Acute coronary syndromes (ACS) are a leading cause of mortality, yet patients with active cancer are often under-represented in clinical trials, leaving a gap in evidence for their management. We conducted a PRISMA-compliant systematic review and meta-analysis (PROSPERO-registered) searching PubMed, Cochrane, Web of Science, and Scopus through August 2025. We compared mortality, myocardial infarction (MI), and bleeding risks between ACS patients with and without active cancer using random-effects models to calculate risk ratios (RR). Twenty studies involving 1,154,050 patients were analyzed; 5.0% had active cancer. Patients with cancer had significantly higher in-hospital (RR 2.56; 95% CI 1.07 to 6.15) and long-term mortality (RR 3.55; 95% CI 1.71 to 7.36). Notably, the increased in-hospital mortality risk was significant only in those not undergoing percutaneous coronary intervention (PCI) (RR 4.02) and was non-significant in the PCI group (RR 1.45). While cancer patients faced higher long-term mortality regardless of treatment, the risk was lower for those treated with PCI (RR 2.16) compared to those without (RR 6.13). Bleeding risk was consistently higher in cancer patients (RR 1.47) across all management strategies, while MI risk (RR 1.01) did not differ significantly between groups. In conclusion, active cancer is associated with increased mortality and bleeding in ACS patients. PCI appears to mitigate early mortality risk and reduce the magnitude of long-term mortality risk. These findings suggest that invasive management may be beneficial for this vulnerable population, though further prospective studies are required.
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