Percutaneous treatment for obstructive coronary artery disease has evolved in conjunction with technological advances from the initial era of balloon angioplasty to the first bare metal stents (BMS) and then through various iterations of drug eluting stent (DES) technology.  Current generation DES data suggest progressively improved re-stenosis and thrombosis rates and on-going trials are examining shorter duration dual antiplatelet therapy regimens, all of which raises questions about the utility of BMS. However, BMS technology has also improved and these stents generally remain less costly. Thus, in this large scale multi-center Norwegian study, over 9000 patients were randomized to receive latest generation BMS or DES technology when undergoing PCI. The primary composite outcome was all cause death and myocardial infarction over 5 years of follow-up.  The primary outcome was neutral between the two groups with rates of 17.1% (BMS) vs 16.6% (DES) (P=0.66), but rates of further revascularization were significantly lower in the DES group (16.5% vs 19.8%; P<0.001) suggesting lower rates of restenosis.  Definite stent thrombosis was also marginally lower in the DES group (0.8% vs 1.2%; P=0.0498) allaying concerns of very late stent thrombosis associated with early generation DES.

Conclusions

This large trial demonstrates no difference in rates of death or MI in patients receiving contemporary BMS or DES. Ongoing reductions in future revascularization episodes in patients receiving DES suggest their superiority in reducing restenosis.  Incremental cost differences and potentially shorter dual antiplatelet therapy will need to be weighed against an absolute 3% difference in revascularization events at 5 years when determining optimal stent choice.

Bønaa KH, Mannsverk J, Wiseth R, Aaberge L, Myreng Y, Nygård O, Nilsen DW, Kløw NE, Uchto M, Trovik T, Bendz B, Stavnes S, Bjørnerheim R, Larsen AI, Slette M, Steigen T, Jakobsen OJ, Bleie Ø, Fossum E, Hanssen TA, Dahl-Eriksen Ø, Njølstad I, Rasmussen K, Wilsgaard T, Nordrehaug JE; NORSTENT Investigators.  Drug-Eluting or Bare-Metal Stents for Coronary Artery Disease.  N Engl J Med. 2016 Aug 29. [Epub ahead of print]

Hussain Contractor & James M. McCabe