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GERICLINICS

GeriQBank · Paper IV · Q2

Drug-Eluting Stents — Advantages and Disadvantages over Bare-Metal Stents

Very High YieldAsked ×37-mark note
Topic
Cardiovascular Medicine
Chapter
Cardiology
Years asked
Not recorded in the source
Frequency
Set 3× in Paper IV (2009–2025)

As set in the university paper

  • Drug eluting stents — pros and cons; advantages and disadvantages over bare metal stents.

    Paper IV · Cardiovascular Medicine · asked ×3 · 7-mark note · see in paper list

Answer framework

  1. Background and mechanism — bare-metal stents; drug-eluting stents and their drugs; stent generations
  2. Advantages of DES — restenosis, target vessel revascularisation, MI, avoiding repeat procedures in older people, the SENIOR trial
  3. Disadvantages of DES — delayed endothelialisation and stent thrombosis, longer DAPT and bleeding, DAPT interruption, polymer reactions and neoatherosclerosis, cost
  4. DAPT duration in older people
  5. Recent updates — ACC/AHA 2025, short-DAPT evidence, clopidogrel monotherapy, ESC 2023, newer stents and drug-coated balloons

An exam answer plan drawn from the detailed answer below. Use it to attempt the question first.

Detailed answer

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Attempt it firstOutline your answer as a 7-mark note before revealing it — definition, causes, evaluation, management and the geriatric angle.Reveal answer

Short revision answer

  • Bare-metal stents prevent recoil but not neointimal hyperplasia, so restenosis is high. Drug-eluting stents carry an antiproliferative drug (sirolimus, everolimus, zotarolimus, biolimus or paclitaxel) on a polymer that suppresses hyperplasia.
  • Generations: first (thick struts, durable polymer), second (thin cobalt-chromium struts, biocompatible polymer), third (bioabsorbable polymer or polymer-free).
  • Advantages: far less restenosis and repeat revascularisation — repeat procedures are especially risky in older people. SENIOR (≥75): DES with short DAPT cut death, MI, stroke and revascularisation by 29% compared with BMS. BMS are no longer supported in older patients.
  • Disadvantages: delayed endothelialisation with late and very late stent thrombosis, traditionally requiring DAPT for ≥6 months (against 1 month for BMS) with more bleeding; risky DAPT interruption for surgery; polymer reactions and neoatherosclerosis; higher cost.
  • In older people bleeding is commoner than thrombosis, so shorter DAPT is safer: 1 month for stable disease and 6 months for ACS is safe at ≥75, and 1–3 months followed by single antiplatelet therapy is possible with newer DES.
  • ACC/AHA 2025: 12 months of DAPT by default in ACS, de-escalating to P2Y12 monotherapy after 1–3 months at high bleeding risk. ESC 2023 recommends DES over BMS for everyone.
  • Long-term single antiplatelet therapy follows DAPT; clopidogrel is increasingly preferred to aspirin (HOST-EXAM).

Condensed by GeriClinics from the detailed answer below, with no new facts added.

15–20 High-Yield Points

BACKGROUND AND MECHANISM

1.

Bare-metal stents (BMS) are plain metal scaffolds. They abolish elastic recoil but do nothing to prevent neointimal hyperplasia, so restenosis rates are high.

2.

Drug-eluting stents (DES) have a metal platform coated with a polymer carrying an antiproliferative drug (sirolimus, everolimus, zotarolimus, biolimus, or paclitaxel).

3.

The eluted drug inhibits smooth muscle proliferation and migration, thereby suppressing neointimal hyperplasia and restenosis.

4.

Generations of DES: first generation (thick struts, durable polymer, sirolimus/paclitaxel), second generation (thinner cobalt-chromium struts, biocompatible polymer, everolimus/zotarolimus), and third generation (bioabsorbable polymer or polymer-free).

ADVANTAGES OF DES OVER BMS

5.

Superior reduction in restenosis — this is the single greatest advantage and the reason DES have superseded BMS.

6.

Marked reduction in target vessel revascularisation and therefore fewer repeat procedures.

7.

Reduced incidence of myocardial infarction in subsequent years with third-generation drug-eluting and drug-coated stents.

8.

Repeat interventions are particularly hazardous in older people (contrast nephropathy, bleeding, vascular injury), so avoiding them is a major geriatric gain.

9.

The SENIOR trial (patients ≥75 years) showed DES plus short DAPT gave a 29% reduction in the composite of all-cause death, MI, stroke, and revascularisation at one year compared with BMS.

10.

Because of this, the available evidence no longer supports the use of BMS in elderly patients.

DISADVANTAGES OF DES

11.

Delayed endothelialisation of the stent struts leaves metal exposed to blood for longer, creating a risk of late and very late stent thrombosis.

12.

This mandates a longer duration of DAPT, traditionally at least 6 months after DES versus 1 month after BMS.

13.

Longer DAPT means more bleeding, which older patients with multimorbidity tolerate poorly.

14.

Older patients frequently need DAPT interruption — for example, to allow safe major non-cardiac surgery — and premature interruption after DES carries thrombotic risk.

15.

Polymer hypersensitivity and chronic inflammation contribute to neoatherosclerosis within the stent.

16.

DES are more expensive than BMS — a real consideration in the Indian public-sector setting.

CURRENT POSITION ON DAPT DURATION

17.

In older people, bleeding is more common than recurrent thrombotic events after revascularisation, so shorter DAPT is often the safer choice.

18.

A short DAPT strategy of 1 month for stable ischaemic heart disease and 6 months for ACS with a DES is safe and effective in patients ≥75 years.

19.

Emerging data show 1–3 months of DAPT followed by single antiplatelet monotherapy is possible with newer DES.

20.

Lifelong single antiplatelet therapy (usually aspirin) follows completion of DAPT in all patients.

Current Practice Update

Textbook position (Pathy’s 6th ed.) Current evidence (2023–2026)

DES require prolonged DAPT (≥6 months), a concern in the elderly 1–3 months DAPT then P2Y12 monotherapy is now well established for contemporary DES, even in high-bleeding-risk patients BMS still an option when short DAPT is needed BMS are effectively obsolete; the 2025 ACC/AHA ACS guideline no longer positions BMS as a strategy to shorten DAPT Aspirin as the long-term single agent after DAPT Growing evidence favours P2Y12 inhibitor (clopidogrel) monotherapy over aspirin for long-term single antiplatelet therapy Concern about late stent thrombosis with DES Very late stent thrombosis is now rare with second/third-generation DES; neoatherosclerosis is recognised as the dominant late failure mechanism Latest Updates (2023–Present)

The 2025 ACC/AHA ACS Guideline sets DAPT for at least 12 months as the default in ACS patients who are not at high bleeding risk, but formally endorses de-escalation to P2Y12 inhibitor monotherapy after 1–3 months in patients at high bleeding risk.

Randomised evidence and meta-analyses through 2024–2025 confirm that abbreviated DAPT with contemporary DES does not increase ischaemic events while significantly reducing major bleeding — the strategy of choice in frail older adults.

Clopidogrel monotherapy is increasingly preferred over aspirin monotherapy for chronic single antiplatelet therapy after PCI, based on trials such as HOST-EXAM and its extended follow-up. The 2023 ESC ACS Guideline recommends DES over BMS in all patients regardless of bleeding risk, with DAPT duration then tailored to bleeding risk rather than stent type.

Polymer-free and bioabsorbable-polymer DES and drug-coated balloons are expanding the options for patients in whom prolonged DAPT is undesirable.

Examiner’s Tip — Mark-Earning Lines

“DES suppress neointimal hyperplasia via an antiproliferative drug on a polymer coating.” “The chief advantage is reduced restenosis and target vessel revascularisation; the chief disadvantage is delayed endothelialisation requiring longer DAPT.”

“The SENIOR trial showed a 29% reduction in death/MI/stroke/revascularisation with DES plus short DAPT in patients ≥75 years.”

“The evidence no longer supports the use of BMS in elderly patients.”

“Short DAPT (1 month stable IHD, 6 months ACS) with a DES is safe in older people; current practice extends this to 1–3 months followed by monotherapy.”

“In older people, bleeding risk exceeds recurrent thrombotic risk after revascularisation.”

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