What is the preferred choice between a drug-eluting stent and a bare metal stent for patients requiring stent placement?

Drug-Eluting Stents vs Bare Metal Stents: Evidence-Based Selection

Drug-eluting stents (DES) should be considered as the first-line choice over bare metal stents (BMS) for most patients requiring coronary stent placement due to significantly lower rates of restenosis and need for target vessel revascularization. 1

Advantages of Drug-Eluting Stents

• DES significantly reduces restenosis rates compared to BMS:

  • In the RAVEL trial, binary restenosis rates were 0% for DES vs 26% for BMS at 6 months 2
  • In the SIRIUS trial, angiographic restenosis rates were 8.9% for DES vs 36.3% for BMS at 8 months 2
  • Target vessel revascularization rates were substantially lower with DES (4.1% vs 16.6%) 2

• Long-term durability of DES has been demonstrated:

  • 3-year follow-up of the RAVEL trial showed target-vessel revascularization in 11.4% of DES group compared with 33.6% of BMS group 2

Patient Selection Algorithm

DES is Preferred When:

1. Patient can tolerate and comply with prolonged dual antiplatelet therapy (DAPT) for 12 months 1
2. Patient has clinical or anatomic factors that increase restenosis risk:
   • Diabetes mellitus
   • Small vessel diameter
   • Long lesions 1

BMS May Be 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 (increased bleeding risk with triple therapy) 1, 3

Duration of Antiplatelet Therapy

• BMS: Minimum of 30 days of DAPT
• DES: Minimum of 12 months of DAPT 1
• For drug-eluting stents, combination antiplatelet treatment should be maintained for at least 6–12 months 2

Special Considerations

Left Main Coronary Artery Disease

• Both DES and BMS have been used for unprotected left main coronary artery disease
• DES has shown lower rates of target-vessel revascularization (6% vs 17%) and MACE (8% vs 26%) compared to BMS at 12 months 2
• Patients undergoing PCI to unprotected left main coronary artery should be followed up with coronary angiography between 2 and 6 months after PCI 2

ST-Elevation Myocardial Infarction (STEMI)

• Both BMS and DES are useful in primary PCI for STEMI patients
• Newer-generation DES have demonstrated safety and efficacy in this population 1, 4

Common Pitfalls to Avoid

1. Underestimating DAPT compliance issues: Always assess patient's ability to comply with DAPT before choosing DES
2. Not discussing DAPT duration with patients: Patients must understand the importance of this long-term regimen
3. Ignoring planned procedures: Consider any surgeries or procedures likely to occur within 12 months before selecting DES
4. Automatic DES selection: Not all patients benefit from DES; consider individual circumstances 1, 3

Stent Thrombosis Risk

• Withdrawing antiplatelet therapy is a major risk factor for thrombosis for all types of stent
• High-risk factors for stent thrombosis include:
  • Discontinuation of antiplatelet therapy within 6-12 months after DES placement
  • History of stent thrombosis
  • Multiple stents or long stents
  • Stents placed at bifurcations
  • Incomplete revascularization
  • Diabetes
  • Low ejection fraction 2

By following this evidence-based approach to stent selection, clinicians can optimize outcomes by reducing both restenosis and thrombosis risks while considering individual patient factors that influence the risk-benefit ratio.