Active internal bleeding and high blood pressure are additional contraindications for alteplase. The safety of alteplase in the pediatric population has not been determined definitively. Additional contraindications for alteplase when used specifically for acute ischemic stroke include current intracranial hemorrhage and subarachnoid hemorrhage. Contraindications for use of alteplase in people with a STEMI are similar to those of acute ischemic stroke. People with an acute ischemic stroke may also receive other therapies including mechanical thrombectomy. Adverse effects Given that alteplase is a thrombolytic medication, a common adverse effect is bleeding, which can be life threatening. Adverse effects of alteplase include symptomatic intracranial hemorrhage and fatal intracranial hemorrhage. Angioedema is another adverse effect of alteplase, which can be life-threatening if the airway becomes obstructed. Other side effects may rarely include allergic reactions. Mechanism of action Alteplase binds to fibrin in a blood clot and activates the clot-bound plasminogen. Alteplase cleaves plasminogen at the site of its Arg561-Val562 peptide bond to form plasmin. Plasmin is a fibrinolytic enzyme that cleaves the cross-links between polymerized fibrin molecules, causing the blood clot to break down and dissolve, a process called fibrinolysis. Regulation and inhibition Plasminogen activator inhibitor 1 stops alteplase activity by binding to it and forming an inactive complex, which is removed from the bloodstream by the liver. Fibrinolysis by plasmin is extremely short-lived due to plasmin inhibitors, which inactivate and regulate plasmin activity. Society and culture Alteplase was added to the World Health Organization's List of Essential Medicines in 2019, for use in ischemic stroke. As early use of alteplase is important for ischemic stroke, treatment delay is a serious concern. Many reasons for delay exist, including lack of access to healthcare, late presentation, late assessment, misdiagnosis, and management of comorbidities. Alteplase is extremely underused in low- and middle-income countries. This may be due to its high cost and the fact that it is often not covered by health insurance. There may be citation bias in the literature on alteplase in ischemic stroke, as studies reporting positive results for tissue plasminogen activator are more likely to be cited in following studies than those reporting negative or neutral results. There is a sex difference in the use of intravenous tissue plasminogen activator, as it is less likely to be used for women with acute ischemic stroke than men. However, this difference has been improving since 2008. Economics The cost of alteplase in the