Abstract Body (Do not enter title and authors here): Background
Acute coronary syndrome (ACS) remains one of the leading causes of death globally. Accurate and reliable mortality risk prediction of ACS patients is essential for developing targeted treatment strategies. Existing traditional models offer moderate discriminative value, and do not incorporate contemporary predictors of ACS prognosis. Machine learning (ML) models have emerged as an alternate method that may offer improved risk assessment. This study aims to compare machine learning models with traditional risk scores for predicting all-cause mortality in patients with ACS.

Methods
PubMed, EMBASE, Web of Science and Cochrane databases were searched until 1^st November 2023 for studies comparing ML models with traditional statistical methods for event prediction of ACS patients. The primary outcome was comparative discrimination measured by C-statistics with 95% confidence intervals between ML models and traditional methods in estimating the risk of all-cause mortality.

Results
Ten studies were included (239627 patients). The summary C-statistic of all ML models across all endpoints was 0.89 (95% CI, 0.86-0.92), compared to traditional methods 0.82 (95% CI, 0.79-0.85). The difference in C-statistic between all ML models and traditional methods was 0.07 (p<0.05). Three models undertook external validation, and calibration was inconsistently reported.

Conclusion
ML models demonstrated superior discrimination of all-cause mortality for ACS patients compared to traditional risk scores. Despite outperforming well-established prognostic tools such as the GRACE and TIMI scores, current clinical applications of ML approaches remain uncertain, particularly in view of the methodological limitations of existing studies and the need for greater model validation.