (TTE) to cardiac magnetic resonance imaging (CMR) for detecting LVT in patients with reduced ejection fraction.Method This cross-sectional study evaluated the diagnostic accuracy of transthoracic echocardiography (TTE) compared to cardiac magnetic resonance imaging (CMR) as the gold standard. The study was conducted at a tertiary care hospital. Patients with reduced ejection fraction underwent both imaging modalities, and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were assessed. Medical records were reviewed to extract demographic and clinical characteristics, along with TTE and CMR findings.Results A total of 59 patients were included. TTE detected LVT in only two cases (3%), whereas CMR identified thrombus in 45 cases (76%). Sensitivity and specificity of TTE were 4% and 100%, respectively, while CMR had 100% sensitivity and specificity. The positive predictive value (PPV) of TTE was 100%, while the negative predictive value (NPV) was 25%.Conclusion TTE demonstrates high specificity but low sensitivity in LVT detection. Given its superior diagnostic accuracy, CMR should be prioritized for patients at high risk of LVT. This study suggests the need for supplemental imaging in high-risk patients, especially those with recent myocardial infarction or severe left ventricular dysfunction. Our findings underscore the importance of considering CMR in patients with high clinical suspicion of LVT, despite the availability of TTE in resource-limited settings