From the Guidelines
Drug-eluting stents (DES) are preferred over bare-metal stents (BMS) in most clinical scenarios following angiography, particularly for patients with complex coronary lesions, diabetes, and those at high risk of restenosis. The indications for DES over BMS include:
- Left main disease
- Small vessels
- In-stent restenosis
- Bifurcations
- Diabetes
- Long lesions
- Multiple lesions
- Saphenous vein grafts These recommendations are based on the findings of studies such as 1, which demonstrated that DES are associated with a reduced need for repeat revascularization and no increase in death or MI compared with BMS at 4 years’ follow-up. Additionally, DES have been shown to decrease the risk of restenosis compared with BMS in patients with diabetes 1. However, DES require longer dual antiplatelet therapy (DAPT) - typically aspirin indefinitely plus a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) for at least 6-12 months, which may not be suitable for patients who cannot tolerate prolonged DAPT, have upcoming surgeries, or have high bleeding risk 1. The decision between DES and BMS should balance the reduced restenosis risk against the extended DAPT requirement and associated bleeding risk.
Some key considerations when deciding between DES and BMS include:
- The patient's ability to tolerate and comply with DAPT
- The risk of restenosis with BMS
- The risk of stent thrombosis with DES
- The presence of financial or social barriers to continuing prolonged DAPT
- The need for invasive or surgical procedures in the following year that would interrupt antiplatelet therapy
- The risk of bleeding with long-term “triple therapy” (aspirin, P2Y12 inhibitor, and warfarin) 1.
Overall, the choice between DES and BMS should be individualized based on the patient's specific clinical scenario and risk factors, with consideration of the potential benefits and risks of each type of stent.
From the Research
Indications for Drug Eluting Stent
The indications for drug eluting stent over normal stent after angiography include:
- Reduced risk of restenosis, particularly in patients with diabetes mellitus 2
- Improved outcomes in patients with small vessel coronary artery disease, although drug-coated balloons may be a preferable option in this setting 3
- Reduced risk of in-stent restenosis compared to bare metal stents 4, 5, 6
- Potential benefits in patients with complex lesions or renal failure, although late stent thrombosis and restenosis remain concerns 2
Patient-Specific Considerations
When considering the use of drug eluting stents, the following patient-specific factors should be taken into account:
- Diabetes status: patients with diabetes may benefit from the use of drug eluting stents, particularly those with everolimus eluting stents 5
- Vessel size: patients with small vessel coronary artery disease may be at higher risk for restenosis and stent thrombosis 3
- Lesion complexity: patients with complex lesions may be at higher risk for restenosis and stent thrombosis 2
- Renal function: patients with renal failure may be at higher risk for restenosis and stent thrombosis 2
Stent Selection
The selection of a drug eluting stent should be based on individual patient characteristics and lesion-specific factors, including:
- Stent type: different types of drug eluting stents have varying levels of efficacy and safety 4, 5, 6
- Drug coating: the type of drug coating used can affect the risk of restenosis and stent thrombosis 5
- Stent design: advancements in stent design have improved the safety and efficacy of drug eluting stents 4, 6