Background: Biventricular pacing (BVP) and conduction system pacing (CSP) can enhance pacing-induced cardiomyopathy (PICM) patients’ clinical outcomes, yet guidelines lack a specified preferred pacing strategy. This meta-analysis compares the efficacy and safety of CSP and BVP in PICM patients. Methods: Databases including PubMed, Cochrane Library, Web of Science, and Embase were searched from their establishment to February 2025, Data analysis was performed using Stata 17. Results: Eighteen observational studies involving 679 patients with PICM were included, among which 322 patients were treated with BVP and 357 patients with CSP. Results showed CSP group had a greater QRS duration (QRSd) reduction than BVP group (MD = -54.61 ms, 95% CI: -59.67, -49.54 vs MD = -28.22 ms, 95% CI: -32.13, -24.31; P < 0.001). After 14-months follow-up, CSP group had a higher response rate (84.0% vs 66.4%) and lower incidences of adverse outcomes and device-related complications (9.6% vs 17.2%) than BVP group. Subgroup analysis showed His bundle pacing (HBP) was associated with greater QRSd shortening and stable pacing thresholds, while left bundle branch area pacing (LBBAP) had lower thresholds. Conclusions: The results indicate that CSP is superior to BVP in improving PICM patients’ clinical outcomes, suggesting that CSP may be a promising alternative pacing strategy for PICM patients. However, since most of the included studies were case series, there are certain limitations in the results. Large-scale randomized controlled trials are required to further verify the effectiveness and safety of CSP in PICM.