What is the preferred choice between bare metal stent (BMS) and drug-eluting stent (DES) for patients requiring stent placement?

From the Guidelines

Drug-eluting stents (DES) are generally preferred over bare metal stents (BMS) for most patients requiring coronary stent placement. This is because DES are coated with medications like everolimus, zotarolimus, or sirolimus that are gradually released to prevent cell proliferation within the stent, significantly reducing the risk of restenosis compared to BMS (5-10% versus 20-30%) 1. After DES placement, patients typically require dual antiplatelet therapy (DAPT) with aspirin 81mg daily indefinitely plus a P2Y12 inhibitor (usually clopidogrel 75mg daily) for at least 6-12 months, whereas BMS may require only 1 month of DAPT 1.

The decision between stent types should be individualized based on the patient's clinical characteristics, bleeding risk, and ability to comply with the antiplatelet regimen. For example, BMS might still be considered in specific situations: patients who cannot adhere to prolonged DAPT, those with high bleeding risk, individuals requiring urgent non-cardiac surgery within 30-90 days, or when anticoagulation is also needed 1.

Some key considerations for choosing between DES and BMS include:

• Left main disease: DES are generally preferred due to lower risk of restenosis 1
• Small vessels: DES may be preferred due to lower risk of restenosis, but BMS may be considered in certain cases 1
• In-stent restenosis: DES are generally preferred due to lower risk of restenosis 1
• Diabetes: DES may be preferred due to lower risk of restenosis 1
• Long lesions: DES may be preferred due to lower risk of restenosis, but BMS may be considered in certain cases 1
• Multiple lesions: DES may be preferred due to lower risk of restenosis, but BMS may be considered in certain cases 1
• Saphenous vein grafts: DES may be preferred due to lower risk of restenosis, but BMS may be considered in certain cases 1

Modern DES have largely addressed earlier concerns about late stent thrombosis, making them the standard choice for most patients undergoing percutaneous coronary intervention 1. However, the choice between DES and BMS ultimately depends on the individual patient's needs and circumstances, and should be made in consultation with a healthcare provider.

From the Research

Comparison of Bare Metal Stents and Drug-Eluting Stents

• The choice between bare metal stents (BMS) and drug-eluting stents (DES) depends on various factors, including the patient's risk of bleeding or thrombosis, restenosis risk, and the need for long-term oral anticoagulation 2, 3, 4.
• Studies have shown that DES reduce the risk of restenosis and target vessel revascularization compared to BMS, but may require longer periods of dual antiplatelet therapy to prevent stent thrombosis 5, 6.
• The use of DES in patients at high risk of bleeding or thrombosis has been prospectively studied, and results suggest that DES can be safely used in these patients with a lower risk of major adverse cardiovascular events (MACE) compared to BMS 2.
• Angiographic variables, such as vein graft PCI, in-stent restenosis lesion, longer stent length, and smaller stent diameter, can significantly improve the assessment of restenosis risk and guide stent selection 3.

Safety and Efficacy of Drug-Eluting Stents

• DES have been shown to be safe in patients with an indication for long-term oral anticoagulation, with similar rates of total bleeding and major bleeding compared to BMS 4.
• Second-generation DES have been developed to overcome the issues of delayed arterial healing and polymer hypersensitivity reactions associated with first-generation DES, and have been shown to have lower rates of stent thrombosis compared to BMS 6.
• The thin-strut, fluoropolymer-coated cobalt-chromium everolimus-eluting stent (CoCr-EES) has been associated with lower rates of definite stent thrombosis than other DES and BMS 6.

Clinical Implications

• The choice of stent should be individualized based on the patient's clinical characteristics, angiographic factors, and the need for long-term oral anticoagulation 2, 3, 4.
• DES may be preferred in patients with a high risk of restenosis, while BMS may be preferred in patients with a high risk of bleeding or thrombosis 5.
• Further studies are needed to fully understand the safety and efficacy of DES in different patient populations and to guide stent selection 2, 3, 4, 5, 6.