Drug-Coated Balloon in STEMI
Drug-coated balloons (DCB) should NOT be used instead of drug-eluting stents (DES) in primary PCI for STEMI—current guidelines universally recommend stent implantation (preferably new-generation DES) as the standard of care, with no established role for DCB as a primary treatment strategy in this setting.
Guideline-Mandated Stent Strategy
The evidence is unequivocal across all major cardiology societies:
Stenting is mandatory over balloon angioplasty alone during primary PCI for STEMI (Class I, Level A recommendation) 1, 2.
New-generation DES are specifically recommended over bare-metal stents (BMS) for primary PCI in STEMI patients (Class I, Level A) 1, 2.
No guideline from ESC, ACC/AHA, or EACTS mentions drug-coated balloons as an acceptable alternative to stenting in the acute STEMI setting 1.
Why Stents Are Superior
The rationale for mandatory stenting is based on robust mortality and morbidity data:
Stenting reduces target vessel revascularization and reinfarction risk compared to balloon angioplasty alone, though mortality benefit is primarily seen with DES over BMS in long-term follow-up 1.
New-generation DES demonstrate superior safety profiles with lower rates of stent thrombosis (0.8% vs. 1.2% for BMS) and significantly reduced repeat revascularization (16.5% vs. 19.8%) 1.
Five-year follow-up data from the EXAMINATION trial showed mortality reduction with DES compared to BMS in AMI patients 1.
When to Choose BMS Over DES
The only scenario where BMS is preferred over DES (but stenting is still mandatory):
High bleeding risk patients who cannot tolerate prolonged dual antiplatelet therapy (DAPT) 1, 2.
Inability to comply with 12 months of DAPT due to financial, social, or medical barriers 1, 2.
Anticipated need for invasive or surgical procedures within the next year that would require DAPT interruption 1.
Independent indication for long-term anticoagulation where triple therapy would pose excessive bleeding risk 1.
Critical Antiplatelet Requirements
Regardless of stent type, DAPT is non-negotiable:
Aspirin 162-325 mg loading dose before primary PCI (Class I, Level B) 1, 2, 3.
P2Y12 inhibitor loading as early as possible: clopidogrel 600 mg, prasugrel 60 mg, or ticagrelor 180 mg (Class I, Level B) 1, 2, 3.
Minimum 12 months of uninterrupted DAPT after DES implantation (Class I, Level A/B) 1, 2, 4.
Premature DAPT discontinuation is the leading preventable cause of stent thrombosis, which carries mortality rates exceeding 40% 4.
Procedural Technical Standards
Additional evidence-based technical recommendations:
Radial access is preferred over femoral access when performed by experienced operators (Class I/IIa, Level A) 1, 3.
Routine thrombus aspiration is NOT recommended (Class III, Level A) 1, 3.
Routine deferred stenting is NOT recommended based on the DANAMI 3-DEFER trial showing no benefit and higher target vessel revascularization 1.
Common Pitfall to Avoid
Do not confuse DCB use in stable coronary disease (e.g., in-stent restenosis, small vessel disease) with its role in STEMI—the thrombotic, high-risk milieu of acute MI requires the mechanical scaffolding and sustained drug delivery that only stents provide 1. Drug-coated balloons lack the structural support to prevent acute vessel recoil and cannot address the massive thrombus burden characteristic of STEMI 5, 6, 7.
Quality of Life and Long-Term Outcomes
DES reduce the need for repeat revascularization procedures, which directly improves quality of life by avoiding recurrent angina and additional interventions 1, 5, 6, 7.
Lower stent thrombosis rates with new-generation DES translate to fewer catastrophic events and better long-term survival 1, 5.
The DEDICATION trial showed 5-year MACE rates favoring DES (16.9% vs. 23% for BMS), though cardiac mortality findings were mixed and likely related to first-generation DES 8, 9.