What are the criteria for starting daptomycin (Dapt) in patients with stroke?

Criteria for Starting Dual Antiplatelet Therapy (DAPT) in Stroke

For patients with non-cardioembolic ischemic stroke or high-risk TIA, dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel should be initiated early (ideally within 12-24 hours of symptom onset and at least within 7 days of onset) and continued for 21 to 90 days, followed by single antiplatelet therapy (SAPT), to reduce the risk of recurrent ischemic stroke. 1

Patient Selection Criteria for DAPT

Clinical Event Criteria

• Minor stroke: Patients with recent minor (NIHSS score ≤3) non-cardioembolic ischemic stroke 1
• High-risk TIA: Patients with high-risk TIA (ABCD2 score ≥4) 1
• Timing: DAPT should be initiated early, ideally within 12-24 hours of symptom onset and at least within 7 days of onset 1, 2

Alternative DAPT Regimen

• For patients with recent (< 24 hours) minor to moderate stroke (NIHSS score ≤5) or high-risk TIA (ABCD2 score ≥6), or symptomatic intracranial or extracranial ≥30% stenosis of an artery that could account for the event, DAPT with ticagrelor plus aspirin for 30 days may be considered 1
• This alternative regimen may reduce 30-day recurrent stroke risk but may also increase the risk of serious bleeding events, including intracranial hemorrhage 1

DAPT Loading Dose Recommendations

• Initial loading dose: Aspirin (160-325 mg) AND clopidogrel (300-600 mg) should be administered after excluding intracranial hemorrhage on neuroimaging 2
• Maintenance dose: Continue with clopidogrel 75 mg daily plus aspirin 81 mg daily for the duration of DAPT therapy 2
• Alternative loading regimen: Aspirin (300-325 mg) AND ticagrelor (180 mg), followed by aspirin 75-100 mg daily and ticagrelor 90 mg twice daily for 30 days 2

Duration of DAPT

• DAPT should be continued for 21 to 90 days after the initial event 1
• After this period, patients should be transitioned to single antiplatelet therapy (SAPT) 1
• The benefit in stroke reduction with DAPT may be maximized as early as the first 21 days after the event 1

Important Considerations and Cautions

• DAPT should only be initiated after intracranial hemorrhage has been ruled out on neuroimaging 2
• Continuous use of DAPT (aspirin plus clopidogrel) for >90 days is associated with excess risk of hemorrhage 1
• Triple antiplatelet therapy is not recommended due to increased bleeding risk without additional benefit in stroke reduction 1
• For patients already taking aspirin at the time of non-cardioembolic ischemic stroke or TIA, the effectiveness of increasing the dose of aspirin or changing to another antiplatelet medication is not well established 1

Special Populations

• For patients with symptomatic intracranial atherosclerotic disease, there are no strong recommendations supporting the use of DAPT over SAPT 1
• For patients with aortic arch atheroma, antiplatelet therapy is recommended to prevent recurrent stroke, but the effectiveness of long-term DAPT compared with aspirin monotherapy is unknown 1
• For patients with moyamoya disease and a history of ischemic stroke or TIA, the use of antiplatelet therapy, typically aspirin monotherapy, may be reasonable 1

Clinical Pitfalls to Avoid

• Do not continue DAPT beyond 90 days without a specific indication (e.g., recent drug-eluting cardiac stent placement) 1
• Do not use enteric-coated aspirin for the loading dose as it has a slower onset of action 2
• Do not confuse DAPT (dual antiplatelet therapy) with daptomycin (an antibiotic used for gram-positive infections) 3, 4
• Do not initiate DAPT in patients who have received acute thrombolysis without careful consideration of bleeding risk 1