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

Drug-Eluting Stents Should Be the Default Choice for Nearly All Patients

Drug-eluting stents (DES) should be used as the preferred stent type in nearly all patients undergoing percutaneous coronary intervention, with bare-metal stents (BMS) reserved only for patients who cannot tolerate or comply with 12 months of dual antiplatelet therapy (DAPT). 1

Primary Decision Algorithm

The stent selection process follows this hierarchy:

Step 1: Assess DAPT Capability (Most Critical Factor)

Use bare-metal stents if ANY of the following apply:

• Patient cannot afford or access aspirin plus clopidogrel for 12 months 1
• Patient has documented non-compliance with medications 1
• Surgery requiring DAPT discontinuation is planned within 6-12 months 2
• Active bleeding disorder or recent major hemorrhage 2
• Chronic conditions requiring long-term anticoagulation where triple therapy duration must be minimized 3

Otherwise, proceed to drug-eluting stents 1

Step 2: Confirm DES Advantages Apply

Drug-eluting stents provide superior outcomes by reducing:

• Restenosis rates (by approximately 50% compared to BMS) 4, 5
• Need for repeat revascularization 2
• Myocardial infarction risk (with newer generation DES) 1, 5

These benefits are sustained at 4-year follow-up without increased mortality 2

Specific Clinical Scenarios

High Restenosis Risk Lesions (Strongly Favor DES)

Drug-eluting stents are particularly superior for:

• Left main coronary artery disease 1, 6
• Small vessel diameter (≤2.5 mm) 1
• Long lesions 1
• Diabetes mellitus 1
• Bifurcation lesions 1
• Saphenous vein grafts 1
• Chronic total occlusions 2

In these anatomic subsets, bare-metal stents carry restenosis rates of 32-55%, making DES the clear choice 2

Acute Coronary Syndromes

In STEMI patients who can comply with prolonged DAPT, drug-eluting stents are both safe and effective with lower restenosis rates than bare-metal stents 1, 7. The historical concern about increased stent thrombosis with DES in acute settings has not been confirmed in contemporary trials 7

Patients on Anticoagulation

For patients requiring long-term oral anticoagulation:

• Bare-metal stents are preferred when triple therapy is necessary because they allow shorter duration (2-4 weeks vs 3-6 months) 1, 3
• However, recent evidence shows DES can be used safely in anticoagulated patients with similar bleeding rates and lower restenosis 3
• The decision hinges on whether the patient can safely tolerate extended triple therapy 3

Critical DAPT Duration Requirements

The antiplatelet regimen differs substantially:

Bare-metal stents: Minimum 1 month of DAPT (aspirin + clopidogrel) 1

Drug-eluting stents: Minimum 12 months of DAPT 2, 1

This difference is the primary reason to choose BMS—when 12 months of uninterrupted DAPT poses unacceptable risk 2, 1

Common Pitfalls to Avoid

The "Planned Surgery" Trap

If surgery is anticipated within 6-12 months, this must be identified BEFORE stent placement 2. Placing a DES and then discovering the patient needs surgery creates a dangerous situation where:

• Stopping DAPT risks catastrophic stent thrombosis 2
• Continuing DAPT risks surgical bleeding 2

The solution is to use bare-metal stents when surgery is planned within this timeframe 2

The Cost Consideration

Drug-eluting stents are substantially more expensive than bare-metal stents 2. However, cost alone should not drive the decision when DES provides clear clinical benefit 2. The reduced need for repeat revascularization with DES may offset initial costs 2

Late Stent Thrombosis Concerns

Earlier concerns about increased late thrombosis with first-generation DES have been addressed with newer-generation devices 5. Second-generation drug-eluting stents (especially everolimus-eluting) demonstrate superior safety profiles with reduced stent thrombosis compared to bare-metal stents 5. This represents a paradigm shift where DES are now safer than BMS in appropriately selected patients 5

Technical Considerations

Drug-eluting stents have a polymer coating that makes them stiffer and less conformable than bare-metal stents 2. In complex anatomy where deliverability is challenging, bare-metal stents may be technically easier to implant successfully 2. This is a practical, not theoretical, consideration during the procedure itself 2

The Bottom Line

The evidence strongly supports drug-eluting stents as the default choice 2, 1. The only legitimate reasons to choose bare-metal stents are:

1. Inability to complete 12 months of DAPT (compliance, cost, bleeding risk, planned surgery) 2, 1
2. Technical factors preventing DES delivery 2
3. Need to minimize triple therapy duration in anticoagulated patients 1, 3

In all other circumstances, drug-eluting stents provide superior clinical outcomes with acceptable safety when DAPT is maintained 1, 5.