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Introduction Polycystic ovary syndrome (PCOS) affects 5-26% of reproductive-age women and is associated with cardiometabolic risk factors. While linked to cardiovascular risk, its impact on outcomes in non-ST-elevation myocardial infarction (NSTEMI) remains unclear. We investigated in-hospital outcomes among women with PCOS admitted for NSTEMI using a nationally representative dataset.Methods We conducted a retrospective analysis using the National Inpatient Sample (2016–2022) to identify female patients aged 18–50 years admitted with NSTEMI. Patients were stratified by PCOS diagnosis. Demographics, comorbidities, and in-hospital outcomes were compared. Subgroup analyses were performed for patients undergoing percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), or no revascularization. Multivariable logistic regression models were employed to adjust for potential confounders, considering the complex survey design.Results A total of 950 women with PCOS constituted 0.9% of patients aged 18-50 years who were hospitalized for NSTEMI. The PCOS cohort was younger, with a mean age of 40.5 years compared to 43.6 years for the non-PCOS group (p < 0.001). The PCOS cohort exhibited higher rates of diabetes (53.2% vs. 40.1%, p < 0.001), obesity (67.9% vs. 40.0%, p < 0.001), dyslipidemia (62.6% vs. 54.1%, p = 0.018), and coagulopathy (8.4% vs. 4.4%, p = 0.008). Conversely, they had a lower prevalence of chronic kidney disease (5.3% vs. 13.1%, p = 0.001). No significant differences were observed in the length of hospital stay (mean 3.6 days vs. 3.3 days, p = 0.382), total charges (mean $101,789 vs. $91,922, p = 0.189), or Charlson comorbidity index (2.5 vs. 2.5, p = 0.848). The racial distribution also differed, with the PCOS cohort comprising 77.9% White, 14.2% Black, and 4.7% Hispanic individuals, compared to 57% White, 20.3% Black, and 12.1% Hispanic in the non-PCOS group (p < 0.001). Private insurance was more prevalent among the PCOS cohort (51.1% vs. 40.9%, p = 0.037). There were no significant differences in mortality, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), or major in-hospital complications after multivariate adjustment. Sub-group analyses for patients undergoing PCI, CABG, or no revascularization did not reveal any significant differences in outcomes, other than higher use of ICU care among non-revascularized PCOS patients(aOR 3.588, 95%CI: 1.213-10.613, p=0.0209).Conclusion Women with PCOS hospitalized for NSTEMI are younger and have higher rates of metabolic comorbidities including diabetes, obesity, dyslipidemia, and coagulopathy. In the non-revascularized cohort, PCOS was independently associated with significantly higher ICU admission odds, suggesting increased illness severity. PCOS represents a high-risk phenotype requiring targeted preventive interventions and closer monitoring, particularly in patients not undergoing revascularization.