The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines.

Methods—

Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council’s Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers’ comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format.

Results—

These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings.

Conclusions—

These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

See related article, p 3331

New high-quality evidence has produced major changes in the evidence-based treatment of acute ischemic stroke (AIS) since the publication of the guidelines for the early management of patients with acute ischemic stroke in 2013.¹ Much of this new evidence has been incorporated into American Heart Association (AHA) focused updates, guidelines, or scientific statements on specific topics relating to the management of patients with AIS since 2013. The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations for clinicians caring for adult patients with acute arterial ischemic stroke in a single document. These guidelines address prehospital care, urgent and emergency evaluation and treatment with intravenous (IV) and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are often begun during the initial hospitalization. We have restricted our recommendations to adults and to secondary prevention measures that are appropriately instituted within the first 2 weeks. We have not included recommendations for cerebral venous sinus thrombosis because these were covered in a 2011 scientific statement and there is no new evidence that would change those conclusions.²

An independent Evidence Review Committee was commissioned to perform a systematic review of a limited number of clinical questions identified in conjunction with the writing group, the results of which were considered by the writing group for incorporation into the “2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke” (2018 AIS Guidelines)^2a and this 2019 update. The systematic reviews for the 2018 AIS Guidelines have been previously published.^3,4

These guidelines use the American College of Cardiology (ACC)/AHA Class of Recommendations (COR) and Level of Evidence (LOE) format shown in Table 1. New or revised recommendations that supersede previous guideline recommendations are accompanied by 250-word knowledge bytes and data supplement tables summarizing the key studies supporting the recommendations in place of extensive text. These data supplement tables can be found in Data Supplement 1 and literature search information for all data supplement tables can be found in Data Supplement 2. Because this guideline represents an update of the 2018 AIS Guidelines, the term “New Recommendation” refers to recommendations that are new to either the 2018 AIS Guidelines or to this 2019 update. Existing recommendations that are unchanged are reiterated with reference to the previous publication. These previous publications and their abbreviations used in this document are listed in Table 2. When there is no new pertinent evidence for these unchanged recommendations, no knowledge byte or data supplement is provided. For some unchanged recommendations, there are new pertinent data that support the existing recommendation, and these are provided. Additional abbreviations used in this guideline are listed in Table 3.

**Table 1.** Applying ACC/AHA Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015)
Table 1. Applying ACC/AHA Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015)

**Table 2.** Guidelines, Policies, and Statements Relevant to the Management of AIS
Document Title	Year Published	Abbreviation Used in This Document
“Recommendations for the Implementation of Telemedicine Within Stroke Systems of Care: A Policy Statement From the American Heart Association”⁵	2009	N/A
“Diagnosis and Management of Cerebral Venous Thrombosis: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”²	2011	N/A
“Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”¹	2013	2013 AIS Guidelines
“Interactions Within Stroke Systems of Care: A Policy Statement From the American Heart Association/American Stroke Association”⁶	2013	2013 Stroke Systems of Care
“2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society”⁷	2014	N/A
“Recommendations for the Management of Cerebral and Cerebellar Infarction With Swelling: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”⁸	2014	2014 Brain Swelling
“Palliative and End-of-Life Care in Stroke: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”⁹	2014	2014 Palliative Care
“Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”¹⁰	2014	2014 Secondary Prevention
“Clinical Performance Measures for Adults Hospitalized With Acute Ischemic Stroke: Performance Measures for Healthcare Professionals From the American Heart Association/American Stroke Association”¹¹	2014	N/A
“Part 15: First Aid: 2015 American Heart Association and American Red Cross Guidelines Update for First Aid”¹²	2015	2015 CPR/ECC
“2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”¹³	2015	2015 Endovascular
“Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”¹⁴	2015	2015 IV Alteplase
“Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”¹⁵	2016	2016 Rehab Guidelines
“Poststroke Depression: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”¹⁶	2017	N/A
“Treatment and Outcome of Hemorrhagic Transformation After Intravenous Alteplase in Acute Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”¹⁷	2017	N/A
“2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines”¹⁸	2018	N/A
“2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines”¹⁹	2018	2018 Cholesterol Guidelines

AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; AAPA, American Academy of Physician Assistants; ABC, Association of Black Cardiologists; ACC, American College of Cardiology; ACPM, American College of Preventive Medicine; ADA, American Diabetes Association; AGS, American Geriatrics Society; AHA, American Heart Association; AIS, acute ischemic stroke; APhA, American Pharmacists Association; ASH, American Society of Hypertension; ASPC, American Society for Preventive Cardiology; CPR, cardiopulmonary resuscitation; ECC, emergency cardiovascular care; HRS, Heart Rhythm Society; IV, intravenous; N/A, not applicable; NLA, National Lipid Association; NMA, National Medical Association; and PCNA, Preventive Cardiovascular Nurses Association.

**Table 3.** Abbreviations in This Guideline
ACC	American College of Cardiology
AHA	American Heart Association
AIS	Acute ischemic stroke
ARD	Absolute risk difference
ASA	American Stroke Association
ASCVD	Atherosclerotic cardiovascular disease
ASPECTS	Alberta Stroke Program Early Computed Tomography Score
BP	Blood pressure
CEA	Carotid endarterectomy
CeAD	Cervical artery dissection
CMB	Cerebral microbleed
COR	Class of recommendation
CPAP	Continuous positive airway pressure
CS	Conscious sedation
CT	Computed tomography
CTA	Computed tomographic angiography
CTP	Computed tomographic perfusion
DTN	Door-to-needle
DVT	Deep vein thrombosis
DW-MRI	Diffusion-weighted magnetic resonance imaging
ED	Emergency department
EMS	Emergency medical services
EVT	Endovascular therapy
GA	General anesthesia
GWTG	Get With The Guidelines
HBO	Hyperbaric oxygen
HR	Hazard ratio
HT	Hemorrhagic transformation
ICH	Intracerebral hemorrhage
IPC	Intermittent pneumatic compression
IV	Intravenous
LDL-C	Low-density lipoprotein cholesterol
LMWH	Low-molecular-weight heparin
LOE	Level of evidence
LVO	Large vessel occlusion
M1	Middle cerebral artery segment 1
M2	Middle cerebral artery segment 2
M3	Middle cerebral artery segment 3
MCA	Middle cerebral artery
MI	Myocardial infarction
MR	Magnetic resonance
MRA	Magnetic resonance angiography
MRI	Magnetic resonance imaging
mRS	Modified Rankin Scale
mTICI	Modified Thrombolysis in Cerebral Infarction
NCCT	Noncontrast computed tomography
NIHSS	National Institutes of Health Stroke Scale
NINDS	National Institute of Neurological Disorders and Stroke
OR	Odds ratio
OSA	Obstructive sleep apnea
PFO	Patent foramen ovale
RCT	Randomized clinical trial
RR	Relative risk
rt-PA	Recombinant tissue-type plasminogen activator
SBP	Systolic blood pressure
sICH	Symptomatic intracerebral hemorrhage
TIA	Transient ischemic attack
UFH	Unfractionated heparin

Members of the writing committee were appointed by the AHA Stroke Council’s Scientific Statements Oversight Committee, representing various areas of medical expertise. Strict adherence to the AHA conflict-of-interest policy was maintained throughout the writing and consensus process. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. Writing group members accepted topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations. Draft recommendations and supporting evidence were discussed by the writing group, and the revised recommendations for each topic were reviewed by a designated writing group member. The full writing group then evaluated the complete guidelines. The members of the writing group unanimously approved all recommendations except when relations with industry precluded members voting. Prerelease review of the draft 2018 guidelines was performed by 4 expert peer reviewers and by the members of the Stroke Council’s Scientific Statements Oversight Committee and Stroke Council Leadership Committee. The 2018 AIS Guidelines were approved by the AHA Science Advisory and Coordinating Committee on November 29, 2017, and by the AHA Executive Committee on December 11, 2017. It was published online January 24, 2018. On April 18, 2018, the AHA published a revision to the AIS Guidelines online, deleting 7 specific recommendations and all of Section 6, In-Hospital Institution of Secondary Prevention. The writing group was asked to review the entire guideline, including the deleted recommendations. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials (RCTs) with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent out to 14 peer reviewers. The writing group evaluated the peer reviewers’ comments and revised when appropriate. This revised document was reviewed by Stroke Council’s Scientific Statements Oversight Committee and the AHA Science Advisory and Coordinating Committee. To allow these guidelines to be as timely as possible, RCTs addressing AIS published between November 2018 and April 2019 were reviewed by the writing group. Modifications of Section 3.5.6., Recommendation 1, Section 3.6., Recommendation 4, and Section 3.7.2., Recommendation 2 resulted. To allow these modifications to be incorporated, the standard peer review process was abbreviated, with review provided by the members of the Stroke Council’s Scientific Statements Oversight Committee and by liaisons from the endorsing organizations listed on the masthead. The list of these reviewers is provided at the end of the guideline. The final document was approved by the AHA Science Advisory and Coordinating Committee and Executive Committee.

These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. They will not be applicable to all patients. Local resources and expertise, specific clinical circumstances and patient preferences, and evidence published since the issuance of these guidelines are some of the additional factors that should be considered when making individual patient care decisions. In many instances, only limited data exist demonstrating the urgent need for continued research on treatment of AIS.

A focused update addressing data from additional relevant recent RCTs is in process.

1. Prehospital Stroke Management and Systems of Care

1.1. Prehospital Systems

1.2. EMS Assessment and Management

1.3. EMS Systems

1.4. Hospital Stroke Capabilities

1.5. Hospital Stroke Teams

1.6. Telemedicine

1.7. Organization and Integration of Components

1.8. Establishment of Data Repositories

1.9. Stroke System Care Quality Improvement Process

2. Emergency Evaluation and Treatment

2.1. Stroke Scales

**Table 4.** National Institutes of Health Stroke Scale
Tested Item	Title	Responses and Scores
1A	Level of consciousness	0—Alert
		1—Drowsy
		2—Obtunded
		3—Coma/unresponsive
1B	Orientation questions (2)	0—Answers both correctly
		1—Answers 1 correctly
		2—Answers neither correctly
1C	Response to commands (2)	0—Performs both tasks correctly
		1—Performs 1 task correctly
		2—Performs neither
2	Gaze	0—Normal horizontal movements
		1—Partial gaze palsy
		2—Complete gaze palsy
3	Visual fields	0—No visual field defect
		1—Partial hemianopia
		2—Complete hemianopia
		3—Bilateral hemianopia
4	Facial movement	0—Normal
		1—Minor facial weakness
		2—Partial facial weakness
		3—Complete unilateral palsy
5	Motor function (arm)	0—No drift
	a. Left	1—Drift before 10 s
	b. Right	2—Falls before 10 s
		3—No effort against gravity
		4—No movement
6	Motor function (leg)	0—No drift
	a. Left	1—Drift before 5 s
	b. Right	2—Falls before 5 s
		3—No effort against gravity
		4—No movement
7	Limb ataxia	0—No ataxia
		1—Ataxia in 1 limb
		2—Ataxia in 2 limbs
8	Sensory	0—No sensory loss
		1—Mild sensory loss
		2—Severe sensory loss
9	Language	0—Normal
		1—Mild aphasia
		2—Severe aphasia
		3—Mute or global aphasia
10	Articulation	0—Normal
		1—Mild dysarthria
		2—Severe dysarthria
11	Extinction or inattention	0—Absent
		1—Mild loss (1 sensory modality lost)
		2—Severe loss (2 modalities lost)

2.2. Head and Neck Imaging

2.3. Other Diagnostic Tests

3. General Supportive Care and Emergency Treatment

3.1. Airway, Breathing, and Oxygenation

3.2. Blood Pressure

****Table 5.** Options to Treat Arterial Hypertension in Patients With AIS Who Are Candidates for Emergency Reperfusion Therapy***
Table 5. Options to Treat Arterial Hypertension in Patients With AIS Who Are Candidates for Emergency Reperfusion Therapy*

3.3. Temperature

3.4. Blood Glucose

3.5. IV Alteplase

**Table 6.** Management of Symptomatic Intracranial Bleeding Occurring Within 24 Hours After Administration of IV Alteplase for Treatment of AIS
Table 6. Management of Symptomatic Intracranial Bleeding Occurring Within 24 Hours After Administration of IV Alteplase for Treatment of AIS

**Table 7.** Management of Orolingual Angioedema Associated With IV Alteplase Administration for AIS
Table 7. Management of Orolingual Angioedema Associated With IV Alteplase Administration for AIS

**Table 8.** Eligibility Recommendations for IV Alteplase in Patients With AIS
Table 8. Eligibility Recommendations for IV Alteplase in Patients With AIS

**Table 9.** Treatment of AIS: IV Administration of Alteplase
Infuse 0.9 mg/kg (maximum dose 90 mg) over 60 min, with 10% of the dose given as a bolus over 1 min.
Admit the patient to an intensive care or stroke unit for monitoring.
If the patient develops severe headache, acute hypertension, nausea, or vomiting or has a worsening neurological examination, discontinue the infusion (if IV alteplase is being administered) and obtain emergency head CT scan.
Measure BP and perform neurological assessments every 15 min during and after IV alteplase infusion for 2 h, then every 30 min for 6 h, then hourly until 24 h after IV alteplase treatment.
Increase the frequency of BP measurements if SBP is >180 mm Hg or if DBP is >105 mm Hg; administer antihypertensive medications to maintain BP at or below these levels (Table 5).
Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters if the patient can be safely managed without them.
Obtain a follow-up CT or MRI scan at 24 h after IV alteplase before starting anticoagulants or antiplatelet agents.

AIS indicates acute ischemic stroke; BP, blood pressure; CT, computed tomography; DBP, diastolic blood pressure; IV, intravenous; MRI, magnetic resonance imaging; and SBP, systolic blood pressure.

3.6. Other IV Fibrinolytics and Sonothrombolysis

3.7. Mechanical Thrombectomy

3.8. Other Endovascular Therapies

3.9. Antiplatelet Treatment

3.10. Anticoagulants

3.11. Volume Expansion/Hemodilution, Vasodilators, and Hemodynamic Augmentation

3.12. Neuroprotective Agents

3.13. Emergency Carotid Endarterectomy Carotid Angioplasty and Stenting Without Intracranial Clot

3.14. Other

4. In-Hospital Management of AIS: General Supportive Care

4.1. Stroke Units

4.2 Head Positioning

4.3. Supplemental Oxygen

Note: Recommendations in this section are repeated from Section 3.1 because they apply to in-hospital management as well.

4.4. Blood Pressure

Note: Recommendation 1 in this section is repeated from Section 3.2 because it applies to in-hospital management as well.

4.5. Temperature

Note: Recommendations in this section are repeated from Section 3.3 because they apply to in-hospital management as well.

4.6. Glucose

Note: Recommendations in this section are repeated from Section 3.4 because they apply to in-hospital management as well.

4.7. Dysphagia

4.8. Nutrition

4.9. Deep Vein Thrombosis Prophylaxis

4.10. Depression Screening

4.11. Other

4.12. Rehabilitation

5. In-Hospital Management of AIS: Treatment of Acute Complications

5.1. Brain Swelling

5.2. Seizures

6. In-Hospital Institution of Secondary Stroke Prevention

The recommendations in this section reference other current AHA guidelines for secondary stroke prevention where applicable (Table 10). These other guidelines should be referred to for further information on secondary stroke prevention not covered in this document. These other guidelines are updated regularly, and the most recent versions should be used.

**Table 10.** Guidelines Relevant to Secondary Stroke Prevention
Document Title	Year Published	Abbreviation Used in This Document
“Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”¹⁰	2014	2014 Secondary Prevention
“2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines”¹⁸	2017	N/A
“2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines”¹⁹	2018	2018 Cholesterol Guidelines

AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; AAPA, American Academy of Physician Assistants; ABC, Association of Black Cardiologists; ACC, American College of Cardiology; ACPM, American College of Preventive Medicine; ADA, American Diabetes Association; AGS, American Geriatrics Society; AHA, American Heart Association; APhA, American Pharmacists Association; ASH, American Society of Hypertension; ASPC, American Society for Preventive Cardiology; N/A, not applicable; NLA, National Lipid Association; NMA, National Medical Association; and PCNA, Preventive Cardiovascular Nurses Association.

6.1. Brain Imaging

6.2. Vascular Imaging

6.3. Cardiac Evaluation

6.4. Glucose

6.5. Other Tests for Secondary Prevention

6.6. Antithrombotic Treatment

6.7. Carotid Revascularization

6.8. Treatment of Hyperlipidemia

6.9. Institution of Antihypertensive Medications

6.10. Smoking Cessation Intervention

6.11. Stroke Education

Additional reference support for this guideline is provided in online Data Supplement 1.^394–544

Disclosures

**Writing Group Disclosures**
Writing Group Member	Employment	Research Grant	Other Research Support	Speakers’ Bureau/Honoraria	Expert Witness	Ownership Interest	Consultant/Advisory Board	Other
William J. Powers	University of North Carolina, Chapel Hill	None	None	None	Wake Forest University Baptist Medical Center*	None	None	None
Alejandro A. Rabinstein	Mayo Clinic	None	None	None	None	None	None	None
Teri Ackerson	Saint Luke’s Health System, AHA/ASA	None	None	None	None	None	None	None
Opeolu M. Adeoye	University of Cincinnati	None	None	None	None	None	None	None
Nicholas C. Bambakidis	University Hospitals, Cleveland Medical Center	None	None	None	None	None	None	None
Kyra Becker	University of Washington School of Medicine, Harborview Medical Center	None	None	None	Defense and prosecution*	None	None	None
José Biller	Loyola University Chicago	None	None	None	None	None	None	None
Michael Brown	Michigan State University College of Human Medicine, Emergency Medicine	None	None	None	2018 Defense, Sandberg, Phoenix & Von Gontard; 2018 Defense, Kamykowski, Gavin & Smith	None	None	Cochrane (senior editor)†
Bart M. Demaerschalk	Mayo Clinic, Mayo Clinic Hospital	None	None	None	None	None	None	None
Brian Hoh	University of Florida	None	None	None	None	None	None	None
Edward C. Jauch	Mission Health System Research Institute	NINDS (StrokeNet coinvestigator); Diffusion Pharmaceuticals (PHAST-TSC DSMB member)	None	None	Plaintiff and defense*	None	Biogen*	None
Chelsea S. Kidwell	University of Arizona	None	None	None	None	None	None	None
Thabele M. Leslie-Mazwi	Massachusetts General Hospital	None	None	None	None	None	None	None
Bruce Ovbiagele	UCSF	None	None	None	None	None	None	None
Phillip A. Scott	University of Michigan Department of Emergency Medicine	NIH (principal investigator)†	University of Michigan (co-medical director, Clinical Trials Support Unit)*	None	Expert testimony 2017; 2018	None	None	University of Michigan (associate chair, Research Department of Emergency Medicine)†
Kevin N. Sheth	Yale University School of Medicine	Astrocyte (advisory); Bard (PI, Stroke Trial)†; Biogen (PI Stroke Trial)†; Hyperfine (PI, Imaging Trial including stroke patients)†; Zoll (DSMB chair)	None	None	None	Alva Health*	Biogen*	None
Andrew M. Southerland	University of Virginia	Diffusion Pharmaceuticals, Inc (Prehospital Administration of Acute Stroke Therapy with Trans-sodium Crocetinate [PHAST-TSC])†; NINDS UO1 NS069498 (SHINE Trial); NHLBI-NINDS U01 HL088942 (Cardiothoracic Surgical Trials Network)†; Coulter Translational Research Foundation (Brain and Neurological Deficit Identification Tool [BANDIT] Study)	None	None	Plaintiff and defense cases focused on questions related to stroke*	iTREAT Project, US Patent Application No. 14/910,890; BANDIT Project, US Provisional Patent Application No. 62/620,096	None	None
Deborah V. Summers	Saint Luke’s Health System	None	None	None	None	None	None	None
David L. Tirschwell	Harborview Medical Center	NIH†	None	None	None	None	None	None

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.

*Modest.

†Significant.

**Reviewer Disclosures**
Reviewer	Employment	Research Grant	Other Research Support	Speakers’ Bureau/Honoraria	Expert Witness	Ownership Interest	Consultant/Advisory Board	Other
Mark J. Alberts	Hartford HealthCare	None	None	Genentech (speakers’ bureau)†	None	None	None	None
Joseph P. Broderick	University of Cincinnati	NIH (trial)†; NIH (investigator)†	Genentech (PRISMS)†; Genentech (TNK)†	None	None	None	None	None
Colin P. Derdeyn	University of Iowa	None	None	None	None	Pulse therapeutics*	Penumbra*	None
Marc Fisher	Beth Israel Deaconess Medical Center	None	None	None	None	None	None	American Heart Association†
Karen L. Furie	Rhode Island Hospital	None	None	None	None	None	None	None
Philip B. Gorelick	Michigan State University	None	None	None	Employer received compensation for expert witness work†	None	IMPACT clinical trial; NeuroSpring	None
Walter N. Kernan	Yale University	None	None	None	None	None	None	None
Steven J. Kittner	Veterans Affairs Maryland Health Care System; University of Maryland School of Medicine	None	None	None	None	None	None	None
Patrick D. Lyden	Cedars-Sinai Medical Center	NIH*	None	None	None	None	None	None
Philip M. Meyers	Columbia University	None	None	None	None	None	None	None
Jeffrey L. Saver	UCLA	None	None	None	None	Rapid Medical*	Medtronic; Stryker; Neuravi/Ceronovus; Boehringer Ingelheim; St. Jude Medical*	University of California (employer)*
Steven Warach	University of Texas at Austin	State of Texas†	None	None	Private law firm*	Stock holdings in various pharma companies in a managed investment portfolio (myself); stock holdings in various pharma companies in a managed investment portfolio (family)	Genentech*	None
Lawrence R. Wechsler	University of Pittsburgh	None	None	None	None	None	None	None
Babu G. Welch	UT Southwestern Medical Center	None	None	Stryker Neurovascular (speakers’ bureau); Stryker Neurovascular (honoraria)	None	None	Stryker Neurovascular*	None

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.

*Modest.

†Significant.

Footnotes

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on September 12, 2019, and the American Heart Association Executive Committee on October 3, 2019. A copy of the document is available at https://professional.heart.org/statements by using either “Search for Guidelines & Statements” or the “Browse by Topic” area. To purchase additional reprints, call 843-216-2533 or email kelle.ramsay@wolterskluwer.com.

The online-only Data Supplements are available with this article at https://www.ahajournals.org/doi/suppl/10.1161/STR.0000000000000211.

The American Heart Association requests that this document be cited as follows: Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL; on behalf of the American Heart Association Stroke Council. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50:e344–e418 doi: 10.1161/STR.0000000000000211.

The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit https://professional.heart.org/statements. Select the “Guidelines & Statements” drop-down menu, then click “Publication Development.”

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Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

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Abstract

Background and Purpose—

Methods—

Results—

Conclusions—

1. Prehospital Stroke Management and Systems of Care

1.1. Prehospital Systems

1.2. EMS Assessment and Management

1.3. EMS Systems

1.4. Hospital Stroke Capabilities

1.5. Hospital Stroke Teams

1.6. Telemedicine

1.7. Organization and Integration of Components

1.8. Establishment of Data Repositories

1.9. Stroke System Care Quality Improvement Process

2. Emergency Evaluation and Treatment

2.1. Stroke Scales

2.2. Head and Neck Imaging

2.3. Other Diagnostic Tests

3. General Supportive Care and Emergency Treatment

3.1. Airway, Breathing, and Oxygenation

3.2. Blood Pressure

3.3. Temperature

3.4. Blood Glucose

3.5. IV Alteplase

3.6. Other IV Fibrinolytics and Sonothrombolysis

3.7. Mechanical Thrombectomy

3.8. Other Endovascular Therapies

3.9. Antiplatelet Treatment

3.10. Anticoagulants

3.11. Volume Expansion/Hemodilution, Vasodilators, and Hemodynamic Augmentation

3.12. Neuroprotective Agents

3.13. Emergency Carotid Endarterectomy Carotid Angioplasty and Stenting Without Intracranial Clot

3.14. Other

4. In-Hospital Management of AIS: General Supportive Care

4.1. Stroke Units

4.2 Head Positioning

4.3. Supplemental Oxygen

4.4. Blood Pressure

4.5. Temperature

4.6. Glucose

4.7. Dysphagia

4.8. Nutrition

4.9. Deep Vein Thrombosis Prophylaxis

4.10. Depression Screening

4.11. Other

4.12. Rehabilitation

5. In-Hospital Management of AIS: Treatment of Acute Complications

5.1. Brain Swelling

5.2. Seizures

6. In-Hospital Institution of Secondary Stroke Prevention

6.1. Brain Imaging

6.2. Vascular Imaging

6.3. Cardiac Evaluation

6.4. Glucose

6.5. Other Tests for Secondary Prevention

6.6. Antithrombotic Treatment

6.7. Carotid Revascularization

6.8. Treatment of Hyperlipidemia

6.9. Institution of Antihypertensive Medications

6.10. Smoking Cessation Intervention

6.11. Stroke Education

Disclosures

Footnotes

References

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