Drug-Coated Balloons in Acute Coronary Syndromes: A Systematic Review

Drug-coated balloon (DCB) angioplasty is increasingly being explored as an alternative strategy in percutaneous coronary intervention (PCI), including PCI for acute coronary syndrome (ACS). The evidence base, however, remains heterogeneous across PCI subtypes, especially PCI for ACS, lesion substrates, treatment strategies, imaging use, comparator eras, end point definitions, and follow-up periods. It includes early pilot studies and randomized trials in ST-segment elevation myocardial infarction (STEMI), randomized data in non-ST-elevation myocardial infarction (NSTEMI), retrospective propensity-matched comparisons with DES, mechanistic intravascular imaging studies, and more recent registry analyses incorporating sirolimus-coated balloon platforms. Across these studies, the most consistent signal is that DCB may achieve low rates of target lesion revascularization and clinically acceptable rates of major adverse cardiovascular events in carefully selected lesions when lesion preparation is optimal, and bailout stenting is reserved for significant recoil or flow-limiting dissection. The contemporary literature also suggests that lesion phenotype matters. Plaque erosion and low residual thrombus burden appear to be more favorable substrates for DCB than plaque rupture with persistent thrombus or calcified nodules. In contrast, for in-stent restenosis occurring in ACS, lesion pattern remains important, and DES may still be superior to DCB in nonfocal in-stent restenosis. High bleeding risk may represent a potential niche for DCB, as several registry studies suggest that DCB-only PCI with abbreviated or even single antiplatelet strategies may be feasible in selected patients. This systematic review aimed to synthesize current evidence on the use of drug-coated balloons in acute coronary syndromes, focusing on lesion selection, procedural strategies, and clinical outcomes to identify where a DCB-first approach is most suitable in current practice.