Primary PCI in STEMI: Stent Preference and Technical Recommendations

1. Mandatory Stent Use

Primary PCI for STEMI requires stent implantation rather than balloon angioplasty alone (Class I, Level A) – endorsed by the European Society of Cardiology (ESC) and the American College of Cardiology/American Heart Association (ACC/AHA) guidelines. 1

New‑generation DES are the preferred stent type over bare‑metal stents (BMS) for primary PCI in STEMI patients (Class I, Level A) – ESC and ACC/AHA recommendations. 1
Compared with BMS, new‑generation DES show lower rates of stent thrombosis (≈ 0.8 % vs 1.2 %) and reduced repeat revascularization (≈ 16.5 % vs 19.8 %) (Class I, Level A). 2
Five‑year follow‑up of the EXAMINATION trial demonstrated a mortality reduction with DES versus BMS in acute myocardial infarction patients (Class I, Level A). 2

In patients at high bleeding risk who cannot tolerate prolonged dual antiplatelet therapy (DAPT), BMS may be preferred (Class IIa, Level B). 3
When adherence to a 12‑month DAPT regimen is unlikely due to financial, social, or medical barriers, BMS may be selected (Class IIa, Level B). 3
If an invasive or surgical procedure is anticipated within the next year that would require interruption of DAPT, BMS is an alternative (Class IIa, Level B). 3
For patients requiring long‑term anticoagulation where triple therapy would pose excessive bleeding risk, BMS may be used (Class IIa, Level B). 3

A loading dose of aspirin 162–325 mg should be administered before primary PCI (Class I, Level B) – ACC/AHA guideline. 3
A P2Y12 inhibitor loading dose should be given as early as possible (clopidogrel 600 mg, prasugrel 60 mg, or ticagrelor 180 mg) (Class I, Level B) – ACC/AHA guideline. 4
After DES implantation, a minimum of 12 months of uninterrupted DAPT is required (Class I, Level A/B) – ESC and ACC/AHA guidelines. 3

Radial arterial access is preferred over femoral access when performed by experienced operators (Class I/IIa, Level A) – ESC recommendation. 1
Routine thrombus aspiration is not recommended (Class III, Level A) – ESC guideline. 1
Routine deferred stenting is not recommended; the DANAMI‑3‑DEFER trial showed no clinical benefit and higher target‑vessel revascularization (Class III, Level A). 2

No major cardiology guideline (ESC, ACC/AHA, or EACTS) lists DCB as an acceptable alternative to stenting in the acute STEMI setting (Class III, Level A). 1
DCBs are appropriate for stable coronary disease (e.g., in‑stent restenosis, small‑vessel disease) but lack the structural support needed to prevent acute vessel recoil and cannot adequately address the high thrombus burden of STEMI (Class III, Level A). 5

DES use reduces the need for repeat revascularization procedures, thereby improving patients’ quality of life by avoiding recurrent angina and additional interventions (Class I, Level A). 2
The lower stent‑thrombosis rates observed with new‑generation DES translate into fewer catastrophic events and better long‑term survival (Class I, Level A). 2

The American College of Cardiology recommends primary PCI in STEMI patients with ischemic symptoms <12 hours duration (Class I, Level of Evidence A) 6, 7, 8
The American College of Cardiology recommends primary PCI in STEMI patients with contraindications to fibrinolytic therapy, regardless of time delay (Class I, Level of Evidence B) 6, 7
The American College of Cardiology recommends primary PCI in STEMI patients with cardiogenic shock or acute severe heart failure, regardless of time delay from MI onset (Class I, Level of Evidence B) 6, 7
The American College of Cardiology recommends primary PCI in STEMI patients with clinical/ECG evidence of ongoing ischemia between 12-24 hours after symptom onset (Class IIa, Level of Evidence B) 9, 10, 8

The American College of Cardiology recommends both DES and BMS as acceptable options for primary PCI in STEMI (Class I, Level of Evidence A), with DES reducing target vessel revascularization rates without increasing mortality, reinfarction, or stent thrombosis compared to BMS 9, 6, 11
The American College of Cardiology recommends using BMS in patients with high bleeding risk, inability to comply with 1 year of dual antiplatelet therapy, or anticipated invasive or surgical procedures within the next year 9, 6, 8
The American College of Cardiology recommends against using DES in patients unable to tolerate or comply with prolonged DAPT due to increased risk of stent thrombosis with premature discontinuation (Class III: Harm) 9, 6, 7

The American College of Cardiology recommends aspirin 162-325 mg before primary PCI (Class I, Level of Evidence B) 9, 6, 8
The American College of Cardiology recommends a P2Y12 inhibitor loading dose as early as possible or at time of primary PCI (Class I, Level of Evidence B), with options including clopidogrel 600 mg, prasugrel 60 mg, or ticagrelor 180 mg 9, 6, 8
The American College of Cardiology recommends against administering prasugrel to patients with prior stroke or TIA (Class III: Harm, Level of Evidence B) 6, 7

The American College of Cardiology recommends two acceptable anticoagulation regimens for primary PCI: unfractionated heparin or bivalirudin (Class I, Level of Evidence C and B, respectively) 9, 6, 7
The American College of Cardiology recommends against using fondaparinux as sole anticoagulant due to catheter thrombosis risk (Class III: Harm, Level of Evidence B) 9

The American College of Cardiology recommends avoiding PCI of non-infarct arteries during primary PCI in hemodynamically stable patients (Class III: Harm, Level of Evidence B) 9, 10, 8
The American College of Cardiology strongly recommends routine stenting over balloon angioplasty alone (Class I, Level of Evidence A) 9, 12