Aim To analyze the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) in patients with different types of acute coronary syndrome (ACS) undergoing coronary artery rotational atherectomy (RA) within two years. Methods 268 patients with ACS who underwent RA in the Department of Cardiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School of Nanjing University, between November 2011 and December 2022 were retrospectively included. According to whether ST-segment elevation myocardial infarction (STEMI) occurred, they were divided into 25 cases in the ST-segment elevation myocardial infarction (STEMI) group and 243 cases in the non-ST-segment elevation acute coronary syndrome (NSTE-ACS) group. The NSTE-ACS group included unstable angina pectoris (UAP) and non-STEMI (NSTEMI). The basic information and intraoperative data related to percutaneous coronary intervention (PCI) in the two groups were collected, and the occurrence of MACCE (including cardiovascular death, non fatal myocardial infarction, worsening heart failure, ischemic stroke and target vessel revascularization) within two years after RA was followed up and analyzed. Results Compared with the NSTE-ACS group, the STEMI group had a higher incidence of MACCE and cardiovascular mortality during the two-year follow-up period (10.3% and 0.4% vs. 28.0% and 8.0%; P＜0.05). There was no statistical difference between the incidence of target vessel revascularization, nonfatal infarction, ischemic stroke and worsening heart failure between the two groups (P＞0.05). According to subgroup analysis based on enrollment periods, the results showed that over time (2011-2017 compared to 2018-2022), the incidence of MACCE in all patients within two years after RA showed a decreasing trend (18.97% vs. 6.58%). Combined with previous studies, gender, hypertension, diabetes, renal insufficiency, smoking and left ventricular ejection fraction (LVEF) were included in the Cox regression model. It was found that the use of intravascular ultrasound (IVUS) was an independent factor to reduce the incidence of MACCE in ACS patients within two years after RA (HR＝0.3,5%CI:0.153～0.723, P＜0.01). Kaplan-Meier analysis showed that among ACS patients undergoing RA, the cumulative incidence of MACCE events was higher in the STEMI group than that in the NSTE-ACS group (P＜0.05). Conclusion STEMI patients have a higher incidence of MACCE and cardiovascular mortality within two years after RA compared to NSTE-ACS patients, and the use of IVUS during RA surgery can reduce the incidence of MACCE in ACS patients after RA.