Stent Selection Guidelines

Primary Recommendations

The American College of Cardiology recommends drug-eluting stents as the default choice in nearly all patients undergoing percutaneous coronary intervention to prevent restenosis, myocardial infarction, and acute stent thrombosis, with bare-metal stents reserved only for patients who cannot tolerate or comply with 12 months of dual antiplatelet therapy (DAPT) 3, 4
The American College of Cardiology and European Heart Society suggest that bare-metal stents should be used instead of drug-eluting stents in specific circumstances where prolonged DAPT poses unacceptable risk, such as inability to tolerate or comply with 12 months of DAPT, anticipated surgery requiring DAPT discontinuation within 12 months, high bleeding risk, financial barriers to continuing prolonged DAPT, and social barriers limiting patient compliance 1, 6, 2

For patients with left main coronary artery disease, small vessel diameter (≤2.5 mm), long lesions, diabetes mellitus, bifurcation lesions, multiple lesions, or saphenous vein grafts, drug-eluting stents are strongly preferred due to higher restenosis risk with bare-metal stents 1, 2
In patients with high bleeding risk (HAS-BLED score ≥3), bare-metal stents or shortened DAPT with newer drug-eluting stents may be considered to minimize bleeding risk 7, 2
For patients requiring long-term oral anticoagulation, bare-metal stents allow shorter duration of triple therapy (2-4 weeks vs 3-6 months) and may be preferred 8, 9, 7

The American College of Cardiology recommends a minimum of 1 month of DAPT for bare-metal stents and a minimum of 12 months of DAPT for drug-eluting stents to prevent late stent thrombosis 1, 6, 2
For patients with high bleeding risk, a shorter duration of DAPT (3-6 months) may be considered with newer drug-eluting stents 7

In ST-elevation myocardial infarction (STEMI) patients who can comply with prolonged DAPT, drug-eluting stents are safe and effective, with lower restenosis rates compared to bare-metal stents 2, 4
In acute coronary syndrome (ACS) with atrial fibrillation, bare-metal stents are preferred when triple therapy is required to reduce the duration of triple therapy 7
In elective percutaneous coronary intervention (PCI) for stable coronary disease, drug-eluting stents should be the default choice unless contraindications to prolonged DAPT exist 3, 4

Assess DAPT tolerance/compliance capability first, and use bare-metal stents if patient cannot safely take or afford aspirin + clopidogrel for 12 months 1, 6, 2
Evaluate bleeding risk and use bare-metal stents or consider shortened DAPT with newer drug-eluting stents if high risk is present 7, 2
Assess restenosis risk and strongly favor drug-eluting stents if high-risk features are present 1, 2

Meta-analyses show that newer drug-eluting stents reduce myocardial infarction and stent thrombosis compared to bare-metal stents, with a trend toward lower cardiac mortality 3
Second-generation drug-eluting stents demonstrate superior outcomes to first-generation drug-eluting stents in head-to-head trials 4
The 2021 ACC/AHA/SCAI guidelines recommend drug-eluting stents in preference to bare-metal stents to prevent restenosis, myocardial infarction, and acute stent thrombosis, with limited roles for bare-metal stents except in unusual circumstances requiring extremely short-duration DAPT (<1 month) 3