Pooled and meta-analyses have demonstrated that in patients with diabetes, use of DES decreases the risk of restenosis compared with BMS.471,472 DES may be more appealing for unprotected left main PCI, given the rate and clinical consequences of restenosis in this location.473 475 The risk of stent thrombosis is higher in populations or lesion types excluded from RCTs of DES (eg, STEMI, smaller arteries [ 2.5 mm diameter], longer lesions, bifurca- tions).210,465 Importantly, these features also predict both stent thrombosis476 and restenosis in BMS.477 The greatest risk of stent thrombosis is within the first year, ranging from 0.7% to 2.0%, depending on patient and lesion complexity. Late stent thrombosis risk after 1 year with DES is observed at a rate of Levine et al 2011 ACCF/AHA/SCAI PCI Guideline e601 Compared with balloon angioplasty, routine BMS implan- tation during primary PCI decreases risk for target-vessel revascularization and possibly reduces MI rates but does not reduce mortality rates.479 More recent primary PCI studies and meta-analyses have demonstrated lower restenosis rates without increased risk of adverse stent outcome with DES compared with BMS. Although stent thrombosis rates in trials of STEMI are higher than in trials of elective PCI, the rates of stent thrombosis are not higher with DES compared with BMS in STEMI.453,456 459 The greatest risk for DES thrombosis is early discontinu- ation of DAPT.208,460 462 It is therefore important to deter- mine that the patient will likely be able to tolerate and comply with DAPT before implantation of DES. Therefore, DES should not be used in the presence of financial barriers to continuing prolonged DAPT, social barriers that may limit patient compliance, or medical issues involving bleeding risks or the need for invasive or surgical procedures in the following year that would interrupt antiplatelet therapy. 