Introduction <p>Acute coronary syndrome (ACS) is a serious clinical condition linked to considerable morbidity and mortality. While percutaneous coronary intervention (PCI) is the mainstay of treatment, the occurrence of adverse cardiovascular events (MACE) following the procedure remains a significant challenge. Although numerous studies have explored risk factors for MACE in female ACS patients after PCI, inconsistent results exist due to sample size and regional variations. The purpose of this meta-analysis and systematic review is to evaluate these risk factors to obtain higher-level evidence in ACS patients.</p> Methods <p>Computerized searches were conducted in CNKI, Wanfang, VIP, China Biology Medicine disc, PubMed, Web of Science, Embase, and Cochrane Library databases to identify literature on risk factors for MACE in female patients with ACS after PCI. The search period spanned from database inception to September 2025. Based on predefined inclusion and exclusion criteria, articles were screened by reviewing titles, abstracts, and full texts. Data extraction was performed, and quality assessment was conducted independently by two researchers using the Newcastle–Ottawa Scale (NOS). Meta-analysis was performed using RevMan 5.4 software and Stata 14.0.</p> Results <p>A total of 22 studies comprising 16,500 female patients were included. All studies were cohort studies and reported adjusted odds ratios from multivariable analyses. The meta-analysis identified eight significant risk factors for MACE in female ACS patients after PCI: advanced age (OR = 1.08, 95%CI: 1.00–1.15), decreased LVEF (OR = 1.77, 95%CI: 1.19–2.62), hypertension (OR = 1.73, 95%CI: 1.40–2.15), diabetes mellitus (OR = 1.69, 95%CI: 1.51–1.88), smoking (OR = 2.43, 95%CI: 1.74–3.39), multivessel coronary artery disease (OR = 1.69, 95%CI: 1.43–1.99), history of cerebrovascular disease (OR = 2.18, 95%CI: 1.55–3.05), and symptom-to-balloon time delay (OR = 1.33, 95%CI: 1.24–1.42) were identified as risk factors for MACE in female ACS patients with PCI management. Subgroup analyses demonstrated consistent effect sizes across geographic regions, publication years, sample sizes, and study quality levels. Meta-regression analyses identified no significant sources of heterogeneity for advanced age (<i>I</i>² = 91%), suggesting that clinical rather than methodological factors account for this variability. Insufficient reporting in the original studies prevented a meta-analysis of female-specific risk factors, including premature menopause, gestational diabetes, and PCOS, which constitutes a critical gap in the literature.</p> Discussion <p>The incidence of MACE is elevated in female ACS patients following PCI. Healthcare professionals should monitor patients' clinical status promptly, develop personalized treatment strategies. Perioperative management must be enhanced, particularly for patients with comorbidities such as advanced age and diabetes, to mitigate the risk of major adverse cardiovascular events.</p>