1) A 70-year-old man presented with chest pain and a recent hemorrhagic stroke. He required PCI but had a high risk of bleeding from prolonged DAPT. 2) Studies show that newer generation DES with optimized biocompatibility can be safely used with as little as 1 month of DAPT, even in high bleeding risk patients. The Synergy BP-DES has been studied in over 5,300 patients in short DAPT trials. 3) For this patient who could only tolerate a single antiplatelet, a Synergy stent was successfully implanted with 4 month follow up showing no issues, providing an alternative to BMS for those requiring very short DAPT.

1. Are They Still Relevant: Bare
Metal Stent?
Dr Gopal C Ghosh
DM, FACC, FSCAI

2. Case Scenario
• 70 years old gentleman
• Chest Pain for 4 hours
• Known Hypertensive
• Had recent hemorrhagic CVA, one week before

3. EKG

4. NCCT Brain

5. NCCT Brain

6. Management options?
• Thrombolysis-Contraindicated
• Percutaneous Coronary Intervention

7. Coronary Angiography

8. Options?
• POBA
• PCI with BMS
• PCI with DES
• CABG

9. Consider BMS: Conditions
1. High bleeding risk patients who needs PCI
2. Who will not tolerate DAPT for longer duration(more than 3 months)
3. Known or suspected to have poor adherence to DAPT due to
Psychological, social, and socioeconomic factors
4. Atrial Fibrillation
5. Need noncardiac surgery in less than 3-6 months post PCI

10. Why to consider BMS?
• DAPT duration post PCI: atleast 2weeks to 30 days
• DAPT after DES: 6-12 months atleast (current guidelines)
• Much faster endothelialisation of stent surface as there is no drug or
polymer to inhibit it

11. Position of Bare-Metal Stent in Present Era: India
Thus, it is apparent that BMS (as compared to DES) has the following advantages:
• Less late and very late ST
• Need a lesser duration of DAPT
• Less costly (in India, the average cost is INR 8000, compared to INR 32,000 for DES)
The major disadvantages are:
• More ISR, necessitating more TLR/TVR
• Not designed for bifurcation lesions, chronic total occlusion, or complicated lesions
• Not suitable for small arteries (especially below 3.0 mm diameter), left main disease, or
saphenous venous graft lesion
J Indian coll cardiol 2021;11:1-4.

12. Newer Generation DES
• Multiple RCTS showing they are still very effective with shorter
duration of DAPT

13. NORSTENT: Drug-Eluting or Bare-Metal Stents for CAD
• NORSTENT trial that randomized
over 9,000 patients to "modern" DES
& BMS.
• After 5-yr follow-up, there was no
difference in the risk of death
combined with non-fatal,
spontaneous MI, although there was
a lower rate of recurrent
revascularization in the DES group
N Engl J Med 2016;375:1242-52.

14. RCTs comparing DESs with BMSs with shortened
DAPT durations in patients who have high bleeding
risk or are uncertain candidates for prolonged DAPT,
coronary intervention with specific DESs optimized
for biocompatibility is not only safe but also
efficacious, even with only 1 month of DAPT
JAMA Cardiol. 2018;3(11):1050-1059.

15. 15
©2021 Boston Scientific Corporation or its affiliates. All rights reserved. INDH-IC-SYN-973802AA-0221
Competitive Landscape
SYNERGY BP-DES
ASET SENIOR
POEM
SYNIVUS
EVOLVE Short DAPT Ideal Left Main
Resolute Onyx PP-DES
Onyx One
Onyx One Clear
Xience PP-DES
Xience 28
Xience 28 USA
STOPDAPT
STOPDAPT-II
Xience 90
Drug-
Eluting
Stent
0-month
DAPT
1-month
DAPT
3-month
DAPT
4-month
DAPT
OUS trial
US Trial – data to be used to support HBR indication
Data available
IC-707605-AE SEPT20

16. SYNERGY™ BP Stent in Short DAPT Trials
SYNERGY in
Short DAPT Trials:
>5,300 pts
being studied
SYNIVUS-
DAPT
- HBR pts
- 1m DAPT
EVOLVE
Short DAPT
- HBR pts
- 3m DAPT
SENIOR
- Elderly Pts (>75 yrs.)
- 1m DAPT Stable pts
- 6m DAPT ACS pts
2,009 pts
1,200 pts
1,023 pts
818 pts
IDEAL LM
- Pts w/ LM Disease
- 4m DAPT SYNERGY
-12m DAPT XIENCE
201 pts
POEM
- Real-world HBR pts
- 1m DAPT
ASET
- Zero DAPT
- Chronic stable pts
100 pts

17. Final Management: My case

18. Continue......
• Not willing for CABG
• Single antiplatelet (Ecosprin) after consultation with Neurosurgeon
• Synergy 2.75 x 12mm stent postdilated to 3mm
• Doing well at 4 months follow up

19. Recommendations on Stents
• New-generation DES should be the stent of choice for PCI including in STEMI
• If a shortened DAPT regime is required, the use of DES is still preferable with
safety of a 3-month strategy established
• If very short DAPT duration is required (1 month), then the use of a polymer-free
biolimus A9-coated stent, Synergy if available, is preferable to BMS
• BMS should not be used for complex anatomical subsets with higher rates of ISR

20. Thank you