Percutaneous Coronary Intervention for ST-elevation Myocardial Infarction: Drug-Eluting Stents or Bare Metal Stents?

Abstract

The treatment paradigm for patients with an ST-elevation myocardial infarction (STEMI) has shifted greatly in the last 20 years. The use of fibrinolytic agents vastly altered the landscape in treating this entity and was further advanced by the introduction of percutaneous catheter-based methods of therapy. Percutaneous coronary intervention (PCI) has become the preferred method of treatment for patients with this condition when compared with thrombolytic agents as evidenced by a number of positive clinical trials. However, PCI in itself has had several adaptations over the last decade, namely in the shift from a balloon-only approach to the widespread usage of balloon-expandable metallic stents. The use of bare metal stents has proven to be more efficacious in regard to rates of repeat procedures when compared with the balloon-only approach and has become a standard in PCI for STEMI. The composition of the stents themselves had also undergone transformation as evidenced by the introduction of drug-eluting stents (DES). Although there have been encouraging data to support the use of DES in the elective setting, the use of these devices in primary PCI has been controversial. The pathologic milieu that is present in the STEMI setting is distinctly different than that seen in the elective, stable atherosclerotic setting and the use of DES has raised concerns over safety issues with their implementation. There have been a host of recent studies dedicated to elucidating the risk of using DES versus bare metal stents in the setting of STEMI and although the results have been generally favorable for the use of DES, this subject remains one that is under significant scrutiny.