Percutaneous Coronary Intervention vs. Coronary Artery Bypass Grafting in Acute Coronary Syndromes: A Systematic Review and Meta-Analysis of Contemporary Evidence

All articles of this category (opens in new window) Background: In the setting of acute coronary syndromes (ACS), percutaneous coronary intervention (PCI) is the predominant invasive strategy when urgent restoration of coronary perfusion is required. Coronary artery bypass grafting (CABG) is undertaken in only a minority of patients, typically in the presence of complex coronary anatomy, left main disease, or failed PCI. Current European and American guidelines recommend PCI as the primary approach in ACS, reserving CABG for selected high-risk patients or specific subgroups. However, these recommendations are largely based on expert consensus, extrapolation from stable coronary artery disease trials, or observational studies, as no randomized controlled trials (RCTs) directly comparing CABG and PCI in the context of ACS exist. This lack of high-level evidence creates uncertainty regarding the optimal treatment strategy in this high-risk population. We therefore performed a meta-analysis of the available contemporary evidence. Methods: We systematically searched three databases, selecting studies published in the last 10 years comparing PCI and CABG in ACS. The primary outcome was long-term mortality. Secondary outcomes were short-term mortality, myocardial infarction (MI), major adverse cardiac events (MACE), and stroke. For long-term outcomes, pooled Kaplan–Meier survival curves after reconstruction of individual patient data were generated. Results: A total of 15 studies totaling 179,158 patients were included. In the pooled Kaplan–Meier analysis, CABG showed significantly better long-term survival (HR: 0.746, 95% CI, 0.73–0.76, p < 0.001). During the observation period, CABG was also associated with lower rates of MACE (HR: 0.733, 95% CI, 0.68–0.79, p < 0.001) and MI (HR: 0.671, 95% CI, 0.64–0.70, p < 0.001). All other outcomes did not differ significantly. Outcome Studies Patients Effect Estimate Long-term mortality 11 175,147 HR: 0.746, 95% CI, 0.73–0.76, p < 0.001 Long-term MI 4 62,915 HR: 0.671, 95% CI: 0.64–0.70, p < 0.001 Long-term MACE 6 12,401 HR: 0.733, 95% CI: 0.68–0.79, p < 0.001 Long-term stroke 3 62,276 HR: 1.018, 95% CI: 0.97–1.06, p = 0.438 Short-term mortality 3 6,161 OR: 0.61, 95% CI: 0.21–1.77, p = 0.358 Conclusion: CABG is associated with superior long-term survival compared to PCI in patients with ACS. This survival advantage is associated with fewer MACE and MI. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany