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ObjectivePatients with a prior history of coronary artery bypass grafting (CABG) presenting with non-ST-elevation acute coronary syndrome (NSTE-ACS) represent a high-risk population in whom revascularization decisions are frequently individualized in real-world practice. Objective biomarkers capable of supporting treatment selection in this setting remain limited. The Naples Prognostic Score (NPS), a composite index integrating inflammatory and nutritional parameters, may reflect overall clinical vulnerability.MethodsIn this retrospective, single-center observational cohort study, the association between NPS and treatment strategy selection was evaluated in 367 patients with prior CABG presenting with NSTE-ACS between January 2019 and October 2025. NPS was calculated at admission prior to coronary angiography using total cholesterol, neutrophil-to-lymphocyte ratio, lymphocyte-to-monocyte ratio, and serum albumin levels. Patients were categorized into low (0-2) and high (3-4) NPS groups. Treatment strategies were determined through routine multidisciplinary clinical assessment and were not influenced by study investigators. Multivariable logistic regression and prespecified stratified sensitivity analyses were performed.ResultsRevascularization was selected in 169 patients (46.0%), including 164 percutaneous coronary interventions and 5 redo CABG procedures. Patients undergoing revascularization had significantly lower NPS values. High NPS was independently associated with a lower likelihood of being selected for revascularization (OR 0.28, 95% CI 0.17-0.48; p < 0.001). Procedural success rates following PCI were similar between NPS groups (89.0% overall; p = 0.161). Results remained consistent across stratified sensitivity analyses according to clinical presentation, chronic kidney disease status, and age categories.ConclusionsHigher NPS values were associated with a lower likelihood of revascularization without affecting procedural success. NPS appears to reflect disease burden and clinical vulnerability rather than treatment benefit. It may also capture acute inflammatory status and should be considered a complementary, not decisive, clinical marker.