Despite the Strengths of Next-Gen DES, BMS Deserve a Place at the Cath Table, Review Asserts

Bare-metal stent use is on the decline but shouldn’t exit the scene entirely, according to authors of a review published earlier this week in the Journal of the American College of Cardiology. In fact, they say, in some cases BMS should even be preferred.

As to what inspired the pro-BMS review, Antonio Colombo, MD (San Raffaele Scientific Institute, Milan, Italy), told TCTMD it arose “because people now are under the assumption that bare-metal stents can be dispensed with.” The idea that BMS are unnecessary in the cath lab “is the view of many reputable, experienced people,” he said. “This is a very opinionated view supported by no data.”

What lies behind the widespread shift away from BMS is hard to pinpoint, Colombo said, adding it may simply be that “people get enthusiastic” about newer devices.

In the review, Colombo, along with Francesco Giannini, MD, and Carlo Briguori, MD, PhD (San Raffaele Scientific Institute), outline the evidence base on stent selection, pointing out that numerous studies have backed the use of new-generation DES versus first-generation DES and BMS. “Consequently, the use of new-generation DES has become the standard of care in revascularization, for efficacy and safety,” they write. “Moreover, the reduction in late and very late [stent thrombosis] with new DES, which allows the duration of dual antiplatelet therapy (DAPT) to be shortened, raises the question of the current need for BMS in clinical practice.”

But there are still situations in which BMS are ideal, they suggest, outlining categories of “special-risk” patients in a decision tree. Specifically, those who have problems with DAPT compliance or are likely to need urgent surgery within 1 month are the best candidates for BMS.

“The main issue with respect to the patient’s characteristics is whether DAPT can be tolerated for a time period sufficient to guarantee the lowest possible risk of [stent thrombosis], with minimal risk of bleeding,” Colombo and colleagues point out.

‘Cannot Remember . . . the Last Time’

David Kandzari, MD (Piedmont Hospital, Atlanta, GA), said that when reading the review, he was “surprised there would be any recommendation or any endorsement for the need for bare-metal stent.”

In terms of his own experience, Kandzari was candid. “I cannot remember in years the last time I used a bare-metal stent, and further I’m not sure what brand of bare-metal stents we keep in inventory at our hospital if at all,” he told TCTMD. “And so it’s not just me as an isolated practitioner but our whole program.”

Colombo concurred that “most of the laboratories don’t carry bare-metal stents at all, and don’t use bare-metal stents. And they see no negative events.” But even if going the all-DES route seems safe, he cautioned, it may be that events are either rare or undetected. “A single institution may not be able to spot a 1% absolute difference [in event rates], and this may be unnoticeable. So I think we draw conclusions based on personal experience, which is not necessarily extendable to general people’s experience.”

I cannot remember in years the last time I used a bare-metal stent. David Kandzari

Kandzari said that for him “the real challenge is in patients who have active bleeding or a very urgent need for surgery. These are the patients where it becomes less relevant what type of stent but whether to perform the procedure altogether.”

Polymer-free stents, which hold a prominent spot in the decision tree, aren’t available in the United States, he pointed out. So when BMS seem to be the only option, Kandzari said there’s another path: “Treat the patient conservatively with effective medical therapy to get them through the operation and then perform revascularization with [DES] afterward.”

What May Hasten Change

Overall, BMS use in the United States averages at 10%, though there is wide variation among regions and hospitals, Kandzari reported. He predicted that the new review will get some attention but not lead to big debates or shifts in practice.

We have to provide data. I know it may be expensive, but money is made to be used. Antonio Colombo

“We would only expect further decline in the use of bare-metal stents. I certainly don’t see this as [supporting] the escalation of bare-metal stent use,” he said, adding that most interventionalists “have made up their minds already about their selection of stent type for the majority of their practice.”

The potential for shortening DAPT to 1 month, or even less, will likely be what seals the deal for the most recent DES, both Colombo and Kandzari agree.

Odds are this goal will be met, Colombo said. “But like everything, we have to demonstrate. We have to provide data. I know it may be expensive, but money is made to be used. So if you have to use money to do a meaningful study, there’s nothing wrong.” Such trials are on the way.