Department of Cardiology, University of Ferrara, Cardiovascular Institute, Arcispedale S Anna, Italy.
J Cardiovasc Med (Hagerstown). 2009 Oct;10 Suppl 1:S17-26. doi: 10.2459/01.JCM.0000362040.25767.f5.
The controversial choice between bare metal stents and drug-eluting stents (DES) in primary percutaneous coronary intervention (PCI) seems to be driven by a growing body of evidence. Although evidence supporting the use of DES in the setting of ST-segment elevation myocardial infarction (STEMI) has been demonstrated, including a lower target vessel revascularization (TVR) rate without increased mortality, at present the proportion of DES implants in STEMI patients is low. This may be due to higher costs of DES, cultural issues, lack of concerns about restenosis in STEMI, lack of information on patient bleeding risk and the need for surgery within a limited time. In addition, initial enthusiasm about the efficacy of DES in reducing restenosis is now decreasing as a result of the safety concerns regarding in-stent thrombosis. Moreover, DES requires long-term dual antiplatelet therapy (DAT), which may pose problems in patients prone to bleeding or in candidates for elective surgery. Nevertheless, benefits associated with use of DES include significantly lower TVR rates without remarkable adverse effects in terms of death and myocardial infarction. Data about the efficacy of DES are still limited to 1-year follow-up in most trials. Uncoated stents permit early arterial wall healing, requiring a shorter duration of DAT and are potentially associated with a reduced risk of thrombus formation at long-term follow-up. Importantly, however, this potential late threat has not been confirmed in recent data from the limited number of studies with longer than 2-years follow-up. Anatomical features and individual risk profiles can sometimes help in the choice of the most suitable type of stent. In conclusion, stent choice in primary PCI cannot be standardized for all patients and appears to be influenced by various factors that need to be considered to provide better revascularization in terms of both efficacy and safety.
在经皮冠状动脉介入治疗（PCI）中，裸金属支架与药物洗脱支架（DES）的选择备受争议，这似乎是大量证据所驱动的结果。尽管已经有证据支持在 ST 段抬高型心肌梗死（STEMI）患者中使用 DES，包括降低靶血管血运重建（TVR）率而不增加死亡率，但目前 STEMI 患者中 DES 的植入比例仍然较低。这可能是由于 DES 成本较高、文化因素、对 STEMI 患者再狭窄问题的关注不足、缺乏对患者出血风险和在有限时间内需要手术的信息，以及最初对 DES 降低再狭窄疗效的热情正在因支架内血栓形成的安全性问题而减退。此外，DES 需要长期双联抗血小板治疗（DAT），这可能会给容易出血的患者或择期手术的患者带来问题。尽管如此，DES 的使用相关益处包括 TVR 率显著降低，而死亡率和心肌梗死发生率无明显不良影响。在大多数试验中，DES 的疗效数据仍仅限于 1 年随访。无涂层支架允许早期动脉壁愈合，需要 DAT 的时间更短，并且在长期随访中血栓形成的风险可能降低。然而，重要的是，在最近的研究中，在超过 2 年随访的有限数量的研究中，这种潜在的晚期威胁尚未得到证实。解剖学特征和个体风险特征有时有助于选择最合适的支架类型。总之，在直接 PCI 中，不能为所有患者标准化支架选择，而且似乎受到各种因素的影响，需要考虑这些因素以提供更好的疗效和安全性。
