Coronary Artery Disease Management

Introduction to Drug-Eluting Stents

• The European Society of Cardiology and the American College of Cardiology recommend drug-eluting stents (DES) as the default choice for nearly all patients with coronary artery disease requiring stent placement, due to their ability to reduce restenosis and re-occlusion, with a Class I, Level A recommendation 1, 2, 3, 4
• DES is preferred over bare-metal stents (BMS) due to lower rates of target vessel revascularization, with significantly lower rates of restenosis (0% for DES vs 26% for BMS at 6 months) and need for target vessel revascularization (4.1% vs 16.6% at 6 months, and 8.9% vs 36.3% at 8 months) 2, 3, 4

Patient Selection for Drug-Eluting Stents

• Patients with diabetes mellitus, small vessel diameter (<2.5mm), and complex lesions (bifurcations, multivessel disease) have a strong indication for DES (Class I recommendation) 1, 5, 6
• Liver transplant candidates with MELD <30 should receive DES with minimum 3 months DAPT 7
• Patients with clinical or anatomic factors that increase restenosis risk, such as diabetes mellitus, small vessel diameter, and long lesions, are suitable for DES, especially those who can tolerate and comply with prolonged DAPT (12 months) 3, 8

Contraindications and Considerations

• Inability to comply with extended DAPT (12 months), high bleeding risk, anticipated invasive or surgical procedures within 12 months, and need for long-term anticoagulation are contraindications or considerations for alternative strategies for DES 6, 3, 8
• Patients who require long-term anticoagulation may not be suitable for DES due to increased bleeding risk with triple therapy 3, 8, 6

Dual Antiplatelet Therapy (DAPT) Duration

• Minimum duration of DAPT is 12 months for all patients receiving DES, with extended DAPT may be reasonable beyond 1 year for patients with high-risk features, such as renal insufficiency, diabetes, multiple stents, or bifurcation lesions 6, 3, 8
• Low-dose aspirin should be continued indefinitely 6
• Combination antiplatelet treatment should be maintained for at least 6–12 months for drug-eluting stents, and withdrawing antiplatelet therapy is a major risk factor for thrombosis for all types of stent 9, 3, 6

Clinical Decision-Making

• Assess bleeding risk and DAPT compliance capability before selecting DES or BMS, and evaluate lesion characteristics, such as small vessels, long lesions, bifurcations, and diabetes, to determine the strength of indication for DES 6, 1, 5, 6
• Consider clinical context, such as STEMI, planned non-cardiac surgery within 12 months, or liver disease, when selecting DES or BMS, and discuss the need for and duration of DAPT with the patient before choosing DES 3, 6, 7
• For unprotected left main coronary artery disease, DES has shown lower rates of target-vessel revascularization (6% vs 17%) and MACE (8% vs 26%) compared to BMS at 12 months, and patients undergoing PCI to unprotected left main coronary artery should be followed up with coronary angiography between 2 and 6 months after PCI 10, 11
• For primary PCI in STEMI patients, newer-generation DES have demonstrated safety and efficacy, and both BMS and DES are useful in this population, with DES being the preferred treatment for in-stent restenosis 4, 8, 12

Special Considerations