(COR I; LOE B-R) Urgency Treatment should be initiated as quickly as possible within the above-listed time frames because time to treatment is strongly associated with outcomes. (COR I; LOE A) BP IV alteplase is recommended in patients with BP <185/110 mmHg and in those patients whose BP can be lowered safely to this level with antihypertensive agents, with the physician assessing the stability of the BP before starting IV alteplase. (COR I; LOE B-NR) Blood glucose IV alteplase is recommended in otherwise eligible patients with initial glucose levels >50 mg/dL. (COR I; LOE A) CT IV alteplase administration is recommended in the setting of early ischemic changes on NCCT of mild to moderate extent (other than frank hypodensity). (COR I; LOE A) (Continued) Powers et al 2019 Guidelines for Management of AIS e367 Prior antiplatelet therapy IV alteplase is recommended for patients taking antiplatelet drug monotherapy before stroke on the basis of evidence that the benefit of alteplase outweighs a possible small increased risk of sICH. (COR I; LOE A) IV alteplase is recommended for patients taking antiplatelet drug combination therapy (eg, aspirin and clopidogrel) before stroke on the basis of evidence that the benefit of alteplase outweighs a probable increased risk of sICH. (COR I; LOE B-NR) End-stage renal disease In patients with end-stage renal disease on hemodialysis and normal aPTT, IV alteplase is recommended. (COR I; LOE C-LD) However, those with elevated aPTT may have elevated risk for hemorrhagic complications. Additional recommendations for treatment with IV alteplase for patients with AIS (COR IIa) And (COR IIb) 3 to 4.5 h Age For patients >80 y of age presenting in the 3- to 4.5-h window, IV alteplase is safe and can be as effective as in younger patients. 