What are the indications for drug-eluting stents (DES) in patients with coronary artery disease (CAD)?

Indications for Drug-Eluting Stents in Coronary Artery Disease

Drug-eluting stents (DES) are recommended as the default choice for nearly all patients with coronary artery disease requiring stent placement, except when there are contraindications to extended dual antiplatelet therapy (DAPT). 1

Primary Indications for DES

• Reduction of restenosis and re-occlusion (Class I, Level A recommendation) 1
• Default treatment option in nearly all clinical conditions and lesion subsets 1
• Preferred over bare-metal stents (BMS) due to significantly lower rates of target vessel revascularization 2

Patient Selection Considerations

Ideal Candidates for DES

• Patients who can tolerate and comply with prolonged DAPT (12 months) 2
• Patients with clinical or anatomic factors that increase restenosis risk:
  • Diabetes mellitus 1
  • Small vessel diameter (<2.5mm) 1
  • Long lesions 2
  • Complex lesions (bifurcations, multivessel disease) 1
  • In-stent restenosis 2

Specific Clinical Scenarios

• Diabetes mellitus: DES is strongly recommended (Class I recommendation) 1
• Multivessel coronary disease: DES shows good medium-term results with low revascularization rates 3
• ST-elevation myocardial infarction (STEMI): Newer-generation DES have demonstrated safety and efficacy 2
• Unprotected left main coronary artery disease: DES shows lower rates of target-vessel revascularization (6% vs 17%) and MACE (8% vs 26%) compared to BMS 2
• Liver transplant candidates: DES is recommended with minimum 3 months DAPT for MELD <30 1

Contraindications and Cautions for DES

• Inability to comply with extended DAPT (12 months) 1, 2
• High bleeding risk patients 2
• Anticipated invasive or surgical procedures within 12 months requiring DAPT interruption 2
• Need for long-term anticoagulation (increased bleeding risk with triple therapy) 2

DAPT Requirements with DES

• Minimum duration: 12 months for all patients receiving DES 1
• Extended DAPT: May be reasonable beyond 1 year for patients with high-risk features 1:
  • Renal insufficiency
  • Diabetes
  • Multiple stents
  • Bifurcation lesions
• Low-dose aspirin: Should be continued indefinitely 1

Common Pitfalls in DES Selection

• Automatic DES selection without considering individual patient circumstances 2
• Underestimating DAPT compliance issues 2
• Not discussing DAPT duration with patients before procedure 2
• Ignoring planned procedures that might require DAPT interruption 2

Stent Selection Algorithm

1. Assess bleeding risk and DAPT compliance capability:

   • If patient can tolerate 12+ months of DAPT → Consider DES
   • If high bleeding risk or unable to comply with DAPT → Consider BMS or alternative strategies

2. Evaluate lesion characteristics:

   • Small vessels, long lesions, bifurcations, diabetes → Strong indication for DES
   • Simple, large vessel lesions → DES still preferred but BMS may be reasonable if DAPT concerns

3. Consider clinical context:

   • STEMI → Newer-generation DES recommended
   • Planned non-cardiac surgery within 12 months → Caution with DES
   • Liver disease (MELD >30) → Consider shorter DAPT duration 1

DES technology continues to evolve with newer generations showing improved safety profiles and potentially allowing for shorter DAPT durations in the future 4, but the current standard remains 12 months of DAPT for most patients receiving DES 1.