What is the preferred type of stent, bare metal stent (BMS) or drug eluting stent (DES), for patients requiring stent placement?

Drug-Eluting Stents vs. Bare Metal Stents: Clinical Decision Making

Drug-eluting stents (DES) are generally preferred over bare metal stents (BMS) for most patients requiring coronary stent placement due to their significantly lower rates of restenosis and need for target vessel revascularization, provided patients can tolerate and comply with dual antiplatelet therapy (DAPT).

Evidence-Based Comparison

Efficacy Advantages of DES

• DES significantly reduces restenosis rates compared to BMS 1
• DES decreases the need for repeat revascularization procedures 1
• Newer-generation DES have shown superior safety and efficacy compared to first-generation DES 1
• Long-term follow-up (5 years) has shown DES may reduce all-cause mortality compared to BMS in some populations 1

Safety Considerations

• Both DES and BMS have similar rates of death and MI at 2-4 years of follow-up 1
• Newer-generation DES have lower rates of stent thrombosis compared to first-generation DES 1
• The primary safety concern with DES is the requirement for longer DAPT duration (typically 12 months) 1

Clinical Decision Algorithm

DES is Preferred When:

1. Patient can tolerate and comply with prolonged DAPT (12 months) 1
2. Patient has clinical or anatomic factors that increase restenosis risk:
   • Diabetes mellitus
   • Small vessel diameter
   • Long lesions
   • Multiple lesions
   • Left main disease
   • Bifurcation lesions
   • In-stent restenosis
   • Saphenous vein grafts 1

BMS is Preferred When:

1. Patient has high bleeding risk
2. Patient is unable to comply with 12 months of DAPT
3. Patient has anticipated invasive or surgical procedures within the next 12 months that would require interruption of DAPT
4. Patient requires long-term anticoagulation (increasing bleeding risk with triple therapy) 1

Implementation Considerations

Before DES Implantation:

• The interventional cardiologist must discuss with the patient:
  • The need for and duration of DAPT
  • Confirm the patient's ability to comply with the recommended therapy 1
  • Assess financial barriers that might limit compliance with DAPT
  • Evaluate bleeding risk and need for future procedures 1

DAPT Duration Requirements:

• BMS: Minimum 30 days of DAPT 1
• DES: Minimum 12 months of DAPT is the current consensus 1
• For patients who cannot maintain DAPT for the required duration, DES should be avoided due to increased risk of stent thrombosis 1

Special Populations

STEMI Patients:

• Both BMS and DES are useful in primary PCI for STEMI patients 1
• Newer-generation DES have demonstrated safety and efficacy in STEMI patients 1
• The same considerations regarding DAPT duration apply in STEMI patients 1

Patients with Recurrent In-Stent Restenosis:

• DES is the preferred treatment for in-stent restenosis 1
• For recurrent diffuse in-stent restenosis, CABG may be preferred over repeat PCI 1

Common Pitfalls to Avoid

1. Underestimating DAPT compliance issues: Always assess the patient's ability to comply with DAPT before choosing DES
2. Ignoring planned procedures: Failure to consider upcoming surgeries or procedures that might require DAPT interruption
3. Not discussing DAPT duration: Patients must understand the importance of uninterrupted DAPT therapy to prevent stent thrombosis
4. Automatic DES selection: Not all patients benefit from DES; some patients are better served with BMS due to their clinical circumstances

By carefully considering these factors, clinicians can make appropriate stent selections that optimize outcomes while minimizing risks for each individual patient.