Less metal, same outcomes: drug-coated balloon PCI in acute coronary syndrome - real-world registry data

Background Drug-coated balloon (DCB)-based strategies are increasingly explored as an alternative or adjunct to drug-eluting stent (DES) implantation to reduce permanent metal burden. However, real-world data on the utilization and safety of DCB-based strategies in acute coronary syndrome (ACS) remain limited. Purpose To evaluate real-world utilization and clinical outcomes of a DCB-based strategy compared with DES in patients undergoing PCI for ACS. Methods We performed a retrospective registry analysis of consecutive patients treated with PCI for ACS at a tertiary centre. Patients were stratified by revascularization strategy: DES-only versus DCB-based (DCB-only or hybrid approach). The primary endpoint was all-cause mortality at 1 year. Multivariable logistic regression adjusted for age, sex, diabetes, hypertension, prior coronary events, ACS presentation (ST-elevation myocardial infarction vs non-ST-elevation myocardial infarction (NSTEMI) or unstable angina), coronary complexity (SYNTAX score), and cardiogenic shock. Safety outcomes included in-hospital and 30-day mortality. Results A total of 2,684 patients were included, of whom 239 (8.9%) underwent a DCB-based strategy. Compared with DES-treated patients, those receiving a DCB-based strategy more frequently had diabetes (30.1% vs 22.6%, p=0.008), NSTEMI/unstable angina (59.8% vs 37.1%, p<0.001), prior myocardial infarction (23.4% vs 10.9%, p<0.001), and bifurcation lesions (15.3% vs 5.0%, p<0.001). Rates of complete revascularization were comparable between strategies (61.9% vs 59.1%, p=0.417). One-year mortality was 5.9% in the DCB-based group and 7.1% in the DES group (p=0.503). After adjustment, a DCB-based strategy was not associated with higher 1-year mortality compared with DES (OR 1.08, 95% CI 0.56-2.09, p=0.81). Age, coronary complexity (SYNTAX score), and cardiogenic shock were independent predictors of mortality. There were no significant differences between DCB-based and DES strategies in in-hospital mortality (3.3% vs 3.1%, p=0.844) or 30-day mortality (4.6% vs 4.1%, p=0.718). Conclusion In this real-world ACS registry, a DCB-based, metal-minimizing revascularization strategy demonstrated comparable early and 1-year mortality to DES. These findings support lesion-tailored PCI strategies that minimize permanent metal implantation in contemporary ACS management.