Acute coronary syndromes represent the acute, life-threatening phases of coronary heart disease. Patients with acute coronary syndromes are at high risk of major adverse cardiac events. Treatment of these patients remains controversial because of the heterogeneous nature of these conditions and recent advances in their management options. The older standbys of aspirin, heparins, nitrates, beta-blockers, and thrombolytic therapy have given way to vastly improved interventional capabilities (with improved adjunctive pharmacotherapy), low molecular weight heparins, glycoprotein IIb/IIIa antagonists, safer theinopyridines, thrombin inhibitors, and newer generation fibrinolytics. Despite these substantial advances, a great deal of confusion remains. Clinicians know that there are better forms of therapy but are not sure how to use them, when to use them, or even what to use. They do not have all the answers at present and probably have more questions than answers.