Follow-up to: what is the difference between hard and soft plaque
Question explored with the scientific record
do stents work
The short version: stents reduce the need for repeat procedures but do not clearly prevent heart attacks or death in stable patients.
The evidence here is almost entirely about which stent type works better, not whether stenting itself beats medical therapy. Every trial compares drug-eluting stents (DES) to bare-metal stents (BMS) or one DES to another [1, 4, 7, 11, 16, 18, 20, 22]. The consistent finding is that DES cuts restenosis and the need for repeat revascularization by roughly half compared to BMS [16, 18, 20, 22]. In diabetics, the restenosis reduction is even larger, from 41% with BMS to 8% with DES [23]. But death and heart attack rates are essentially the same between stent types across multiple trials and meta-analyses [18, 19, 23, 25]. The SYNTAX trial shows that for multivessel disease, bypass surgery beats stenting on long-term major events, especially repeat revascularization [10, 15]. At five years, PCI had 37.3% MACCE versus 26.9% for CABG [10].
The critical missing comparison is stenting versus optimal medical therapy without any stent. That question is not answered here. What the evidence does show is that stents are a mechanical fix for a narrowed artery, and they keep that artery open better than they did before. But the benefit is almost entirely in symptom relief and avoiding a second procedure, not in preventing the outcomes that actually kill you.
| Outcome | DES | BMS | Relative effect |
|---|---|---|---|
| Restenosis (diabetics) | 8% | 41% | 87% reduction [23] |
| Target lesion revascularization | ~5% | ~13% | ~60% reduction [20] |
| Death (any stent type) | ~2.4% | ~2.3% | No difference [23] |
| Heart attack (any stent type) | ~3.5% | ~7.2% | No clear difference [23] |
| Stent thrombosis | ~1.1% | ~1.2% | No difference [23] |
My call: stents reduce repeat procedures but the evidence does not show they prevent death or heart attack compared to medical therapy alone. Confidence: high for the restenosis benefit, moderate for the mortality question because the key comparison was never run.
Sources examined 27
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Comparison of Everolimus- and Sirolimus-Eluting Stents in Patients With Long Coronary Artery Lesions
This study compares the efficacy of everolimus-eluting stents (EES) and sirolimus-eluting stents (SES) in patients with long coronary artery lesions, finding that EES is associated with greater angiographic in-segment late loss and higher rates of in-segment restenosis compared …
DOI: 10.1016/j.jcin.2011.05.024 -
Bedside Monitoring to Adjust Antiplatelet Therapy for Coronary Stenting
This study evaluates the effectiveness of bedside monitoring to adjust antiplatelet therapy in patients undergoing coronary stenting, finding no significant improvement in clinical outcomes compared to standard treatment without monitoring.
DOI: 10.1056/NEJMoa1209979 -
A bioresorbable everolimus-eluting scaffold versus a metallic everolimus-eluting stent for ischaemic heart disease caused by de-novo native coronary artery lesions (ABSORB II): an interim 1-year analysis of clinical and procedural secondary outcomes from a randomised controlled trial
The ABSORB II trial compares the clinical outcomes of a bioresorbable everolimus-eluting scaffold with a metallic everolimus-eluting stent in patients with ischemic heart disease, finding similar secondary clinical outcomes at one year despite differences in acute performance me…
DOI: 10.1016/s0140-6736(14)61455-0 -
Biodegradable Polymer Versus Permanent Polymer Drug-Eluting Stents and Everolimus- Versus Sirolimus-Eluting Stents in Patients With Coronary Artery Disease
This study compares the 3-year efficacy and safety of biodegradable polymer drug-eluting stents (DES) versus permanent polymer DES and everolimus-eluting stents (EES) versus sirolimus-eluting stents (SES) in patients with coronary artery disease, finding no significant differenc…
DOI: 10.1016/j.jacc.2011.06.027 -
Randomized Comparison of Coronary Stent Implantation Under Ultrasound or Angiographic Guidance to Reduce Stent Restenosis (OPTICUS Study)
Randomized OPTICUS trial comparing ultrasound-guided versus angiography-guided coronary stent implantation found no advantage of intracoronary ultrasound guidance over angiographic guidance in reducing restenosis or improving long-term clinical outcomes, despite some better shor…
DOI: 10.1161/hc3701.096064 -
Meta-Analysis of Randomized Control Trials Comparing Drug-Eluting Stents Versus Coronary Artery Bypass Grafting for Significant Left Main Coronary Narrowing
This meta-analysis compares the outcomes of drug-eluting stents (DES) versus coronary artery bypass grafting (CABG) for treating significant left main coronary artery narrowing, finding that while both yield similar rates of major adverse cardiac and cerebrovascular events (MACC…
DOI: 10.1016/j.amjcard.2017.01.027 -
Very thin strut biodegradable polymer everolimus-eluting and sirolimus-eluting stents versus durable polymer zotarolimus-eluting stents in allcomers with coronary artery disease (BIO-RESORT): a three-arm, randomised, non-inferiority trial
A large, multicentre, all-comers, three-arm randomized non-inferiority trial comparing two very thin-strut biodegradable-polymer drug-eluting stents (everolimus-eluting Synergy and sirolimus-eluting Orsiro) with a durable-polymer zotarolimus-eluting stent (Resolute Integrity) to…
DOI: 10.1016/S0140-6736(16)31920-1 -
Spot Drug-Eluting Stenting for Long Coronary Stenoses: Long-term Results of a Randomized Clinical Study
This study compares the long-term outcomes of spot drug-eluting stenting versus full lesion coverage in patients with long coronary stenoses, finding that spot stenting results in significantly lower rates of major adverse cardiac events.
DOI: 10.1111/j.1540-8183.2011.00662.x -
The Long-Term Clinical Effects of Heparin-Coated Coronary Stent
A randomized clinical comparison of heparin-coated versus bare coronary stents in 30 PCI patients showed no improvement in long-term clinical or angiographic restenosis outcomes, with similar adverse event rates over about 22 months.
DOI: 10.4070/kcj.2002.32.9.773 -
Surgical Versus Percutaneous Revascularization in Patients with Multivessel Coronary Artery Disease
This review analyzes the SYNTAX trial, which compares the long-term outcomes of percutaneous coronary intervention (PCI) using drug-eluting stents with coronary artery bypass grafting (CABG) in patients with multivessel coronary artery disease, highlighting the implications for …
DOI: 10.1007/s11883-014-0461-x -
Comparison of Durable-Polymer Zotarolimus-Eluting and Biodegradable-Polymer Biolimus-Eluting Coronary Stents in Patients With Coronary Artery Disease
The SORT OUT VI trial demonstrated that the durable-polymer zotarolimus-eluting stent and the biodegradable-polymer biolimus-eluting stent have similar safety and efficacy outcomes in patients with coronary artery disease over a three-year follow-up period.
DOI: 10.1016/j.jcin.2016.11.007 -
Multicenter randomized trial of 3-month cilostazol use in addition to dual antiplatelet therapy after biolimus-eluting stent implantation for long or multivessel coronary artery disease
This multicenter randomized trial evaluated the efficacy of 3-month cilostazol use in addition to dual antiplatelet therapy after biolimus-eluting stent implantation in patients with long or multivessel coronary artery disease, finding no significant improvement in clinical outc…
DOI: 10.1016/j.ahj.2013.08.028 -
The French randomized optimal stenting trial: a prospective evaluation of provisional stenting guided by coronary velocity reserve and quantitative coronary angiography
A multicenter randomized trial showing that provisional stenting guided by coronary velocity reserve (CVR) and quantitative coronary angiography (QCA) achieves similar six-month angiographic outcomes to systematic stenting while greatly reducing the number of stents used, valida…
DOI: 10.1016/s0735-1097(00)00747-6 -
Ten-Year Outcomes After Drug-Eluting Stents Versus Coronary Artery Bypass Grafting for Left Main Coronary Disease
In the 10-year extended follow-up of the PRECOMBAT randomized trial, PCI with sirolimus-eluting stents and CABG showed no statistically significant difference in major adverse cardiac or cerebrovascular events or all-cause mortality, though PCI had a higher rate of ischemia-driv…
DOI: 10.1161/CIRCULATIONAHA.120.046039 -
Coronary artery bypass surgery continues to remain the treatment of choice for multivessel coronary artery disease even in the era of new-generation drug-eluting stents
In multivessel coronary artery disease, a randomized comparison of PCI using everolimus-eluting stents versus CABG shows CABG provides superior long-term outcomes, with PCI associated with higher event rates overall and notably higher MI/revascularisation in diabetics, despite a…
DOI: 10.1136/ebmed-2015-110211 -
Impact of stent diameter and length on in‐stent restenosis after DES vs BMS implantation in patients needing large coronary stents—A clinical and health‐economic evaluation
This study evaluates the impact of stent diameter and length on in-stent restenosis (ISR) rates after drug-eluting stent (DES) versus bare-metal stent (BMS) implantation in patients requiring large coronary stents, revealing that BMS significantly increases ISR risk compared to …
DOI: 10.1111/1755-5922.12229 -
5 Years Experience With Drug Eluting and Bare Metal Stents as Primary Intervention in Transplant Renal Artery Stenosis
Prospective single-center cohort study evaluating drug-eluting stents versus bare metal stents as primary treatment for transplant renal artery stenosis, showing immediate and long-term improvements in renal function and blood pressure with vessel-size–guided stent selection and…
DOI: 10.1097/TXD.0000000000000643 -
Safety and efficacy of drug-eluting vs. bare metal stents in patients with diabetes mellitus: long-term follow-up in the Swedish Coronary Angiography and Angioplasty Registry (SCAAR)
A large, real-world registry study in Sweden (SCAAR) comparing drug-eluting stents versus bare-metal stents in patients with diabetes undergoing PCI, showing no difference in death or MI over up to 4 years, but a substantial reduction in restenosis with DES across most subgroups…
DOI: 10.1093/eurheartj/ehp424 -
Decision-making: Stenting in Acute Myocardial Infarction
A comprehensive review of randomized trials and registries comparing drug-eluting stents (DES) versus bare-metal stents (BMS) for acute myocardial infarction (AMI), detailing the reduction in restenosis/revascularization with DES without clear increases in death, myocardial infa…
DOI: 10.2217/fca.10.12 -
Drug-Eluting Versus Bare Metal Stents in Patients With ST-Segment–Elevation Myocardial Infarction
Drug-eluting stents reduced neointimal proliferation and major adverse cardiac events at eight months versus bare-metal stents in STEMI patients undergoing primary PCI, mainly by lowering target lesion revascularization, with no overall increase in stent thrombosis but a non-sig…
DOI: 10.1161/circulationaha.107.758698 -
Meta-Analysis of Randomized Trials of Drug-Eluting Stents Versus Bare Metal Stents in Patients With Diabetes Mellitus
This meta-analysis evaluates the effectiveness of drug-eluting stents (DESs) compared to bare metal stents (BMSs) in reducing in-stent restenosis and target lesion revascularization in patients with diabetes mellitus, finding significant benefits associated with DESs.
DOI: 10.1016/j.amjcard.2006.12.069 -
Quantitative Assessment of Angiographic Restenosis After Sirolimus-Eluting Stent Implantation in Native Coronary Arteries
This study evaluates the effectiveness of sirolimus-eluting stents (SESs) compared to bare-metal stents (BMSs) in reducing angiographic restenosis in patients with complex native coronary artery lesions at high risk for restenosis.
DOI: 10.1161/01.CIR.0000150331.14687.4B -
Meta-Analysis Comparison (Nine Trials) of Outcomes With Drug-Eluting Stents Versus Bare Metal Stents in Patients With Diabetes Mellitus
This meta-analysis evaluates the efficacy of drug-eluting stents (DESs) compared to bare metal stents (BMSs) in diabetic patients, finding that DESs significantly reduce the incidence of in-stent restenosis (ISR) and target lesion revascularization (TLR) without affecting mortal…
DOI: 10.1016/j.amjcard.2008.07.012 -
The impact of lesion length and vessel size on outcomes after sirolimus-eluting stent implantation for in-stent restenosis
This study evaluates the predictors of recurrent restenosis and the impact of lesion length and vessel size on outcomes in patients treated with sirolimus-eluting stent implantation for in-stent restenosis of bare-metal stents.
DOI: 10.1136/hrt.2007.128595 -
Offsetting Impact of Thrombosis and Restenosis on the Occurrence of Death and Myocardial Infarction After Paclitaxel-Eluting and Bare Metal Stent Implantation
Restenosis-reducing paclitaxel-eluting stents offset the risk of late stent thrombosis, yielding similar seven-day death or MI after ST or TLR between drug-eluting and bare-metal stents over a median 3.2-year follow-up, with lower event rates before 1 year but higher rates after…
DOI: 10.1161/CIRCULATIONAHA.106.687186 -
Drug-Eluting Versus Bare Metal Stents in Patients With ST-Segment–Elevation Myocardial Infarction
A randomized 2x2 factorial trial (DEDICATION) in STEMI patients undergoing primary PCI showed drug-eluting stents reduce late lumen loss and major adverse cardiac events at eight months compared with bare-metal stents, with no clear increase in stent thrombosis but a possible si…
DOI: 10.1161/CIRCULATIONAHA.107.758698 -
Antithrombotic Management and 1-Year Outcome of Patients on Oral Anticoagulation Undergoing Coronary Stent Implantation (from the Registro Regionale Angioplastiche Emilia-Romagna Registry)
A multicenter regional registry (REAL) evaluated antithrombotic management and 1-year outcomes in 632 patients on oral anticoagulation undergoing coronary stent implantation, finding no significant difference in the composite 1-year MACVEs/major bleeding among triple therapy, du…
DOI: 10.1016/j.amjcard.2012.01.353