Dear Editor:

While attending the 2017 AANN Advances in Stroke Care Conference in Chicago, Illinois, this past August, I asked a question that sparked discussion and revealed various practices. My question is: "For inpatients that have acute stroke symptoms, should alteplase be considered if the patient is on a prophylactic dose of a low molecular weight heparin (LMWH)?" In the article written by Demaerschalk et al,1^(p600) the initial guidelines stated, "Intravenous alteplase in patients who have received a dose of LMWH within the previous 24 hours is not recommended. This applies to both prophylactic doses and treatment doses." However, there was an erratum written on October 20162 that stated, "Intravenous alteplase in patients who have received a treatment dose of LMWH within the previous 24 hours is not recommended (class III/level of evidence B)." Because most of our inpatients are on 40 mg of enoxaparin daily for venous thromboembolism prophylaxis, what is the recommendation for administering alteplase to this patient population when acute ischemic stroke is suspected?

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