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Introduction The pleiotropic effects and plaque stabilisation provided by statins are well known. However, it remains uncertain whether long-term intensive statin therapy modifies lesion characteristics favourably, thereby reducing the PCI complexity. This study aimed to determine if high-intensity statin therapy before ACS presentation is associated with less complex lesions during PCI compared with low/moderate-intensity therapy.Methods We analysed retrospectively collected data of adults presenting with ACS who underwent emergency PCI in our tertiary cardiac centre. Patients with no pre-admission statin therapy, prior coronary artery bypass grafts, non-ACS diagnosis, medical management, or in-hospital mortality were excluded. Data on demographics, medication, and angiographic parameters were collected from hospital and primary care records. The cohort was stratified according to statin intensity (high versus low/moderate). Atheroma burden was objectively quantified using Gensini score. Associations between statin intensity and stent length, multivessel PCI, multiple stent use, and calcium modification techniques, were evaluated. Data analysis included multivariable logistic regression adjusted for age, prior coronary artery disease (CAD), hypertension, diabetes mellitus, smoking, and lipid levels, with statistical significance set at p<0.05.Results The study included 91 consecutive patients (mean age 70.3, standard deviation 10.5 years; 71.4% male), of whom 80.2% were on high-intensity statins. Comorbidities included prior CAD (31.9%), hypertension (64.8%), diabetes mellitus (34.1%), smoking (12.1%) and chronic kidney disease (19.8%). Baseline characteristics were largely balanced between the two groups, except that patients on high-intensity statins were younger (p=0.02).In multivariate analysis, high-intensity statin use was associated with significantly higher odds of requiring longer stents (>23 mm) during PCI (odds ratio 5.05, 95% confidence interval [CI] 1.21-21.03, p=0.03). No significant associations were observed for multivessel intervention, multiple stent implantation, or calcium modification techniques.In linear regression models, high-intensity statin use was associated with a marginally non-significant increase in total stent length (coefficient 5.1mm, 95% CI -0.67 to 10.81, p=0.09). No significant associations were observed for number of vessels treated or number of stents placed.Conclusions Our study showed that patients on high-intensity statin regimens prior to ACS were treated with longer stents and complex PCI despite similar serum lipid levels. Statin intensity did not correlate with reduced lesion complexity, and our findings suggest a potential association with qualitatively complex plaques needing complex PCI. This warrants further exploration in larger, prospective studies.