As time goes by: current status and future directions in the controversy over stenting

Drug-eluting stents (DES) have dramatically transformed the landscape of interventional cardiology largely on the basis of empirical evidence showing profound reduction in angiographic and clinical restenosis without any significant increase in adverse events. Recent data, however, raise questions regarding the increased risk of late stent thrombosis associated with DES in more complex lesions and higher-risk patients than those evaluated in the initial clinical trials or Food and Drug Administration-approved indications, the challenge of continuing long-term antiplatelet therapy, and the danger of early discontinuation of antiplatelet therapy. We herein review the current status of this controversy, describe the additional evidence needed for its resolution, and offer recommendations for regulatory reform and 3 specific recommendations to encourage evidence-based patient management: 1) an emphasis on medical therapies with proven long-term benefit; 2) the use of kinetic modeling to estimate long-term outcomes of therapies based on the available near-term data; and 3) the restructuring of reimbursement incentives to encourage the use of evidence-based clinical management strategies.