Recommendations

While there is much new evidence that favors drug-eluting stents in general, researchers have begun to identify the best candidates for each of the two types. Because the pros and cons of drug-eluting stents depend on many factors, the choice should usually be made on an individual basis. The main determinants are your risks of restenosis, bleeding, and thrombosis and, if time permits—as it can in many cases—your personal preferences.

"Your input is crucial in part because the likelihood of successful drug treatment to prevent thrombosis is the most important consideration," says Stone, director of cardiovascular research at Columbia University Medical Center. If you don't want to take anticlotting drugs for a long time because you think it would be too inconvenient, too hard to remember, risky, or expensive, you'll need a bare-metal stent. Brand-name drugs have a retail price of about $160 a month, but insurance coverage varies, so check with your provider. And the drug-eluting stent itself costs more, too: the retail price is about $2,000, vs. $800-$900 for a bare-metal stent.

In addition, the chance of restenosis in some patients is already so small that a bare-metal stent might work almost as well as a drug-eluting one without any increased thrombosis risk or anticlotting medication. Ideal candidates for an uncoated stent, with the least chance of restenosis, are people who don't have diabetes and have a short blockage in a large artery. Conversely, coated stents are best for people with diabetes and a long obstruction in a small vessel.

But even those who in theory should do reasonably well with a bare-metal device might prefer to get a coated one and take the medication, to obtain the somewhat greater protection against restenosis. And personal preferences count even more in the large gray zone between the two ideal candidates.

It's also crucial to give the cardiologist a complete medical history, since other factors may preclude a drug-eluting stent by making anticlotting drugs too hazardous. Those include having a history of serious bleeding, the use of other blood thinners, a heart-rhythm disorder called atrial fibrillation, and having a mechanical heart valve. Also tell the cardiologist if you're facing other surgery, which may require you to stop taking anticlotting medication, or if you have a weakened heart, which raises the risk of thrombosis.