From the Guidelines
For a patient with a STEMI and a bleeding disorder, a bare metal stent (BMS) is generally preferred over a drug-eluting stent (DES) during primary PCI. This recommendation is based on the shorter duration of dual antiplatelet therapy (DAPT) required with BMS, which reduces the risk of bleeding complications in patients with bleeding disorders, as suggested by the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction 1. The guideline recommends BMS for patients with high bleeding risk, inability to comply with 1 year of DAPT, or anticipated invasive or surgical procedures in the next 1 year. Key considerations for managing such patients include:
- Using a BMS to minimize the duration of DAPT, typically 1 month, compared to at least 6-12 months for DES
- Administering loading doses of aspirin and a P2Y12 inhibitor like clopidogrel before the procedure, with clopidogrel preferred over more potent agents for patients with high bleeding risk
- Careful anticoagulation during the procedure with agents like unfractionated heparin, bivalirudin, or enoxaparin, and adjusting doses based on the specific bleeding disorder
- Considering radial access instead of femoral access to reduce bleeding complications. While newer-generation DES have improved safety profiles, the traditional approach prioritizes minimizing bleeding risk through BMS use when a significant bleeding disorder is present, as supported by the guideline's recommendation to avoid DES in patients with elevated bleeding risk 1.
From the Research
Patient with STEMI and Bleeding Disorder
- The patient presents with chest pain and has a STEMI on EKG, and also has a bleeding disorder.
- The choice between PCI with a metal stent or a drug-eluting stent must be made with consideration of the patient's bleeding disorder.
Considerations for PCI in STEMI Patients with Bleeding Disorders
- According to 2, antithrombotic therapy is crucial for patients with STEMI undergoing primary PCI, but the study does not specifically address the choice between metal and drug-eluting stents in patients with bleeding disorders.
- Studies 3, 4, 5 focus on the effectiveness and safety of P2Y12 inhibitors in STEMI patients undergoing PCI, but do not directly compare metal and drug-eluting stents in the context of bleeding disorders.
Comparison of Metal and Drug-Eluting Stents
- A study from 6 compared the long-term clinical outcomes of STEMI patients treated with primary PCI and drug-eluting or bare-metal stents, finding that drug-eluting stents were associated with a reduced risk of target lesion revascularization, but a trend toward increased risk of definite stent thrombosis.
- However, this study did not specifically address the issue of bleeding disorders, and more research is needed to determine the optimal choice of stent in this patient population.
Decision Making
- In the absence of direct evidence comparing metal and drug-eluting stents in STEMI patients with bleeding disorders, the decision should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.
- Consultation with a cardiologist and consideration of the patient's specific condition, including the severity of the bleeding disorder and the risk of stent thrombosis, are necessary to make an informed decision.