Percutaneous coronary intervention: assessing coronary vascular risk associated with bare-metal and drug-eluting stents.Am J Manag Care. 2009 Mar; 15(2 Suppl):S42-7.AJ
Percutaneous coronary intervention (PCI) with stenting is increasingly being utilized for acute coronary syndromes (ACS), and the debate over the safety and efficacy of drug-eluting stents (DESs) versus bare-metal stents (BMSs) has intensified. The difficulty in consistently assessing stent safety is because of the widespread off-label use in patients with clinical features and coronary anatomy inconsistent with the approved use in stable patients with relatively noncomplex coronary stenosis, short-term follow-up of only 1 year in pivotal clinical trials that leads to approval, and inconsistency in the nature and duration of adjunctive antiplatelet therapy. Of concern are the high recurrence rates after the first episode of stent thrombosis, as demonstrated by the Dutch Stent Thrombosis Study. However, more recent analyses using better statistical models favor DESs versus BMSs, both for survival and repeat revascularizations. Recommendations from updated guidelines from the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions are summarized for oral antiplatelet therapy with DESs and BMSs in the management of ACS. For patients undergoing elective PCI, dual antiplatelet therapy with aspirin and clopidogrel is recommended for at least 4 weeks for a BMS and 12 months for a DES, with aspirin continued indefinitely. For patients with non-ST-segment elevation ACS or ST-segment elevation myocardial infarction, dual antiplatelet therapy is recommended for at least 12 months. In summary, more recent data suggest that the benefits outweigh the risks of DESs compared with BMSs, and that the rate of DES placement will continue to rise. It is important that clinicians be aware of the indications for dual antiplatelet therapy and the appropriate durations of dual antiplatelet therapy in patients undergoing PCI.